.^.■ilJJ•^.vn■..•..^•"'.■<::v..■" ■■',.'■ ■•.. ■ • r«4| .v^r.v JV .-. • • vv .„\v, /. , .-.-, C^'iSVk'.if.V^i t>'i. "u.V...'.'.*'." ►.' .".' Y. .',Y»V.' •■***j,±^,..., ....., k.. .......v . ..... ^ymm^^ss^^^:-,- .;>;Mv:v .:■:•;•.■:■■ 'iV'JTt 'J1'! *r>—■ >-»- >>l^'ilV»V.V,'i''.'. »y. ■,"...' vLu«:.Mlt.,.,.l]>ii.rvu V.'1'. t?f *Ba4\?^1 'T'V" '-*•" - * .»:»»••>»..< ►T **'.>.'>»■*£.. kf.W !.,»■• *-. M» T» • . , 4.. . . - ^» »-.... . ^:v;lj^^^vy^v.:^,:.^;^^-./A.^.V■^;v^-^,:^^.<^^^v.', ■rr.-.z * 'iri-"'A****' •" • ' ■ • '■• v. • • •».. • - ... ■ ;v'^.v /-•,r.-f:; K-*r*-v ■■.-'■ ■.•••■--'■• ^ife^ar';::"^>.v.'.-:'-'-. •' l>ij,';.J:m ■;•.••■••*/:: v gi «K ARMY MEDICAL LIBRARY WASHINGTON Founded 1836 >> Section. Number %JCA4..'L,. Form H3c, W. D.. S. G. O. dpo 3—10543 (Revised June 13, 1936) I 3^"* PUBLISHED MEMOIRS AND COMMUNICATIONS (To a"a/XL-u.a2?3r 1st, 1882.) WILLIAM OSLER, M.D., M.R.C.P., Lond., * * % Professor of the Institutes of Medicint,McGill University; Physician and Pathologist to the General Hospital, Montreal. s^uX- FOR PRIVATE CIRCULATION. 1882. No* M*d HUH'*'* TITLES OF PAPERS. 'Y I. On Canadian Diatomaese, Canadian Naturalist, 1870. j IT. On tho action of Atropia and Physostigmia on the Colour- less Blood Corpuscles. Quarterly Microscopical Journal, London, 1873. ITT. On certain Organisms in the Liquor Sanguinis. Proceedings of the Royal Society, 1874. IV. Valedictory Remarks to Class, '75, Met rill University. Can. Medical d- Surgical Journal, 1875. | V. Case of Scarlatina miliaria. ' Can. Medical XXV. Case of Congenital and Progressive Hypertrophy of Eight upper Extremity. Journal of Anatomy & Physiology, London, 1879. A XXVI. Two cases of Striated Myo-Sarcoma of Kidney. Journal, of Anatomy & Physiology, 1880. XXVII. Cases of Cardiac Abnormalities (two plates). Montreal Gen. Hosp. Reports, Vol. I, 1880. XXVIII. On the condition of Fusion of two segments of the Semilunar Valves (with plate). Montreal Gen. Hosp. Reports, Vol. I, 1880 XXIX. Pathological Report, Montreal General Hospital, No. II. With the Reports, Vol. I., 1880. XXX. On the Systolic brain murmur of Children. Boston Med. & Surg. Journal, 1880. XXXI. Cases of Insular Sclerosis. Can. Medi< al d Surgical Journal, 1880. XXXll. On delayed Resolution in Pneumonia. Canada Lancet, 1880. XXXIII. On heredity in progressive Muscular Atrophy as illustrated b}^ the Farr Family. Archives of Medicine Vol. TV., New York, 1881. jl. XXXI V On a remarkable Heart-murmur, heard at a distance from the chest-wall. Med. Tunes ,L Gazette, London, lS8(». XX XV. On a case of Medullary Neumma of Brain (with plate). Journal if Anatomy <£• Physiology, London, 1881. XXXVI. Infectious, so called, Ulcerative Endocarditis (with plate). Archives of Medicine, Vol. V, 1881, N.Y. ?> XXXVII. Cases of Hodgkin's Disease. Can. Medical d Surgical Journal, 1881. h XXXIX. Clinical Lecture on Idiopathic or Pernicious Antemia. Can. Journal of Med. Science, 1881. XL. Clinical Lecture on Fibroid Phthisis. Can. Medical d Surgical Journal, 1881. XLL On some of the effects of the chronic impaction of Gall Stones, and on the "tievre intermittente he"patique" of Charcot. Medical Times do Gazette, London, 1881. XLII. On Renal Cirrhosis, with special reference to its latency, etc. Canada Lancet, 1881. XLII I. Notes on Intestinal Diverticula. Annals of Anatomy & Surgery, Vol. IV., Brooklyn, 1881. X [From the Pkocfetuxgs of the Royal Society, No. 153, 1874."i > AN ACCOUNT OF CERTAIN ORGANISMS OCCURRING 7N THE LIQUOR SANGUINIS. \/ WILLIAM OSLER, M.D. In many diseased conditions of the body, occasionally also in perfectly healthy individuals and in many of the lower animals, careful investi- gation of the blood proves that, in addition to the usual elements, there exist pale granular masses, which on closer inspection present a corpus- cular appearance (Plate V. fig. 1). There are probably few observers in the habit of examining blood who have not, at some time or other, met with these structures, and have been puzzled for an explanation of their presence and nature. 392 Dr. \V. Osier on Organisms [June 18, In size they vary greatly, from half or quarter that of a white blood- corpuscle, to enormous masses occupying a large area of the field or even stretching completely across it. They usually assume a somewhat round or oval form, but may be elongated and narrow, or, from the existence of numerous projections, offer a very irregular outline. They have a compact solid look, and by focusing are seen to possess consider- able depth ; while in specimens examined without any reagents the fila- ments of fibrin adhere to them, and, entangled in their interior, white corpuscles are not unfrequently met with. It is not from every mass that a judgment can be formed of their true nature, as the larger, more closely arranged ones have rather the appear- ance of a granular body, and it is with difficulty that the individual elements can be focused. When, however, the more loosely composed ones are chosen, their intimate composition can be studied to advantage, especially at the borders, where only a single layer of corpuscles may exist; and when examined with a high power (9 or 10 Hartnack) these corpuscles are seen to be pale round disks, devoid of granules and with well-defined contours. Some of the corpuscles generally float free in the fluid about the mass ; and if they turn half over their profile view has the appearance of a sharp dark line (fig. 5, a & b). In water the individual corpuscles composing the mass swell greatly; dilute acetic acid renders them more distinct, while dilute potash solutions quickly dissolve them. Measurements give, for the large proportion of the corpuscles, a diameter ranging from one 8000th to one 10,000th of an inch ; the largest are as much as one 5000th, and the smallest from one 15,000th to one 24,000th of an inch; so that they may be said to be from U-| the size of a red corpuscle. In the blood of cats, rabbits, dogs, guineapigs, and rats the masses are to be found in variable numbers. New-born rats are specially to be recommended as objects of study, as in their blood the masses are commonly both numerous and large. They occur also in the blood of foetal kittens. Considering their prevalence in disease and among some of the lower animals, they have attracted but little notice, and possess a comparatively scanty literature. The late Prof. Max Schultze * was the first, as far as I can ascertain, to describe and figure the masses in question. He speaks of them as constant constituents of the blood of healthy individuals but concludes that we know nothing of their origin or destiny, suggesting however, at the same time that they may arise from the degeneration of granular white corpuscles. Schultze's observations were confined to the blood of healthy persons, and he seemed of the opinion that no pathological significance was to be attributed to them. By far the most systematic account is given by Dr. Riess t in an * Archiv f. mik. Anat. Bd. i. t Reichert u. Du Bois-Reymond's Archiv, 1872. 1874.] in the Liquor Sanguinis. 393 article in which he records the results of a long series of observations on their presence in various acute and chronic diseases. His investigations of the blood of patients, which were much more extensive than any I have been able to undertake, show that, in all exanthems and chronic affections of whatever sort, indeed in almost all cases attended with disturbance of function and debility, these masses are to be found. He concludes that their number is in no proportion to the severity of the disease, and that they are more numerous in the latter stages of an affection, after the acute symptoms have subsided. The former of these propositions is undoubtedly true, as I have rarely found masses larger or more abundant than I, at one time, obtained from my own blood when in a condition of perfect health. These two accounts may be said to com- prise every thing of any importance that has been written concerning these bodies. The following observers refer to them cursorily:—Erb *, in a paper on the development of the red corpuscles, speaks of their presence under both healthy and diseased conditions : he had hoped, in the begin- ning of his research, that they might stand, as Zimmerman supposes (see below), in some connexion with the origin and development of the red corpuscles; but, as he proceeded, the fallacy of this view became evident to him. Bettelheim t seems to refer to these corpuscles when he speaks of finding in the blood of persons, healthy as well as diseased, small punctiform, or rod-shaped, corpuscles of various sizes. Christol and Kiener X describe in blood small round corpuscles, whose measurements agree with the ones under consideration; and they also speak of their exhibiting slight movements. Riess §, in a criticism on a work of the next-mentioned author, again refers to these masses, and reiterates his statements concerning them. Birsch-Hirschfeld|| had noticed them and the similarity the corpuscles bore to micrococci, and suggests that under some conditions Bacteria might develop from them. Zimmerman % has described corpuscular elements in the blood, which, with reference to the bodies in question, demand a notice here. He let blood flow directly into a solution of a neutral salt, and, after the subsidence of the coloured elements, examined the supernatant serum, in which he found, in extra- ordinary numbers, small, round, colourless corpuscles with weak contours, to which he gave the name of " elementary corpuscles." These he met with in human blood both in health and disease and in the blood of the lower animals; and he found gradations between the smaller (always colour- less) forms and full-sized red corpuscles. He gives measurements (for the smaller ones, from one 1000th to one 800th of a line; the largest, one * Virchow's Archiv, Bd. xxxiv. t Wiener med. Presse, 1868, No. 13. J Comptes Rendus, lxvii. 1054. Quoted in ' Centralblatt,' 1869, p. 96. § Centralblatt, 1873, No. 34. || Centralblatt, 1873, No. 39. ** Virchow's Archir. Bd. Tvjii, 394 Dr. W. Osier on Organisms [June 18, 500th to one 400th of a line), and speaks of them also as occurring in clumps and groups of globules. It is clear, on reading his' account, that in part, at any rate, he refers to the corpuscles above described. Gradations such as he noticed between these and the coloured ele- ments I have never met with, and undoubtedly he was dealing with the latter in a partially decolourized condition. Lostorfer's * corpuscles, which attracted such attention a few years ago from the assertion of the discoverer that they were peculiar to the blood of syphilitic patients, require for their production an artificial culture in the moist chamber extending over several days. They appear first after two or three days, or even sooner, as small bright corpuscles, partly at rest, partly in motion, which continue to increase in size, till, by the sixth or seventh day, they have attained the diameter of a red corpuscle, and may possess numerous processes or contain vacuoles in their interior. Blood from healthy individuals, as well as from diseases other than syphilis, has been shown to yield these corpuscles ; and the general opinion at present held of them is that they are of an albuminoid nature. The question at once most naturally arose, How is it possible for such masses, some measuring even one 400th of an inch, to pass through the capillaries, unless supposed to possess a degree of extensibility and elasticity such as their composition hardly warranted attributing to them ? Neither Max Schultze nor Riess offer any suggestion on this point, though the latter thinks that they might, under some conditions, produce embolism. During the examination of a portion of loose connective tissue from the back of a young rat, in a large vein Avhich happened to be in the specimen, these same corpuscles were seen, not, however, aggregated together, but isolated and single among the blood-corpuscles (fig. 8); and repeated observations demonstrated the fact that, in a drop of blood taken from one of these young animals, the corpuscles were always to be found accumulated together; while, on the other hand, in the vessels (whether veins, arteries, or capillaries) of the same rat they were alwavs present as separate elements, showing no tendency to adhere to one another. The masses, then, are formed at the moment of the withdrawal of the blood, from corpuscles previously circulating free in it. To proceed now to the main subject of my communication. If a drop of blood containing these masses is mixed on a slide with an equal quan- tity of saline solution, ^-f per cent., or, better still, perfectly fresh serum, covered, surrounded with oil, and kept at a temperature of about 37° C. a remarkable change begins in the masses. If one of the latter is chosen for observation, and its outline carefully noted, it is seen at first that the edge presents a tolerably uniform appearance, a few filaments of * Wiener med. Presse, 1872, p. 93. Wiener med. Wochenschrift, 1872, No.8. Article in Archiv f. Dermatolog. 1872. 1874.] in the Liquor Sanguinis. 395 fibrin perhaps adhering to it, or a few small corpuscles lying free in the vicinity. These latter soon exhibit apparent Brownian movements, frequently turning half over, and showing their dark rod-like border (fig. 5, a, b). After a short time an alteration is noticed in the presence of fine projections from the margins of the mass, which may be either perfectly straight, or each may present an oval swelhng at the free or attached end or else in the middle (fig. 2, 6). It is further seen that the edges of the mass are now less dense, more loosely arranged, or, if small, it may have a radiated aspect. Sometimes, before any filaments are seen, a loosening takes place in the periphery of the mass, and among these semifree corpuscles the first development occurs. The projecting filaments above mentioned soon begin a wavy motion, and finally break off from the mass, moving away free in the fluid. This process, at first limited, soon becomes more general; the number of filaments which pro- ject from the mass increases, and they may be seen not only at the lateral borders, but also, by altering the focus, on the surface of the mass, as dark, sharply defined objects. The detachment of the filaments proceeds rapidly; and in a short time the whole area for some distance from the margins is alive with moving forms (fig. 2, c, and fig. 3), which spread themselves more and more peripherally as the development continues in the centre. In addition to the various filaments, swarming granules are present in abundance, and give to the circumference a cloudy aspect, making it difficult to define the individual forms. The mass has now become perceptibly smaller, more granular, its borders indistinct and merged in the swarming cloud about them; but corpuscles are still to be seen in it, as well as free in the field. A variable time is taken to arrive at this stage; usually, however, it takes place within an hour and a half, or even much less. The variety of the forms increases as the develop- ment goes on ; and whereas, at first, spermatozoon-like or spindle-shaped corpuscles were almost exclusively to be seen, later more irregular forms appear, possessing two, three, or even more tail-like processes of extreme delicacy (fig. 5, lc). The more active ones wander towards the periphery, pass out of the field, and become lost among the blood-corpuscles. The process reaches its height within 2| hours, and from this time begins almost imperceptibly to decline; the area about the mass is less densely occupied by the moving forms, and by degrees becomes clearer, till at last, after six or seven hours (often less), scarcely an element is to be seen in the field, and a granular body, in which a few corpuscles yet exist, is all that remains of the mass. The above represents a typical develop- ment from a large mass in serum, such as that seen in fig. 3*. AVe have next to study more in detail the process of development and the resulting forms. Commonly, the first appearance of activity is . * The mass from which this sketch was taken w»s seen in full development by several of the foreign visitors to the British Medical Association last year. 396 Dr. W. Osier on Organisms [June 18, displayed by the small free corpuscles at the margins, which, previously quiescent, begin a species of jerky irregular movement, at one time with their pale disk-surfaces uppermost, at another presenting their dark linear profiles (fig. 5, a & b). Not unfrequently, some of these are seen with a larger or smaller segment of their circumference thicker and darker than the other (fig. 5, c). Earliest, and perhaps the most plentiful, of the forms are those of a spermatozoon-like shape (fig. 5, d), attached to the mass either by the head or tail; while, simultaneously, long bow-shaped filaments appear (fig. 5, e), having an enlargement in the centre. Straight hair-like filaments (fig. 5, /) may also be seen, but they are not very numerous. The time which elapses before they begin the wavy movement is very variable, as is also the time when they break away after once beginning it. Fila- ments may be seen perfectly quiescent for more than half an hour before they move, and others may be observed quite as long in motion before they succeed in breaking away from the mass. Commonly it is in the smaller masses, and where the development is feeble, that filaments re- main for any time adherent. The spermatozoon-like forms appear, at the head, on one view flattened and pale, on the other dark and linear (fig. 5, d); consequently the head is discoid, not spheroidal. The bow- shaped filaments also present a dark straight aspect when they turn over (fig. 5, e), and are by far the longest of the forms, some measuring as much as one 900th of an inch. Many intermediate forms between the round discoid corpuscles and those with long tails are met with in the fi3ld, and are figured at fig. 5, g. Small rod-shaped forms are very numerous, most of which, however, on one aspect look corpuscular ; but in others this cannot be detected, or only with the greatest difficulty; slight enlargements at each end may also be seen occasionally in these forms (fig. 5, A). Usually late to appear, and more often seen in the profuse develop- ments from large masses, are the forms with three or more tail-like pro- cesses attached to a small central body (fig. 5, Tc). Among the granules it is extremely difficult to determine accurately the number of these pro- cesses, the apparent number of which may also vary in the different posi- tions assumed by the element. As to the ultimate destiny of the indi- vidual forms, I have not much to offer; I have watched single ones, with this view, for several consecutive hours without noticing any material alteration in them. The one represented at fig. 6 was watched for four hours, that at fig. 7 for five, and the changes sketched. The diffi- culty of following up individual filaments in this way is very great not only from the ensuing weariness, but from the obstacle the red corpuscles offer to it. With regard to the movement of the filaments, this, at first sight, bears some resemblan

)vy^ 6. 7, J) M "b £ U 1 u Q 9 *0X^#s *ob, O- 0 c o ,^v f ) .WEWwUy -3o TV". V. 'i s * 8oCo.i>»i?3. .* VALEDICTORY ADDRESS TO THE McGILL UNIVERSITY. DELIVERED ON BEHALF OF THE MEDICAL FACULTY AT THE ANNUAL CONVOCATION HELD IN THE WILLIAM MOLSON HALL OF THE UNIVERSITY, ON WEDNESDAY, THE 31ST MARCH, 1875. BY WILLIAM OSLER, M.D., L.R.C.P.L., LECTURER ON INSTITUTES OF MEDICINE. {From the Canada Medical and Surgical Journal.) Gentlemen of the Graduating Class.—The pleasant duty devolves upon me of offering you, on behalf of the Faculty of Medicine, congratulations on your present suc- cess, and good wishes for the future. For four years you have been occupied in mastering the elements of your Pro- fession in the Lecture room,Hospital ward, and Dispensary ; and now, having satisfied the requirements of the University, the long looked for degree has been conferred, the coveted title obtained. The time has arrived for you to put in prac- tice what has been taught you here, and your success will depend, in great measure, upon how you have taken advan- tage of the opportunities afforded at this school. At the outset it is necessary for you to bear in mind that your professional education is by no means complete; you have, as it were, only laid the foundation, and, let me say, Gentlemen,while it is to be hoped that a good and promising foundation has been laid under the guidance and instruction of others, it rests with yourselves what the superstructure shall be. The credit of your College, the honour of that Profession to which it is our privilege and pleasure to belong, your advancement in life depend on the course you now mark out and follow for yourselves. You must not be con- tent to rest on your oars. The canons of the church, the formulas of the law, are to a certain extent unalterable, are stereotyped. Not so medicine. It is preeminently a pro- gressive science, day by day receiving fresh acquisitions, opening up new fields for investigation, and it will be your duty, as far as in you lies, to keep pace with this progress. During the first few years, while waiting for practice, you will have ample leisure to work up more thoroughly the various branches of your Profession, and keep posted in the latest medical literature. Cultivate in these early years 2 studious habits. It happens too frequently that after the severe work of the final session, books are thrown aside, and rarely reopened. A glance at the bookshelves of any professional man—Cleric, Lawyer or Physician, will enable you to judge better than anything else, the estimate he has formed of his calling. Let it be also an ambition to add your mite to the store of medical knowledge. Every one can do something ; and the routine of general practice af- fords many cases worth reporting or commenting upon. Our Medical Journals greatly need the cooperation of the profession throughout the country, and in thus recording your experiences you will benefit yourselves, and help to raise the standard of Canadian Medicine. Hitherto, Gentle- men, your relations have been chiefly with your teachers and with each other ; now these relations are changed, and you will have to deal in the future with patients and fellow practitioners. On the first point it would not become me to say much. Remember, however, that every patient upon whom you wait will examine you critically and form an esti- mate of you by the way in which you conduct yourself at the bedside. Skill and nicety in manipulation, whether in the simple act of feeling the pulse, or in the performance of any minor operation will do more towards establishing confidence in you, than a string of Diplomas, or the repu- tation of extensive Hospital experience. Formerly, in the days of apprenticeship, the medical student was brought daily in contact with patients of all classes, now it is too often the case that Hospital practice is the only variety seen, and the sudden change to private practice is found rather trying. Time soon remedies this, and every case success- fully treated adds to the confidence you feel in your own powers. Fortunately, the first patients are among the poor, who are less exacting, more easily pleased, and more disposed to make allowances for a young practitioner than the upper classes. You have of course entered the Profes- sion of Medicine with a view of obtaining a livelihood ; but in dealing with your patients let this always be a secondary consideration. It has been well said, " No one should approach the temple of science with the soul of a money- changer." Let the spirit of our Medical moralist, Sir Thomas Browne, whose Religio Medici I would commend to your perusal, actuate you. He says " Let me be sick myself, if sometimes the malady of my patient be not a dis- ease unto me ; I desire rather to cure his infirmities than my own necessities ; where I do him no good methinks it is scarce honest gain, though, I confess, 'tis but the worthy salary of our well intended endeavours." Upon your rela- tions to fellow-practitioners, allow me to offer you a few words of counsel. It is a fact well known to you all that the great opprobrium of our Profession, especially in the small towns, is the constant rivalry and distrust of one another dis- played by its members. That men whose high calling ought to bind them closely together, and whose interests are so much in common, should thus disagree, is a matter deeply to be regretted ; and, I would urge upon you, during your, let me hope, prosperous career, to do all that may lie in your power to remove this scandal from our midst. A little watch- fulness when commencing practice may prevent it entirely in your own circle, and you may thus have your brother prac- titioners as friends not enemies. The evil, I regret to say, is generally traceable to the patients. You will not be engaged in practice many weeks before one seeks you who has been under the care of some other medical man. He or she gives you a statement of the case, blames the former atten- dant, and expects you to sympathize and add your measure of censure. If you do, it gets talked of, and sooner or later reaching the ears of your rival practitioner forms the nucleus of a serious quarrel. Make it a rule always to dis- courage the tales of a patient about another medical man ; and even when you think he has made a mistake, be slow to judge. Often too you may feel aggrieved, and think yourself wronged or slighted ; instead of giving vent to your feelings, on such occasions, restrain them, and remember the injunc- tion " If thy brother trespass against thee ; go and tell him his fault between thee and him alone ; if he shall hear thee, thou hast gained thy brother." A word now on the Temperance question, which is be- coming an all important one in Canada for us as medical men. That alcohol is a medicine, and a valuable one, nobody not blinded by prejudice denies ; but bear in mind that it is a dangerous remedy, and one that should not be, as it is, so generally recommended by practitioners. There are many conditions, for which alcohol is now freely prescribed, quite amenable to treatment by other medicinal agents combined with a careful regulation of diet. When you do order it, give positive directions about the quantity, and the length of time it is to be continued. In- attention to these matters, especially in patients suffering from any of the neuroses, is occasionally the starting point of dangerous drinking habits. Medical men, more than any other, have opportunities of observing the commencement of such habits, and care should be exercised, lest this ten- dency be fostered by the form of treatment employed. No class of individuals can better wage war against the indis- criminate drinking habits of the public than the Doctors, and the laity will hearken to their admonitions on this point; 4 even when the exhortations of the Divines are treated with contempt. Example, Gentlemen, is better than precept, and by becoming teetotallers yourselves, >ou will neither injure your health nor damage your professional prospects. ' Too many valuable lives in our Profession are sacrificed yearly to intemperance ; and, now is the time for you, with minds still " wax to receive and marble to retain," to lay the foundation of good sober habits. Those of you from Ontario, and intending to practice there, will, I* suppose, present yourselves to the Medical Council for examination. This much abused institution is, I believe, doing good service to the Profession of that pro- vince, and it is to be regretted that such an examining body does not exist for the Dominion. In a country like this where the power of granting degrees in Medicine is pos- sessed by all the sectarian Universities, it is but just that the profession at large, should have some guarantee of the proficiency of the graduates ; and this they can only obtain by combining together, as in Ontario, and examining every man for his license. The examinations are thorough, con- ducted with fairness, and such as no McGill man who has attended to his studies need fear. Just as Edinburgh men sometimes fail at the Primary and Final Examinations before the Royal College of Surgeons, so occasionally will men from the Universities of Canada be rejected at the Ontario board. As an independent examining body it may yet do much towards elevating the standard of Canadian medicine by making the necessary qualifications of a higher order than they are at present. Hitherto it has not afforded much protection against illegal practitioners, but now, as the finances are in a better condition, the Council is pre- pared to take action, and intends to prosecute unlicensed men. One hears the assertion not unfrequently made that the existence of the Board is prejudicial to the interests of our Medical school, as it hinders Ontario students from coming here. I do not see how this can be the case. The Ontario student, whether he attends the Toronto schools or McGill, has the same examinations to pass, one before his University, the other before the Board. It entails an ad- ditional expense, and it is this, not the examinations with which all the students find fault. In conclusion, gentlemen, let us hope, that wherever you go, you will maintain the good name of your Alma Mater, and add to the lustre which already surrounds her. Bend all your energies to the attainment of proficiency in your call- ing ; work while it is yet day, that when your night comes it may be said of you as of Gerard de Narbon, one of Shakespeare's Physicians." " He was in what he did profess, well found." CLINICAL NOTES ON SM A LL-POX I. THE INITIAL RASHES. Q II. HEMORRHAGIC SMALL-POX. 1 III. A FORM OF HEMORRHAGIC SMALL-POX. 0 WILLIAM OSLER, M.D., Latk Physician to the Small-Pox Department of the General Hospital, and Professor of the Institutes of Medicine, McGill University, Montreal. ($ontr,eal: PRINTED AT THE "GAZETTE" PRINTING HOUSE. I. THE INITIAL RASHES. v^ In the abundant literature of small-pox, contained in the standard text-books, and scattered through the various periodi- cals, mention is occasionally made of rashes occurring in the initial stage of the disease. The reference to them in the ordinary English works on the Practice of Medicine is usually limited to two or three lines, stating that the eruption is sometimes pre- ceded by an erythematous or erysipelatous rash. (See text books of Aitken, Wood, Watson, Niemeyer, Barlow.) Many make no mention whatever of them. (Bennett, Tanner). Even in the special works on the subject the notice is scarcely more extended. Thompson* refers to a roseolous rash as a common precursor of varioloid. Munrof speaks of a " rosy efflorescence as in measles pre- ceding the eruption in malignant small-pox." Gregory^ makes no mention of them, but refers to a scarla- tina-like rash in the progress of the secondary fever. • On Varioloid Diseases, pp. 35—151. f On Small-pox, p. 97. J On Eruptive Fevers, p. 49. 2 THE INITIAL RASHES OF ^MALL-POX. Marson* states, that in varioloid the eruption " is very often preceded by roseola, which lasts two or three days—the r. exanthematica." Foreign Physicians appear to have paid more attention to them, and very good accounts are to be found in some of the recently translated works f Many of the older authors believed them to be independent affections, and, according as the eruption was diffuse or mottled, spoke of scarlatina or measles occurring simultaneously with small-pox. Sydenham was evidently acquainted with them, and refers to the difficulty they may cause in the diagnosis. " The afore- said small-pox," speaking of the discrete form, " breaks out some- times after the fashion of erysipelas, sometimes like measles. From these they are difficult to be distinguished even by the practised physician, provided that he goes by the external appearance only."J In some of the cases collected by Murchison§ of the sup- posed coincidence of two fevers at the same time, the mistake has been made of confounding the initial rashes with indepen- dent diseases.—(Illustrations, 3, 4, 5, 6, 7, 8, 9, 10.) Our definite information on the subject dates from the publica- tion by Dr. Theodor Simon of Hamburg (whose premature death last year was a severe loss to the profession in Germany), of a series of articles in the Archives f. Permatologie und Syphilis, Bds II, III, & IV, on the "Prodromal Exanthems of Small-pox." Other papers on the subject appeared in the same journal from the pens of Drs. Knecht and Scheby-Buch, and less important observations have been published in several of the German period- icals within the past four years. The probable reason why such scanty reference to them is found in the records of the older epidemics is that they anpear * Reynolds' System.—Article Small-pox. f Trousseau.—Clinical Medicine (Sydenham Society) Vol. 2. Hebra. Skin Diseases, (Sydenham Society) vol. 1. Ziemssen's Encyclopedia, Curschmann. Art. Small pox. X Works of Sydenham (Sydenham Society) Vol. 1, page 127- § Med. Chirurgical Review, 1859. THE INITIAL RASHES OF SMALL-POX. 3 with great irregularity, some epidemics, as the one now subsid- ing, affording numerous instances, others very few. Two forms of these rashes are to be distinguished, the diffuse scarlatiniform, and the macular or measly, either of which may be accompanied by petechige, and occupy a variable extent of the cutaneous surface. In some instances they are general, covering the whole body ; as a rule, however, they are limited and show a decided preference for certain localities. This holds good especially for the purpuric rashes, which occur with great- est frequence in the abdominal region, occupying a triangle the base of which is formed by a line drawn from one anterior superior spinous process of the ilium to the other, the sides by Poupart's ligaments, the apex corresponding to the pubis. Another favorite situation is the inner surfaces of the thighs, (the crural triangle of Simon). A third is the lateral thoracic region, in a strip extending towards the navel, along the margins of the ribs. The above are the usual sites for the purpuric rashes, and in the majority of cases they occur in one or all of them. The simple erythematous and macular rashes, unaccompanied by petechias, are often much more extensive, spreading over larger areas. When limited, in which case the presence of purpura is common, they occur in the above-named situations, and also, according to Simon, '• in the axillary regions, (axillary triangle) the extensor surfaces of the extremities, especially in the neigh- borhood of the knees and elbows, the backs of the hands and feet, on the genitals, and lastly, as a streak extending from the ankle along the skin over the extensor hallucis longus." My experience has been that they are chiefly purpuric; in the limited number of cases which I have observed, only two, were unaccompanied by petechige. In very many of the cases reported by Simon and Knecht no mention is made of the pre- sence or absence of cutaneous extravasations. Scheby-Buch, on the other hand, believes them to be, in most instances, of an hemorrhagic nature, i. e., numerous petechige occur upon an erythematous base. The following cases will give a good idea of the nature and extent of these initial rashes. 4 THE INITIAL RASH KS OF SM A^L-POX. Case I.—D. R., aet. 14. Admitted November 28th. Vac- cinated, one good mark. Revaccinated 8 days before admission, three points, which had taken, were just passing into the pustu- lar stage. A diffuse erythematous rash of a dark-red hue existed over the abdominal region, extending upwards in the lateral thoracic areas, and downwards upon the thighs. Face much suffused, extremities unaffected. On pressing with the finger upon the skin of the abdomen, numerous petechias were evident, most abundant in the groins, and inner surfaces of the thighs. Temp. 101Q. Slight delirium. A papular eruption over face and arms. 29th.—Erythema has disappeared, leaving the ecchymoses' visible as small, dark, punctiform spots, closely set together in the groin, and more scattered towards the navel. The largest existed in the lateral thoracic regions, over the serrati muscles. A few were also noticed on the legs about the inner surfaces of the tibiae. Course of the Disease.—Eruption became confluent on the face, discrete on the extremities and trunk. Not more than eight pocks appeared on the sites of the erythema. Instead of proceeding to maturation, the majority of the pustules aborted, and on the 11th d^y of the disease desiccation had begun. Case II.—J. C, aet. 23, medical student. Vaccinated, one good mark. Admitted, December 15th, 1874. Initial symptoms, according to his own statements, had been tolerably severe. Papular eruption present on the face and arms. On examining the trunk a fading erythema was noticed over the thorax and abdomen. A diffuse ecchymosis existed over the anterior sur- faces of both shoulder joints, extending above over the acromion processes, and internally over the outer half of the clavicles. Continuing into the axillae, it involved the greater part of the skin in these fossae, terminating below at the level of the fifth rib. A considerable amount of hyperaemia was present, and pressure with the finger revealed the fact that the ecchymosis was not uniform, but here and there left portions of the skin unaffected. THE IMTIAL RASHLS OF SMALL-POX. 5 Numerous purpura? in the groins and lateral thoracic regions, some of which were of considerable size ; none on the extremi- ties, or inner surfaces of the thighs. Temp. 1C0.5°. General symptoms good. Pulse firm and strong. Course of Disease.—Pocks numerous but discrete, and pro- ceeded regularly to pustulation. Ecchymoses faded gradually leaving a yellowish-green discolouration of the skin over the shoulders, and in the axillae. Desiccation early. Rapid recovery. No complications. The first ca3e affords an excellent example of the condition under considerate. The exanthem occupied the most usual situations, viz., the anterior abdominal and lateral thoracic regions, together with the inner surfaces of the thighs. On superficial examination the ecchymoses were not at first evident, becoming so, however, on the following day, when the erythema had faded. The second case presents several points of interest. The initial symptoms were so severe, and such was the intensity of the prodromal exanthem, and extent of the cutaneous extrava- sations, that the gentleman who attended the case, though poss- essed of considerable experience in small-pcx, believed it to b 3 of the true haemorrhagic variety. On first seeing it I expressed a similar opinion. The remarkable extent of the ecchymoses in the neighborhood of the axillae was certainly very misleading, more especially, as it was accompanied by an eruption of pur- pura in the thoracic and lower abdominal regions. Indeed, in such a case, within the first 48 hours, it might be almost impos- sible to decide definitely, whether we had to deal with a simple prodromal exanthem, or with the initial symptoms of genuine hemorrhagic 3mall-pox. In the latter the exanthem would pro- bably be more general, of a deeper hue, and present a greater number of petechias, and even on the second day haemorrhage might take place from the mucous membranes. The two following casas are th-j only instances which have com? under my notice of a simple erythematous rash unaccom- panied by petechiae. Oddly enough, both subsequently became hemorrhagic ; in one the extravasations were limited to the 6 THE INITIAL RASHES OF SMALL-POX. pocks upon the legs, and a good recovery was made ; the other proved to be of the true haemorrhagic variety. Case III.—J. M., aet. 25. Vaccinated, one good mark. Ad- mitted, January 28th. Initial symptoms not severe. A diffuse erythematous rash existed over abdominal and thoracic regions. According to patient's statements, it had been brighter, and was fading at time of admission. It was unaccompanied by any purpuric spots, either in the regions affected, or in other parts of the body. Eruption discrete, papular, very scanty upon the abdomen. Course of Disease.—Progressed favorably, but presented peculiar characters, inasmuch as extravasation took place about the pustules on the legs on the 5th day, and was followed by a subsidence and rapid desiccation of the eruption. Case IV.—A. McR., aet. 19, a strong Scotch girl. Unvac- cinated. Admitted January 31st, from the general wards, where she had been under treatment during two weeks for some ill-defined affection. Initial symptoms very severe. There was on admission a deep erythematous rash over the whole body, most intense on the abdomen and thorax, and unaccompanied by ecchymoses. Face and arms of a deep red colour. Papules very general. Temperature 103.39. Pulse, 116. Respira- tions, 22. Feb. 1st, erythema fading on the trunk. Course df Disease.—This case proved to be of the haemorr- hagic form, and is interesting from the fact, that a simple erythematous rash was among the initial symptoms, the extra- vasation into the skin not occurring until the third day of the eruption, when the erythema had disappeared. Patients are usually sent to hospital on the third or fourth day of the disease. The initial rashes are often among the earliest symptoms, and may, if of the simple erythematous variety have disappeared, whereas, if purpuric in character traces of them will remain for days. In some instances, a fading erythema was noticed on admission ; in others, no history of any could be obtained, though the petechiae were present. The following cases illustrate this: THE INITIAL RASHES OB" SMALL-POX. 7 Case V.—M. C, aet. 15. Vaccinated, one good mark. Ad- mitted Jan. 18th. Initial symptoms severe, well-marked rigor. Temp. 102 2°. Pulse 102. Resp. 24. Only a few papules visible on the face and about the wrists. Petechige on back, sides, groin, and legs. Those upon the back were scattered and *mall, on the abdomen they were thickly set and large, especially in the hypogastric region. On the lower limbs they existed as small circular spots of dark red colour on the inner surface of the thighs and the extensor surfaces of the legs. In this case I could obtain no history of an erythematous rash. Course of Disease.—Favorable. Eruption discrete ; desic- cation early; recovery rapid. Case VI.—T. C, aefc. 20. Vaccinated, one good mark. Ad- mitted Feb. 16th. Initial symptoms moderate. Eruption discrete, in the papular stage. Abundant petechiae in the lower abdom- inal region, and in the groins ; also a few over the serrati magni muscles. None upon the thighs, or legs. No trace of an erythematous rash, nor could it be gathered from the statements of the patient that one had existed. Course of Disease. General symptoms good; pustules formed normally. Purpura faded within the first week. Case VII.—T. B., aet. 22. Vaccinated, one good mark. Admitted December 31st. Eruption discrete and in the vesicular stage. Temperature 98.4.° Ill since the 27th. Initial symptoms mild. Numerous small purpuric spots in the groins, arranged chiefly parallel to Poupart's ligaments, and extending internally over the recti muscles. Similar spots, though somewhat larger, existed in a line with the lower ribs, extending towards the navel. According to the statements of -the patient, on the second and third day of his illness, there was a rash on the lower abdominal region. Course of Disease.—Pustules few in number. Recovery rapid. Case VIII.—R. W., aet. 20. Vaccinated, one indifferent mark. Admitted Jan. 10th. Initial symptoms mild. A plentiful eruption on face, buttocks, and arms. A diffuse erythema pre- 8 THR INITIAL RASHES OF SMALL-POX. sent over the whole trunk, and, in a limited degree, over both elbows. Accompanying this were abundant petechias, espe- cially numerous in the groins, the lumbar region behind, and the posterior surfaces of the the thighs. Jan. 11th. Erythema had disappeared entirely. On the buttocks, back, and extensor surfaces of the arms and thighs, the pustules were collected into small groups. Course of Disease.—Pustules did not maturate fully; des- iccation early. Recovery rapid. This was the only instance in which the initial rash was present on the extensor surfaces of the joints. Occasionally the initial rash is late in appearing, and may follow rather than precede or accompany the eruption. Case IX.—II. A., aet. 28. Vaccinated, five good marks. Admitted April 3rd, with a disseminated papular eruption. Initial symptoms had been tolerably severe. April tih. At morning visit an erythematous rash, accom- panied by numerous petechias existed over the lower abdominal regions, and groins. Erythema not intense, petechias small, and closely set together. April 5th.—Rash had disappeared. Course of Disease. Pustules developed well. General symptoms good. Purpura had faded by the seventh day, leaving light brown discolourations to mark the places where they had existed.. The initial rashes in the foregoing cases, with one exception, (case IV), occurred in the discrete form of variola, and though recovery, as a rule, was rapid, none of the cases could properly (unless, perhaps, case VII), be classed as varioloid. One of the last patients admitted into the Hospital afforded an instance of an initial purpuric rash in the mildest possible form of small-pox. Case X. W. A , aet. 17. Vaccinated, two good marks. Admitted June 2nd. Eruption scattered, pustule? few in num ber, not more than 30. On admission an abundant purpuric •eruption, acco.npanied by a slight degree of erythema, existed THE INITIAL RASHES OF SMALL-POX. 9 over the lateral thoracic regions, the abdomen, and inner surfaces of the thighs. Between the navel and the pubis was a large superficial ecchymosis, about half the size of the banc}, extending in a somewhat semi-lunar form. The purpuric spots in the groins were of large size, and arranged chiefly parallel to Poupart's ligaments, at a distance from |"-1" above them. A few isolated ones extended over them to the anterior region of the thighs,while others existed on the upper third of the inner surfaces. Course of Disease.—Up on the 5th day. The last case observed is interesting from the fact that the initial rash took the form of an extensive urticaria. Case XI.—A. E., aet. 29. Vaccinated, one bad mark. Admitted April 7th. Initial symptoms had been moderate. On examination an eruption was found upon the trunk and extremi- ties which presented the usual characters of urticaria, viz , eleva- ted reddened patches of unequal size, in some places arranged linearly, in others forming broad areas, light in the centre, deep red at the periphery. On the trunk they were chiefly grouped together, being most abundant on the anterior surface, while on the extremities they were arranged in raised lines, the typical wheals of the affection. In the neighbourhood of the ankles and back of the feet they were of large size, and showed better than anywhere else the characteristic features of the eruption. The patient complained of sensations of heat and itching, and wherever he scratched violently a fresh outbreak occurred. A few papules of variola were noticed on the face, and about the wrists. April 8th -.—Urticaria persists, though not so marked on the trunk. April 9th.—Has disappeared from the trunk, and greater part of the extremities ; a few only remain about the ankles. At the evening visit no trace of urticaria could be found. Pocks few in number, not more than 60. Patient got up on tho 10th, and remained in the hospital twelve days. Simon* expresses himself as somewhat skritical about the • Loc. Cit. 10 THE INITIAL BASHES OF SMALL-POX. occurrence of genuine urticaria as a prodromal exanthem in small-pox, believing that most of the cases described as such should be referred to the macular or measly rashes. I think there can be no doubt about this case, the wheals were too characteristic to allow of mistake. A genuine case is also reported by Starck, (Arch. d3r Heilkunde, Vol. iv.) in which the urticaria appeared and disappeared in different parts of the body in the course of the disease. Simon calls attention to the fact that the simple macular and diffuse rashes are not unfrequently accompanied by sensations of heat and itching, which in the case of the former might cause them to be confounded with urticaria. The frequency with which the prodromal exanthems occur is apparently subject to considerable variations, depending, perhaps, on the type of epidemic, which has exhibited marked changes within the present century. The epidemic which has raged in so many parts of the world since 1870 has been of an unexampled severity, owing, in great part, to the large proportion of haemorr- hagic cases, and has been further marked by the very general prevalence of the prodromal exanthems. That no reference is made to them by so many of the old authors, and that such scanty notice is found in the more modern works, can only be explained on the supposition of their infrequence in former epidemics. In 1088 cases of small-pox observed by Knecht, (Arch. f. Derm. u. Syph. iv), prodromal exanthems occurred in 104 or about 10 per cent. In 1413 cases of Scheby-Buch there were 237 instances of these rashes, or 16f per cent. In 81 cases under my care there were 11 instances, i. e., about 13 per cent. Simon does not give the percentage in his cases, but from the number recorded in his series of articles on the subject it must have been large. The localities most commonly affected are the anterior abdom- inal surface, and the inner surfaces of the thighs. Thus, in Scheby-Buch's 237 cases these regions were affected in 190 instances. In the few instances which have come under my notice, the lateral thoracic areas were more frequently the seat / THF, 1NITTAL RASHES OF SMALL-POX. 11 of the exanthem than the inner surfaces of the thigh ; nor did I observe any cases in which the rash was absent from the anterior abdominal regions. Many cases are recorded in which the exanthem remained limited to the regions of the joints, (elbows and knees), or the backs of the hands, the axillae or the inner surfaces of the thighs, without the simultaneous affection of the abdominal surfaces. When confined to the extremities, both upper and under are implicated as a rule, the rash is rarely limited to either alone. Occasionally they are unilateral, in which case they are always of small extent. The general erythematous rashes are rare ; in Scheby-Buch's 237 cases there were only 14 instances. Neither of the above mentioned authors state the proportion between the simole erythematous rashes and those accompanied by purpuric spots. Indeed, in the reports of many of Simon's cases no mention is made of their presence or absence. In the 11 cases which have come under my notice the latter greatly exceeded the former, the proportion being 8 : 3. A consideration of the diagnostic and prognostic value of the initial rashes is of great interest: for, of course, the worth of a symptom is in direct ratio to the amount of knowledge it gives us in deciding upon the nature of a case, and forming an opinion as to its probable issue. From the fact that a patient is rarely or never sent to Hospi- tal until the characteristic eruption has made its appearance, i. e., on or about the fourth day of the disease, none of the above cases were of any service to me in forming a diagnosis ; that had already been made. In any case the value of the initial rash depends greatly on the date of its outbreak, which extends from 1 to 5 days before the appearance of the eruption. In the majority of cases it comes out on the second day, and if of noticeable extent would consequently be of diagnostic importance, more especially if accompanied by petechias. Indeed, Cursch- mann* states that in the initial stage of the disease there is only one pathognomonic symptom, and that is, the haemorrhagic exanthem situated in the triangle of the thigh. The petechial rash is of much greater diagnostic value than the simple erythematous, and a case of fever presenting an eruption of » Loc. Cit. 12 THE INITIAL RASHES OF SMALL-POX. purpura in any of the above oft-named localities on the second or third day should be looked upon with grave suspicion. Simon maintained that even before the onset of the fever, and prior to the general disturbance of the system, the diagnosis could be determined by the appearance of the characteristic prodromal exanthem. This is going very far; still, he has recorded two such cases, and quotes two others. In his 38th case there was an initial rash in the inguinal regions, and about the anus, for tho greater part of a day before the onset of the fever and constitutional disturbance. The former set in with a rigor, and was followed by a great extension of the exanthem. It is to be remembered that prodromal rashes are not peculiar to small-pox, though, no doubt, they occur with much greater frequence in this disease than in any other. Scheby-Buch states that he has met with simple erythematous rashe3 in the initial stage of tonsillitis, typhoid fever, and measles, presenting the sams dis- tribution, and differing only from those of small-pox in intensity and extent. Purpuric rashes, however, are excessively rare, if they occur at all, in the first stage of the ordinary febrile affec- tions ; so that they are of chief moment among the prodromal exanthems of small-pox, and may be regarded as affording a tolerably certain basis for diagnosis. The general erythema, which is met with in a limited number of cases, is usually of the diffuse form, and, occurring on the second or third day, might be confounded with scarlatina. The points to be attended to in the diagnosis would be, the mode of attack, which in the two affec- tions presents certain differences ; the colour and extent of the exanthem, which is brighter in scarlet fever, and, as a rule, much more extensive ; and lastly, the presence of minute pete- chias in the inguinal regions would be in favor of small-pox. The diffuse erythema accompanied by numerous petechiae which occurs on the second or third day in cases of malignant small-pox, could not be distinguished from ths similar condi- tion met with in those rare cases of haemorrhagic scarlatina. The presence of an epidemic of one or other disease would be the only means of deciding the nature of the case. Simon regards the prodromal exanthems as eminently charac- THE INITIAL RASHES OP 8MALL-P0X. 13 teristic of small-pox. and among his cases, which are all of great interest, we met with some of special significance. Thus in the case of a girl who had had a rigor, fever, pains in the back and head, and initial rashes in several places on the extremities, though no eruption followed, the diagnosis of small-pox was made, and confirmed by the fact thit the sister, who had acted as nurse, took the disease badly. He also records cases in which, with the outbreak of the prodromal exanthem, the temperature sank and the general symptoms subsided, coming on again with the appear- ance of the eruption, and finally subsiding on its completion. Whether from a diagnostic point of view we agree with this author's estimate of the value of these initial rashes or not, there can be very little doubt that in a limited number of instances they may be of considerable service, in enabling us to decide upon the nature of a case, and therefore take early precautionary measures for the isolation of the patient. Of the value of the initial exanthem in the prognosis of the disease the opinions of authors differ. Simon makes the general statement, that, " among the severe and fatal cases of variola just as many were accompanied with prodromal exanthems as those without," and he regards their prognostic significance as nil. It struck me, however, in reading over his cases that the number of deaths was comparatively small. Knecht in 115 fatal cases of small-pox met with the initial rashes only 15 times, and as this observer noted 104 instances, his experience supports the view that they are, on the whole, of favorable significance. He states that up to the 30th year they are of no prognostic value, but after this age they indicate a severe course, while in old age they are almost invariably of evil omen. Of Scheby-Buch's 237 cases. 37 died ; i. e., about 15 per cent. His experience does not bear out Knecht's supposition, that after the age of 30 the prodromal exanthems are of serious import. Curschmann believes that the simple macular and erythematous rashes almost invariably precede varioloid, and states, that in many instances the number of pustules was in inverse ratio to the extent of the initial rash. On the other hand, the purpuric rashes, in his experience, especially those in the 14 INITIAL KAEHES OF SMALL-PoX. regions of the groin, are almost always followed by variola vera. The 11 cases above reported do not support this view ; the only fatal case among them was preceded by a simple erythematous rash of considerable extent and the other instance of an erythe- matous rash was not followed by varioloid. Not one of the eight instances of initial purpuric exanthem proved to be variola vera ; they were all followed by the milder forms of the disease, two of them being varioloid. Trousseau* states that while in natural small-pox the scarla- tiniform rashes accompanied with purpuia constitute alarming symptoms, they do not lead to an unfavorable prognosis in the modified form. Professor Seef believes that the scarlatiniform and rubeolic r ashes precede as a rule benign cases, the haemorrhagic variety the severe. HebraJ holds that the appearance of the rash upon the abdomen is not " necessarily to be regarded as an unfavorable sign. These cases do, however, more often terminate badly than in recovery, and particularly when the affection passes beyond mere hyperaemia into haemorrhage, when, in fact, a purpura rather than an erythema shows itself on the abdomen and on the thighs." On the whole the presence of initial rashes in the majority of cases indicates a favorable termination, but it is evident from the foregoing statements that we cannot as yet lay down definite rules with reference to their prognostic value. In forming an opinion we must not rely on the nature and extent of the exan- them alone, but take into account the general symptoms, not. as Sydenham says " go by the external appearance only." The prodromal exanthems it may be remarked occur with much greater relative frequence in men than in women. A debated point has been, whether the small-pox eruption ever appears on the regions which have been affected with the initial rashes. In very many instances these parts present an entire » Loc. Cit., Vol. IT, p. 71. | Journal cL Medicin, Juin, 1875. X Skin Diseases, Vol. 1, p. 58. HEMORRHAGIC SMALL-POX. 15 immunity, which may be owing to the fact that the rashes occupy just those regions most commonly spared by the small- pox pustules. The lower abdominal and inguinal regions are rarely the seats of an abundant eruption, and often remain free, while the rest of the surface is involved to a considerable extent. I have several times seen isolated pustules develop in the hypo- gastric region after an initial rash. Most authors refer the phenomena in question to disturbances in the vaso-motor nerves, caused, Simon supposes, by hyperae- mia of the cord, which affects injuriously the vascular nerves, passing down from the medulla. " If," in his own words, " the affection of these nerves is wide-spread an erythema universale follows, while if limited to certain groups we notice circumscribed erythemas : and, as the chief site of the affection (hyperaemia ?) of the spinal cord is in the lower dorsal and lumbar regions we have in the majority of cases the erythema confined to the lower parts of the trunk." II. HEMORRHAGIC SMALL-POX. True haemorrhagic small-pox occurs under two conditions ; in one the characteristic symptoms come on early, either with or following close upon the prodromata; there are extensive cutaneous extravasations, with haemorrhages from the mucous surfaces, and death ensues with a terrible certainty in from two to six days. This is the purpura variolosa of authors, the petechial, malignant, or black small-pox. In the other, the case progresses as one of variola vera, and it is Dot until the vesicu- lar or pustular stage that haemorrhage takes place into the pocks, and in some cases from the mucous membranes. This, which is almost as invariably fatal as the former, has been called by some It) HEMORRHAGIC SMALL-PuX. writers, variola hoemorrhngica puttulosa, indicating that the haemorrhages occur at a later period of the disease. The epidemic which has raged in this city for the past five years has been remarkable for the prevalence of this variety of the disease ; and the present paper is based on 27 cases, 14 of which came under my own observation, chiefly at the General Hospital, while the remaining 13 were under the care of my predecessor, Dr. Simpson, to whose kindness I am indebted for permission to utilize them. The clinical history of the disease is well exemplified in the reports of the following cases. I.__A. T., aged 6J, unvaccinated. Admitted at 2 p.m., July 14th. Had been ill since the afternoon of Monday, the 10th, with fever, severe pains in the back and head and vomiting. Patient seen at 8.40 p.m. Pulse 144, tolerably firm; tem- perature 105c ; respirations 20, the rythm broken by an occasional deep inspiration, or a series of shorter ones. Pupils dilated. Slight delirium. Tongue thickly coated, white, edges red. General cutaneous surface of a dusky red colour, especially marked in the face, and by careful inspection an exceedingly fine papular eruption was discovered, most evident on the face, less so in other parts. Scattered over the whole skin were numerous ecchymoses, from 1 to 3 lines in diameter, and of a dark red colour. They were most abundant about the neck, in the submaxillary regions, scattered on the extremities. A thickly set group existed over the left biceps. Ordered quinine grs. x, at 9.00. Very restless all night, raving and shouting ; tem- perature at 3 a.m., 104 1, and at this time he had a second ten "•rains of quinine, shortly after the administration of which he vomited a little blood. 15th.—9.15 a.m—Pulse 140. not so full ; temperature 104y ; respirations 18, and still irregular. Is sensible, but will not take nourishment. Ordered a cold pack. At 12 a.m., temperature 103Q. 5.30 p.m., pulse 144 ; temperature 104.2U ; respirations 32. On the back are many elevated wheals, and on the summit of these small groups of vesicles exist. The fine punctiform extravasations almost universal on the skin of the trunk. Lips HEMORRHAGIC SMALL-POX. 17 dry and cracked. Tongue darkly coated. Does not complain of his throat. Ordered a cold pack at 6 p.m., and quinine gr. x, at 9 p.m. To have morphia if sleepless. lQth.—Has been very restless all night, in spite of two draughts of morphia (£• gr. each). Pulse 140, weak but regular; temperature 103.2°; respirations 18, more regular Great restlessness and jactitation. The scattered papules are uniformly haemorrhagic, and the wheals on the back and side, which yesterday were only hyperaemic, are now purpuric. At least one half of the cutaneous surface is the seat of extra- vasation and the free portions are of a dusky-red colour. Purpuric spots numerous about the face, and a few exist beneath the conjunctiva. The urine passed through the night is clear, though scanty. Has passed a considerable amount of blood per rectum, and also a small quantity of bloody urine. Surface of body darker, extravasations appear deeper and more abundant; on exposing the trunk, nothing is noticeable en the skin but the deep plum colour. Restlessness extreme, and slight delirium. According to the nurse he became easier after 3 p.m., passed •more blood from the bowels and bladder, and died at 5.30 p.m., having been in hospital a little over. two days. Duration of illness about six days. The above may be taken as a fair example of the disease in question, but it may occur in a more aggravated form, killing in from three to four days, and before the eruption has become at all evident. One of the worst cases which came under my notice was of this description, and, as I saw it very frequently from the beginning to the close, I will give a short account of it. II. On the evening of Thursday, Oct. 24th, 1874,1 was sent for to see A. N., aged 22, a stout, well-built, young Englishman. I found him in a high fever, complaining of intense pain in the lumbar and praecordial regions, and incessant vomiting. He stated that he had been to the theatre the previous night feeling in his usual health, but that on awaking this morning he felt unwell, had a headache and nausea, and was unable to attend 2 18 HEMORRHAGIC SMALL-POX. to his business. He believed it to be biliousness, to attacks of which he was, at times, subject. On the left arm were two scars of an old vaccination. 25th, 9 a.m. — Found him in the same condition, having, passed a very bad night. The vomiting and pains continue. Temperature 101°; pulse lit?, full and strong; face flushed, skin of chest erythematous. The praecordial pain was specially grievous, and I gave him an injection of \ a gr, of morphia in this region. 12 a.m.—Is a little easier, but the retching continues. 4. 15, pm.—Skin of the trunk very hyperaemic, and a few isolated ecchymoses were noticed along the lower margins of the chest. 9. p.m—Scattered srots of purpura exist also in the groins. Condition much the same, retching not quite so frequent. Pulse 112 ; temperature 1<>2 4°. 26th — Passed a restless, uneasy, night. Skin of trunk much congested, that of extremities less so. Ecchymoses have extended, and are more numerous. In consultation with Dr. Howard in the afternoon, my suspicions were confirmed, and the diagnosis of small-pox made. On careful inspection a few small papules were discovered upon the wrists and forehead, n^ar the roots of the hair. Still complains of the dull, aching pain in the back, and the vomiting continues every 15 or 20 minutes. In the evening he was removed to the small-pox wards of the General Hosjital, and placed under the care of Dr. Simpson shortly after arriving there he vomited a little blood. 9. p.m.—The skin of the trunk is now almost univer- sally purpuric, and the extravasations are extending on the extremities. Pulse 124, soft and compressible ; respirations 26 interrupted, every filth or sixth inspiration deeper than the others. Complains a little of his throat; soreness due probably to the constant retching. Sr1 till complains of the dorsal pains. A hypodermic injeccion of morphia was given in the lumbar region 4 21th.— Passed a vstless night. Haematuria and melaena towa.di moiniusr. ilaematemesis at intervals. Considerable HEMORRHAGIC SMALL-POX. 19 oozing took place from the puncture of the hypodermic needle. General symptoms a little improved. The lumbar pains much relieved. Cutaneous haemorihages are extending on the extremities. Pulse 140, and small; respirations 34 ; temperature 100.2°. Haemorrhages from the bowels, sto- mach, and urinary passages continued through the day, and the symptoms became aggravated. 6 p m.—Pulse 140, and almost imperceptible ; respirations between 40 and 50, and interrupted. The mind, which up to this time had remained clear, now began to wander. The greater part of the skin of the body is ecchymotic. The face is somewhat swollen, dark purplish red in colour, and on pressing with the finger it is seen that colouration is due chiefly to the extravasations, which have also occurred round the orbits. The conjunctivae are swollen and black, haemorrhage having taken place beneath them; the corneae appear sunk in dark red pits, giving to the patient a frightful appearance. The whole trunk is of a deep plum colour, hardly a trace of clear cuticle remains- The purpuric spots are thickly set, and between them are fine punctiform extravasations. On the extremities the petechial eruption is more scattered ; still, even here, more than two- thirds of the cutaneous surface is the seat of haemorrhage, and the whole skin is hyperaemic. The most careful inspec- tion fails to detect any papules, even about the wrists or fore- head, where on Friday evening they were appearing. Just after midnight the respirations became more prolonged, pulse quite imperceptible, extremities cold, and death took place at 12.45 a.m.,on Monday morning. The whole illness lasted hardly four days. With the exception of two, all the cases of haemorrhagic small-pox which I have observed were of the above type—:!ie patients died before the characteristic eruption developed, or the cutaneous ecchymoses completely cloaked it. In two instances the extravasations did not corns on in the initial stage, but 'hir- ing the development of the pocks.— V. hemorrhagica puu*t losa. The following is a brief history of one of these cases : III. A. McR.,aged 19, a well-built Scotch girl, unvaccinjitcd. Admitted January 31st, 1875, from the general wards, where 20 HEMORRHAGIC SMALL-POX. she had been under treatment during two weeks for some ill- defined affection. Only six weeks previous to this she had been discharged from the Hospital convalescent from typhoid fever. In the general wards she had suffered with the usual initial symptoms of the disease. On admission, temperature 103.3 ; pulse 116 ; respirations 22. A deep erythematous rash exists over the whole body, most intense on the abdomen and thorax, unaccompanied by ecchymoses. A papular eruption is present on the face, thorax, and arms, and is just appearing on the legs. Patient dull, heavy, and does not respond to questions. Feb. 1st.—9 a.m.—Temperature 102° ; pulse 110 ; respira- tions 26. Has passed a restless night; delirious at times, vomiting continues at intervals. Erythema persists. 6. p.m. Pulse 112 ; respirations 32 ; temperature 103.4°. Towards the afternoon the nurse states that a small amount of blood was vomited, and she also passed a little from the bladder and bowels. The eruption has extended, many of the papules have now vesi- cular tops. The erythema is not nearly so bright. 2nd., 9 a.m.—Temperature 102.3°; pulse 100 ; respir- ations 26. The haematemesis has continued at intervals through the night. Slight haematuria. The bright erythematous rash has gone, the skin is now of a dusky livid hue. 6. p.m. Tem- perature 103.4° ; pulse 60, and intermittent every fourth beat, but is tolerably full; respirations 28. Cutaneous extravasations noticed for the first time, chiefly about the vesicles on the upper part of the chest, and on the legs. In many the haemorrhage has occurred into the vesicles. The haemorrhages from the mucous membranes have continued at intervals. 3rd, 8.30 a.m.—Temperature, 101° ; pulse, 112 ; respira- tions, 24. Most of the vesicles on the legs are now haemorr- hagic, and the ecchymoses have extended in the abdominal region. The vomiting is still a very troublesome symptom. 5.30 p.m.—Pulse, 120, not irregular ; temperature, 102° ; respirations, 24. On the face and arms the pocks are develop- ing slowly, and only a few in these parts are haemorrhagic ; melaena, haematuria and metrorrhagia (slight). Takes nourish- ment well. HEMORRHAGIC SMALL-POX. 21 4th, 9. a.m.—Pulse, 120 ; temperature, 101.2°; respirations, 28 ; say3 she feels better ; vomiting has stopped. Blood in the urine passed through the night. Pocks are not developing, look dark, and the majority of them are haemorrhagic. 6. p.m.—Pulse, 124 ; temperature, 102°; respirations, 36. The peculiar variolous odour very evident this evening. 5th, 8.C0 a.m.—Pulse 116 ; temperature, 100°; respirations, 18. Slept well, and says she feels much better. Melaena and haematuria through the night. Pocks much flattened at the top, and of a dark colour ; skin between them livid, and covered with minute extravasations. 6 p.m. Pulse, 112, very weak and intermits every tenth beat; temperature, 101°. Is very dull and heavy, and does not care to take nourishment. Not much change noticed in the eruption, the majority of the pocks look like elevated haemorrhagic papules, no umbilication in any of them. Through the evening she lost a good deal of blood from the vagina, got much worse towards morning, and died at 7 a.m., on the 9th day of the disease. The details of the above cases furnish a tolerably accurate picture of the clinical features of this truly terrible disease, and I shall now proceed to make some general remarks upon its symptoms, diagnosis, etiology, and pathology. Symptoms—Satisfactory evidence is wanting as to the period of incubation in haemorrhagic small-pox. Most writers state that it is the same as in the ordinary form, i. e., 12 to 14 days. Zulzer,* however, states that it is shorter, having determined it in 9 cases to be from 6 to 8 days. In the majority of instances it is unaccompanied by any symptoms—perhaps slight languor and malaise—the disease breaking out suddenly in all its vio- lence. So it was in the case above reported of the young Englishman. The day before the attack he had walked round the mountain, (5 miles). The symptoms of the initial stage are those of the pustular form ; indeed, the disease may be regarded as an intensified and prolonged initial stage, combined with a remarkable tendency to cutaneous and mucous haemorrhages. The fever, pain in the back, and vomiting—that triple com- • Berliner klinische Wochenschrift, 1872. 22 HEMORRHAGIC SMALL-POX. bination, which we look upon as almost pathognomonic of small- pox—are the prominent symptoms throughout, even after the characteristic extravasations appear. The fever is usually moderate, varying from 101° to 103° ; only once did I observe a temperature of 105°. It is frequently ushered in with a rigor, or series of chills. The pain in the back is perhaps the most distressing symptom to the patient, and persists longer, and is more constant, in this than in the pustul- ar form of the disease, continuing in some instances to within 12 hours of death. All of my patients complained of it, and when asked to localize it placed the hand over the sacrum. Praecordial pain was also common, in one or two cases much more severe than the dorsal. Headache is rarely absent during the first days of the fever. Vomiting constitutes a very troublesome symptom, and, in my experience, proves exceedingly obstinate, much more so than in ordinary small-pox. It was very unusual for patients with the latter disease to vomit after the appearance of the eruption, while, in cases of the haemorrhagic form, it continued for 3, 4, and 5 days. Dry retching was frequently combined with it, and seemed particularly distressing. Early on the second day, or even in the most severe cases on the evening of the first, a bright scarlatiniform redness spreads over the skin of the trunk, sometimes extending to the extremi- ties, but not often involving the face. In some instances this is not universal, but confined to the lower abdomnial or lateral thoracic regions. It is difficult, or even impossible, to dis- tinguish this general or localized erythema preceding haemorr- hagic small-pox from the similar condition which, as an initial rash, so frequently ushers in the ordinary or modified forms of the disease. For a time simply hyperosmic and disappearing on pres- sure, the character of the rash quickly alters by the occurrence of numerous extravasations, which begin commonly in the groins and lateral thoracic areas. At first punctiform or macular and concealed by the general redness, they soon increase in size and on the trunk form irregular patches, ranging in size from a six-pence to a penny, while on the extremities and face they remain discrete. In 36 hours the ecchymoses may h£ve devel- HEMORRHAGIC SMALL-POX. 23 oped to such an extent as to involve fully two-thirds of the cutaneous surface. The skin of the trunk is now of a rich plum colour, and by pressure very slight difference is made in the intensity. Haemorrhage into the tissue of the eyelids and beneath the conjunctivae is common, and adds greatly to the dis- figurement of the face, already puffed and swollen. The extra- vasations deepen until the end, forming throughout the most distinguishing feature, and the one which has so justly given the name of black small-pox to this variety of the disease. True papules of variola may nearly always be discovered, if carefully looked for upon the forehead and wrists at the end of the second or upon the third day. They were present in all the cases which came under my own observation. In the most malignant form—purpura variolosa—the rapidly extending ecchymoses soon hide them, and it may be difficult or impossible even to feel them ; indeed, in several instances, I could not, post mortem, convince myself of their presence. In the other variety, v. hemorrhagica pustulosa, the eruption comes out as usual, the extravasations occurring either in the vesicular or pus- tular stage. Haemorrhage from the mucous membranes takes place in the . majority of cases, and constitutes one of the most prominent symptoms. Epistaxis is common,especially in the early stage of the disease. Hcematemesis occurs in more than half of the cases. In my experience it is not copious, but the blood is mixed with the thick mucus brought up in the constant attacks of vomiting. Melcena was noticed in about one-third of the cases ; the blood in three was tolerably fresh and bright; as a rule, however, it was dark, and mixed with the mucous discharges. Haemorrhage from the urinary passages occurred in a large proportion of the cases, and was often profuse, the blood coagula- ting in the chamber-pot. Metrorrhagia is stated to be exceedingly common in women. It was only noticed in one out of six females. Hemoptysis occurred in five cases, in one it was profuse and arterial. The sputa hawked up are frequently streaked with blood from the bronchial tubes and fauces. 24 HEMORRHAGIC SMALL-POX. These haemorrhages from the mucous membranes do not always occur. In five of my own cases (Nos. 16, 18, 20, 22, 23,) they were absent, and yet these were among the most severe and rapidly fatal cases of the disease, death ensuing on the 5th, 5th, 6th, 7th and 4th days respectively. In two, (Nos. 22, 23) post mortem examination revealed extensive haemorrhages into the mucous membrane of the stomach, intes- tines, and urinary tract. The pulse in the first days of the disease ranges from 110 to 120 beats in the minute, and is full and compressible. Gradually the arterial tension is increased, the pulse becomes more rapid, 120 to 140, small, hard, and irregular, and at last uncountable or imperceptible. The respirations are unusually increased in frequence in the early stage, without any discoverable disorder in the lungs, and are out of proportion to the intensity of the fever. In the case of a negro whose respirations the morning after admission were 32, and the temperature 101°, after examining the lungs and finding nothing to account for the acceleration, my suspicions were aroused, and on careful inspection I was able, even on the dark skin, to detect the haemorrhagic condition in and about the papules. This symptom alone directed my attention to his dan^ gerous condition, which might otherwise have escaped observa- tion, as there were no haemorrhages from the mucous membranes. An interesting, and by no means unfrequent phenomenon,was the disturbance in the respiratory rhythm, first drawn attention to by Drs. Cheyne and Stokes, consisting in a series of superficial respirations, sometimes almost imperceptible, followed by a deep inspiration. This was noticed chiefly during the last 24 or 36> hours of life. A short hacking cough was not an uncommon symptom.. Many of the patients complained of sore throat, which, in some- instances, appeared to be due to the constant gaggin^ and vom- ting, in others to a foul, horribly foetid, diphtheritic pharyngitis. Consciousness is commonly retained until near the end. In- only six cases was delirium a prominent symptom. A hyperass- thetic condition of the skin, mentioned by Zulzer* as common was not noticed in any of the cases. * Loc Cit. HEMORRHAGIC SMALL-POX. 25 In the true petechial form the patients seldom outlive the sixth or seventh day ; where the haemorrhages do not come on until the vesicular stage, they, of course, last longer. The cases upon which this paper is based died on the following days: 1 on the 3rd day; 2 on »the 4th day; 5 on the 5th day; 6 on the 6th day ; 5 on the 7th day; 4 on the 8th day ; 4 on the 9 th day. The disease, in both its forms, is spoken of as invariably fatal, and such has been our experience in the small-pox department of the General Hospital. Diagnosis.—In an epidemic of small-pox characterized by the presence of haemorrhagic varieties, there is rarely any doubt of the nature of a case of fever presenting extensive cutaneous extravasations, and, perhaps, mucous haemorrhages. Given, however, an individual case, when no epidemic was raging, and the matter would not be so easy. We must be careful, in the first place, to remember that the initial rashes, which so often precede the milder forms of the disease, may be general and purpuric, closely resembling, or identical in appearance with, those accompanying the true pete- chial variety. It might be impossible to decide definitely for 24 hours on the nature of a case of this kind, In the latter the erythema would probably be more intense, the ecchymoses more extensive, and the general symptoms more aggravated. In many instances the progress of the case would alone deter- mine its nature. The bright, rosy-red, rash appearing on the second day might be mistaken for the eruption of scarlet fever, unless the mode of onset of the disease had been carefully watched. The diagnosis between haemorrhagic scarlatina—fortunately a rare disease—and petechial small-pox offers still greater difficulties. Close inspection might discover in the latter papules about the forehead or wrists, and. I think, the characteristic odour of small-pox, which is well developed in this variety, would aid in arriving at a conclusion. Cerebro-spinal meningitis is another disease which, in some of its forms, is apt to be confounded with purpuric variola. The pains in the head and back in the latter simulate those of 26 HEMORRHAGIC SMALL-POX. meningitis, in which disease also cutaneous ecchymoses not unfrequently occur. Indeed, I have the permission of the phy- sician in charge to state that in case 25 on the list the error m diagnosis was made. I remarked to him at the post mortem examination upon the similarity of the pathological changes to those in haemorrhagic variola. The mother, who had nursed the child, a short time subsequently took small-pox, and died. With true Purpura hemorrhagica —the Morbus maculosus Werlhoffii,—this variety of small-pox has many points in com- mon. In both there are cutaneous and mucous haemorrhages, but in the former the extravasations begin on the lower extremities, the skin is not so hyperaemic, the fever not so high, and there may be oedema about the joints, diarrhoea, and ascites. Etiology.—From the table subjoined some interesting facts with reference to the general etiology of the disease may be drawn. It is most common between the ages of 15 and 30. Thus of the cases there were— Under 10 years, 3 ; between 15 and 20, 4 ; between 20 and 25,9 ; btween25 and 35,6 ; between 35 and 45,3; above 50,1. Young, vigorous, muscular persons form the majority of the victims, and this remarkable fact was noticed also in the late epidemic in Germany. (Zulzer, Ponfick). Several of my patients were above the average muscular development, most of them belonging to the artizan class. The predisposing causes mentioned by Aikman,* viz., sudden change of residence, debilitating ner- vous influences, unhealthy dwellings, were not speciallyobserved. Men appear to be more frequently attacked than women. With regard to vaccination the table shows that 14 were un- vaccinated, while 13 showed marks of a by-gone vaccination. In none was there a history of re-vaccination. That is, the whole of these cases were unprotected, for I hold that we have no right whatever to say that a man is vaccinated because he has cicatrices on his arm. The proof that these 13 were not vac- cinated lies in the fact that they died of the worst form of small- pox. No properly vaccinated person, one in whose tissues the impress of vaccina persists, can, I maintain, take small-pox. Similarly fZulzer's cases, 35 in number, all showed scars, • Glasgoio MedicalJournal, 1871, p. 60. t Loc. Cit. HEMORRHAGIC SMALL-POX. 2*1 but none of them had been re-vaccinated. Other observers state that persons without cicatrices of a former vaccination form the majority, or even all, oft he number attacked. The proportion of hemorrhagic cases has been unusually large in this epidemic, not only here but in other parts of the world ; indeed, it has been the most virulent type of small-pox 3niown since the beginning of the century. In the small-pox department of the Montreal General Hospital there were admitted from Dec. 14th 1873, to July 21st 1875, one year and seven months, 260 cases. Of these 24 died of the variety under consideration, or 9.23 per cent. Case. Age. Sex. Unvac. Vac. Day of Death. REMARKS.! 1 27 F. V! 8th Delirium. Haematemebis. 2 28 F. v\ 6th Epistaxis.Melaena. Haemoptysis. 3 29 M. Unv. 8th Delirium. Melaena. 4 53 M. V. 3rd No papules evident. Died 3J hours after admission. 5 20 F. Unv. 6th Epistaxis two days before. Slight convulsions. 6 19 M. v, 7th Haematuria. ~ 35 M. 9th Much Delirium, var. haem. pust. v2 . No mucous haemorrhages. 8 20 M. Y. 6th Delirium. Melaena, frequent. 9 19 M. Unv. 7th Haeinatemesis. Melaena. 10 24 M. Unv. • * . 8th Epistaxis.Melaena. Haematemesis. 11 25 M. Unv. 9th r Var baein. pustulosa. Haemop-tysis Old lung disease. 12 P. Yi 8th Haematuria. Melaena. Haemoptysis. 13 23 M. ..... 7th Epistaxis. Haemoptysis. TJJ4 22 M. T* 4th Haematuria.Hsemoptysis. Melaena. 15 20 M. V 9th V. heem. pustulosa. Haematuria. Haematemesis. 16 21 M. V, 5th No mucous haemorrhages. ' J7 19 F. Unv. 9th " V. haem. pustulosa. Haematuria Haematemesis. 18 44 M. Unv. .. 5th No mucous haemorrhages. 19 24 M. Unv. 5th Haematuria. Metrorrhagia. ' Delirium. No mucous haemorr- 20 36 M. v, 6th hages. Haematuria. Haematemesis Mel- 21 6 M. Unv. .... 4 th aena. 22 35 M. V. 7 th Delirium. No mucous haemorr-hages. 23 16 M. Unv. 4th No mucous haemorrhages. " Haematuria. Haematemesis.Ha&- 24 30 M. Unv. 7th „ moptysis. 5 25 4 F. Unv. , . 6th Haematemes-is. 26 36 M. Unv. 6th Haematuria. Melaena 5 t 27 6 M. Unv. 5th Haematuiii. Haematemesis. • The figures indicate the number of scars. + Cutaneous extravasations occurred in all. 28 HEMORRHAGIC SEALL-POX. Pathology—The condition of the internal organs in this disease has received a good deal of attention within the past few years. The remarks which I shall here make are based upon seven carefully performed autopsies.* The prominent characteristics in all were the haemorrhages into the various tissues and organs. The blood during life was carefully examined in six cases, but no change of importance noticed in the corpuscles. Post mortem it was dark in colour and generally fluid. In the meninges of the brain scattered ecchymoses were noticed in five instances. The venous sinuses of the dura mater and the vessels of the pia mater were full. In cases 21 and 22 thin coagula of blood existed on the surface of the pia mater. The brain appeared normal, the consistence remarkably good. In case 22 there was a small clot in the right ventricle. The spinal cord was examined in one instance, when nothing abnormal was found. On the pericardium maculae were present, often quite large on the visceral layer along the tract of the coronary vessels. The heart substance was firm, dark in colour ; in several instances minute ecchymoses were observed on the endocardium, and in the muscular walls. Both visceral and parietal layers of the pleura contained ecchymoses in 6 cases. The lungs were crepitant, and^contained much blood in the posterior parts. In case 23 there was a patch of catarrhal pneumonia. In five instances apoplectic spots were found, none of them larger than a walnut. The spleen in all was firm, about the natural size, in two a little enlarged. On section the substance was compact, smooth, of a dirty-purplish red colour, and in six of the cases the Mal- pighian corpuscles were remarkably enlarged, appearing as round white bodies on the dark background of the pulp. The kidneys appeared of normal size. Ecchymoses on the capsule common; in one instance a thin clot existed upon the organ. The consistence of parenchyma was good. In three cases minute haemorrhages had taken place into the substance. * For two of these I have to thank Sister Rosalie, apothecary at the K C Civic Small-pox Hospital, who kindly informed me when any of these casea occurred. HEMORRHAGIC SMALL-POX. 29 The vessels as a rule were full. The pelvis of th3 kidneys in lour instances were plugged with dark clots, which extended up into the calyces, and down the ureters. In all ecchymoses were present on the mucous membrane. In the mucous membrane of the bladder small haemorrhages were met with on five occasions. In case 21 the walls of the whole organ were uniformly infiltra- ted with blood, not a trace of normal tissue could be seen on section. The liver in five cases was of normal size, unusually dense and firm, lobules moderately distinct, of natural colour, and con- tained a good deal of blood. In two cases it was large, pale in colour, very friable, and on examination proved fatty. The gen- eral condition in both these cases accounted for the state 01 the liver, one had suffered from chronic disease of the leg, the other was a drunkard. Ecchymoses upon the capsule were common. The mucous membrane of the stomach in all the cases showed an enormous number of extravasations, some small and capillary, others as large as a bean, and projecting on the surface. Similar appearances were found in the small intestines ; in two instances the ecchymoses were most abundant in the ileum, in the others the upper region of the bowel was most affected. Peyer's glands were swollen and prominent in four instances. In the large bowel the extravasations were only noticed in three cases. In two instances the mesenteric glands were uniformly infiltra- ted with blood, looking like dark-purple grapes. Extravasations occurred in all the cases in the retro-peritoneal tissues, about the aorta, along the iliac arteries, and about the lumbar nerves. In most they were small and confined to the adventitia and parts about the vessels, in one, however, quite a large suggillate was found in the region of the right psoas muscle. Similar appearances were noticed twice about the thoracic aorta. Such are the chief pathological changes in the internal organs, and they correspond pretty closely to those described by Ponfick* in the Berlin epidemic. In addition to the haemorrhages, the firm, dense condition of the heart and abdominal glands seems peculiar, and stands in marked contrast to the appearances of these organs in variola vera, in which they are swollen, soft Uwiiner klinische Woohenschrift, 1872. 30 HEMORRHAGIC SMALL-POX. and friable, and in that state of cloudy swelling common to pro- longed fever. So impressed is Ponfick with the pathological and clinical differences between these extremes of small-pox, that he is inclined to group them as distinct diseases. But, just as transitions are met with clinically between the macular haemorr. hagic form and that in which extravasations take place in the vesicular and pustular stages, so also, I think, in a more extended series of post mortems appearances would be found intermediate between the extremes, and where the disease had lasted any time the same pyrexial changes would occur. Indeed, Cursch- mann* states that he has noticed them in variola hemorrhagica pustulosa. On the intimate pathology of this disease I can offer no sug- gestion. We are, as yet, profoundly ignorant of the conditions of its genesis, and do not know whether it depends on the in- tensity of the poison or the extreme susceptibility of the patient. Most histologists are agreed that in these purpuric disorders the red corpuscles pass through altered or thinned and not ruptured vessels, but as to the causes of this general diapedesis, as the process is called, we have no data upon which to form a judgment. The treatment of the disease is eminently unsatisfactory, the patients almost invariably die. A few instances are recorded of recovery from variola haemorrhagica pustulosa. All the usual medicines i dicated under these circumstances were tried, gallic acid, ergot, turpentine, acetate of lead, &c, without the slightest benefit. Quinine was used in large doses, and in three cases I used the cold pack. Since the closure of the wards I have met with an article in the Glasgow Medical Journal by Mr. Aikman, formerly assistant medical officer at the Hampstead Small-pox Hospital, in which he recommends strychnia in large dose3, and states. that under this treatmsnt many of these cases recovered. He gives as much as a drachm and a half of the liquor strychniae. in the twenty-four hours in severe cases, combined with iron and quassia. * Ziemssen's Encyclopedia, Vol. II., Art. Small-pox o 387 Loc. Cit. * *' A FORM OF HEMORRHAGIC SMALL-POX. Six cases of a modified haemorrhagic form came under my notice, which present common features and peculiarities, and are, I think, worthy of record. They were all characterized by haemorrhages into and about the pocks—chiefly those of the lower half of the body—in the vesicular stage. This, instead of being as it was at first regarded an ominous symptom, was followed by abortion of the eruption and speedy recovery. The following was the fourth case observed : J. G., aet. 27. Vaccinated, one indifferent mark. Admitted June 8th. Eruption appeared on the 5th, and is present as a tolerably plentiful crop on the face, more scattered on the trunk and limbs. A few petechiae exist in the groins. Symetrical clusters of papules are observed about the middle of the inner surfaces of the tibiae, upon the internal maleoli, and also on the inner edges of the soles of the feet. General symptoms good. Pulse 106, full and strong ; temperature 99°. 9th.—Vesieulation proceeding normally in the papules en the face, which is becoming much swollen ; the neck also is very large, almost obliterating the angle of the chin. Haemorrhages .have taken place around many of the vesicles on the legs and thighs, the areolae of hyperaemia have become purpuric, and a similar condition is observed about several on the arms. Pulse 96 ; temperature 99.5°. 10th.—According to the nurse he was a little delirious at times. Pulse 88 ; temperature 99.2°. 11th.—Almost all the pocks upon the limbs and abdomen are purpuric, those upon the face show no signs of pustulation, but have become firm and hard. 12th.—The 8th day of the eruption; appearance in the evening was as follows: Face and neck much swollen, eyes almost closed. Varioles isolated, yet nearly in contact, of a firm, hard feel, and of a semi-opaque, somewhat translucent ^ 32 A FORM OP HEMORRHAGIC SMALL-POX. aspect. No true pustule is present, with the exception of a fen about the roots of the hair,—but the face has a rough nodular appearance. Over the legs, arms, and to a less extent the trunk, there are numerous small, dark-red spots, about the size of a pin's head, which on superficial examination, looked like purpura, but on closer inspection prove to be small papules into which extravasation has taken place. On passing the finger over them a slight hard elevation can be felt, and in some a small semi-opaque, vesicular top is observable. Other larger ones, the size of a split pea, flat, with vesicular tops, and situated upon haemorrhagic bases, are common on the legs. Here and there over the trunk and arms true pustules occurred but they are small and have not hyperaemic bases. The symetrical clusters, mentioned as situated on the legs, are elevated into bulla filled with a sero-sanguineous fluid which gives to them a bluish look Upon the walls of the bullae the remains of the septa of the original vesicles are distinctly seen. The separate varioles of the clusters on the tibiae have not coalesced, though they are filled with a fluid of trie same character. Another large bullae filled with a sero-sanguineous fluid exists on the radial side of the ball of the left thumb. The bases upon which these various clusters and bullae are situated are haemorrhagic. Examination of the contents of the bullae and of the larger pocks of the legs showed a large number of normal-looking red-blood corpuscles, and numerous granular leucocytes, many of which were grouped together. The sharply-defined, dark-red spots scattered over the white skin gave a remarkable appearance to the eruption. General symptoms good. Pulse 86 ; temperature normal. IM.—Desiccation proceeding in most of the pocks, and those of an haemorrhagic character present small dark scabs,(represent- ing the contents of the vesicle) situated upon a base of fading extravasation. A few genuine pustules exist upon the chest. Face not so much swollen, but remains rough and uneven from the dry hard pocks. Temperature normal. Got up for a short time. 16th.—Eruption drying up rapidly. 11th.—Temperature rose to 102° this morning, due apparently A FORM OF MEMORRHAGIC SMALL-POX. 33 to inflammatory action in the submaxillary region of the left side. Temperature subsided in the evening. 19^.—Up most of the day and has had a bath. Bullae on legs and feet have dried up to large dark scabs. Convalescence from this date rapid ; the hard nodules left upon the face took a long time to absorb. It is needless to give the other cases in detail. They corres- pond in all essential particulars with the'one here reported (the sanguineous bullae excepted which were only noticed once), and I pass to the consideration of one or two interesting points in connection with them. In all the eruption was tolerably abundant, especially on the face. All had been vaccinated, but only cases I. and II. pre- sented a good mark each. The character of the eruption differed somewhat from the ordinary type. In cases I, II, III and IV, and to a lesser degree in case V, the vesicles were small, miliary in appearance, like the variety of small-pox des- cribed as variola crystallinaov miliaris. The time of appearance of the extravasation was tolerably uniform in each case, viz., at or about the period of vesiculation. The day of the eruption on which it took place in the cases is as follows, in order, 4th, 5th, 4th, 5th, 4th, 4th. This corresponds closely with the stage in the development of the pock, when the most active hyperae- mia takes place about it ; for it is just in the transition of the vesicle into the pustule that the greatest demand is made upon the capilliaries to supply the leucocytes or white blood corpuscles, which to a large extent constitute the formed elements of the latter. The extravasations took place chiefly about i the pocks on the lower extremities and trunk, but they were not confined exclusively to these localities, being met with also in two instances about those on the arms. Curschmann* very properly cautions against regarding those as cases of var. hemorrhagica pustulosa, where patients being delirious get up and wanderabout,and haemorrhages are found to have occurred in the pustules of the lower extremities in a simple mechanical manner. In the cases I refer to such a cause may * Loc. Cit. p. 370. 34 A FORM OF HEMORRHAGIC SMALL-POX. be excluded, and the extravasations took place in the vesicular stage. Next to the occurrence of haemorrhages the abortive nature of the eruption forms the most interesting feature. No patients under my care with an equal extent of eruption made such rapid recoveries. In all of them the skin was perfectly clear of of scabs in about two weeks, the extremes being 11 (case VI) and 14 days (case III). It is difficult to assign a cause for this early desiccation. On the legs and lower abdominal region it may have been directly due to the extravasation. A vesicle with a layer of extravasated blood about and beneath it is cut off, so to speak, from the circulation, and has to draw its nutri- tive supply from a distance. In many instances, also, the haemorr- hage occurred into the vesicles,and they quickly dried up to small dark scabs. On the face and otber parts this condition was absent, or present to a very slight extent, so that this factor can- not here be taken into consideration. In three the retrogression of the pocks on the face produced typical examples of the form v. verrucosa; solid papules, like small warts, were left, which took a considerable time to disappear, even after the rest of the body was quite free. An arrangement of pocks in clusters—v. corymbosa—was noticed in three cases. In case I symetrical groups of exceed- ing by fine vesicles were present on the eyelids, and similar ones, though not so distinct, were on the cheeks. Case II presented several curious clusters, also of small vesicles, on the thighs and in the popliteal regions. In case V—the one above give*—they occurred on the inner surfaces of the tibiae, on the internal maleoli and on the inner sides of the soles of the feet. The individual pocks on the maleoli and soles fused together forming large blebs, which became filled with a sero-sanguineous fluid. This variety is usually regarded as very fatal, but in these cases the arrange ment appeared to have no special significance. The references I have been able to find to this variety of haemorrhagic small-pox are exceedingly limited. The 35th case in Simon's articles* on prodromal rashes presented haemorrhagic rings round the pocks. Cases 20 and 21 in Knecht's paper on * Lo. Cit. p. 2. A FORM OF HEMORRHAGIC SMALL-POX. 35 the same subject are similar. He speaks of haemorrhages into and about the pocks, with abortive retrogression and rapid desiccation of the eruption. Webb in the Boston Medical^ Surgical Journal, (Aug.1873.) writing on the late epidemic in that city, states " that there were a few cases which had a haemorrhagic tendency in the earlier stages of the disease, but the eruption abated early, and the patients recovered." Ogston, also, in the Medico-Ohirurgical Review (Jan. 1873) speaks of the bases of the pocks becoming the seat of extravasation. These cases appear to have been com- mon in Hamburg during the late epidemic, and the only notice worthy of the name is to be found in an article by Dr. Scheby- Buch in the 5th vol. (1874) of the Archiv. f. Dermatologie und Syphilis. Under the term " Haemorrhagien mit Pocken."— Haemorrhages with Pocks—he describes a group in which no doubt the cases here referred to are to be classed. He says, " under this heading I reckon the cases in which the haemorr- hages take a subordinate position. The pocks are tolerably numerous, here and there confluent, mostly flat and imperfectly developed. Haemorrhages occur in and about the same on the lower extremities. Sometimes these are accompanied with free extravasations (purpura) in the skin and conjunctiva, but haemorrhages from the remaining mucous surfaces never occur." Unfortunately none of the cases are reported, many of them, however, were of a severe type and fatal. I did meet with one case in which haemorrhages occurred ahout the pocks on the thighs, legs, and, to a less extent, the thorax in the vesicular stage. Instead of the eruption aborting it went on to maturation, and the man barely escaped with his life. Instances like this may have furnished the fatal contingent in Scheby- Buch's cases, and no doubt in a large experience cases would be met with which might supply the links to unite the mild variety here described with the fatal variola hemorrhagica pustulosa. It will be sufficient if attention has been drawn to the fact, not generally known, that cases of small-pox in which cutaneous haemorrhages occur into and about the pocks are not of necessity fatal. 12. VERMINOUS BRONCHITIS IN DOGS. (READ BEFORE THE MONTREAL VETERINARY MEDICAL ASSOCIATION, March 29th.) v' BY WILLIAM OSLER, M.D., L.R.C.P. Lond., FELLOW OF THE ROYAL MICROSCOPICAL SOCIETY, LONDON ; VICE-PRESIDENT OF THE MONTREAL VETERINARY MEDICAL ASSOCIATION ; PROFESSOR OF PHYSIOLOGY IN MACGILL UNIVERSITY, AND IN THE VETERINARY COLLEGE, MONTREAL. Reprinted from the 'Veterinarian,' June, 1877. LONDON: PRINTED BY J. E. ADLAED, BAETHOLOMEW CLOSE. 1877. VERMINOUS BRONCHITIS IN DOGS/ By William Osler, M.D., L.R.C.P. Lond.; Fellow of the Royal Microscopical Society, London ; Vice-President of the Montreal Veterinary Medical Association ; Pro- fessor of Physiology in McGill University, and in the Veterinary College, Montreal. Early in the month of January I was asked by Principal McEachran, F.R.C.V.S., to aid him in the investigation of a disease which had broken out among the pups at the ken- nels of the Montreal Hunt Club, and which was believed to be of a pneumonic nature. On proceeding to the place we found that the affection was confined almost exclusively to animals under eight months old, and that it had already proved fatal in several instances. At the time of the visit only one pup was ill, presenting symptoms of diminished air space in the chest. In order to ascertain the exact condition of the lungs, one of the pups, which had died a day or two previously, and had meanwhile frozen stiff, was ordered to be sent to the veterinary college for dissection. On the follow- ing day it was found at the autopsy that in addition to the pnuemonia there were numerous small parasite worms in the trachea and bronchial tubes. Knowing how subject many of the lower animals are to bronchial strongyles, I did not think it very remarkable that they should occur in the dog. On referring, however, to Dr. Cobbold's list of entozoa in- festing the dog, I was surprised not to find a bronchial stron- gyle mentioned, and a further search through the standard works on veterinary medicine and helminthology proving fruitless, I then wrote to the editors of the Veterinarian asking for information on the subject. They very kindly replied in a short editorial note in the March number, stating " that '* so far as their knowledge extends " no such cases have been placed formally on record," but Dr. Cobbold tells them " that one such instance has been verbally brought under his notice, though not in such a way as to be thoroughly convincing." * Read before the Montreal Veterinary Medical Association, March 29th. 1 2 VERMINOUS BRONCHITIS IN DOGS. I shall proceed now to speak of the symptoms and pathology of the disease, then give a description of the parasite itself, and make a few general remarks. Symptoms.—Only five of the diseased animals were seen during life, and that rather irregularly, on account of the distance of the fennels from the city. However, I have obtained some important details from the keeper, and a case which was brought to the infirmary and kept for some time was made the subject of cli- nical study. Among the initial symptoms disinclination for food and exercise, together with an unsteadiness of gait, amounting in some of the cases to a subparalytic condition of the hinder extremities, were the most evident. In fully half of the cases convulsions oc- curred. There was rarely diarrhoea or any other symptom referable to gastro-intestinal disorder. Cough was not a promi- nent symptom, being absent in many of the cases. When pre- sent, it was short and husky, " not," as the keeper said, " the regular distemper cough." In the case brought to the infirmary the cough was well marked, and was dry and short. The pulse and respirations were increased, and the temperature elevated. Towards the close all food was refused, and even when fed the soup given was commonly vomited. Death took place in most instances quietly, though sometimes during a convulsion, and the keeper noticed that the pups which lasted the longest had the most fits. The duration of the disease ranged from three days to a week, or even ten days. The whole epidemic lasted about seven weeks. Altogether fifteen couples were attacked, all of which, with the exception of three couples of old dogs, were under eight months old. Of the old dogs three had the disease badly, but only one died. Of the total number affected four and a half couples re- covered, so that twenty-one animals were lost. The dogs which recovered are now in their usual health, though not in such good condition as they were before. With regard to the hygienic surroundings of the animals it may be stated that, at present, the kennels are in an old house which stands by itself on the government property known as Logan's farm, at the east end of the city. It is isolated, being at some distance from any other building, and is situated on an elevated ridge overlooking the Quebec suburbs. The disease showed itself during a remarkably cold spell- indeed, for the first three weeks of the epidemic, the thermometer was almost constantly below zero. It was first observed in two VERMINOUS BRONCHITIS IN DOGS. 3 or three pups of four couples which were kept by themselves in a separate room, 14 ft. by 8 ; the floor being covered with straw, which was changed every week. There was a cupboard in the room, and in this the pups slept. This room was on the exposed Bide of the house, and, according to the keeper, was always very cold. The rest of the animals were kept in tolerably roomy quarters, though at night, with the doors closed, I do not think the ventilation would be sufficient. During the day they had free access to a large yard. The food consisted of porridge and cooked horseflesh, which were given either separately or boiled together. They got nothing else. The oatmeal was of good quality, nor did I find in portions of the food removed from the feeding pans anything which afforded the slightest clue to the origin of the disease. Pathology.—Post-mortem examinations were made in eight cases. The following notes were dictated at the time. Case 1.—Autopsy eighteen hours after death. Body that of a well-nourished, half-grown, fox-hound bitch. On opening the thorax the lungs only partially collapse; the lower borders of the lobes are firm to the touch and dark in colour. The vessels in the lower mediastinum look full, and the tissues in that region are blood-stained. Pericardium natural; heart appears of normal size; right auricle filled with dark grumous clots, which extend into the vessels and are here decolourised. Right ventricle dis- tended with dark, semi-coagulated blood ; the conus arteriosus is filled with a perfectly decolourised clot, which passes into the pulmonary artery to the third and fourth divisions. The left auricle contains a small coagulum. The left ventricle contains no blood, but the whole cavity is occupied by a firm milk-white thrombus, which is connected through the mitral valve with the one in the auricle, while a prolongation from it extends into the aorta. Lungs.—After normal, on inverting them, a quantity of dirty brown frothy fluid escapes through the larynx. The anterior and middle lobes and the anterior half of the posterior lobe of the right lung are solidified, being of a dark reddish-brown colour, and contrasting strongly with the unaf- fected parts. The pleural surfaces are smooth, and there is no exudation. On section the lung tissue is of a dark red colour, the surface of the section finely granular, and bathed with a quantity of reddish-brown serum. On close inspection it is seen that the air cells are uniformly filled a solid exudation; attempts 4 VERMINOUS BRONCHITIS IN DOGS. at inflation of the affected portions with are unsuccessful. Portions excised sink at once when placed in water. In the left lung the apex of the anterior lobe, the whole of the middle, and the root of one of the posterior lobes, are in the same condition. The portions of the organs not diseased are of a rosy red externally, and on section contain much blood and frothy serum. Between the healthy and diseased parts there is a zone of intense hypersemia. Trachea.—On slitting up the windpipe the mucous membrane is found covered with a dark frothy mucus. The membrane looks pale and natural to within an inch of the bifurcation, but at this point it becomes reddened, and uneven from the projec- tion of irregular little masses of a greyish-yellow colour, which on close inspection are found to be localised swellings of the membrane, containing small parasitic worms, the white bodies of which can be seen lying upon and partially imbedded in these elevations. They are most abundant just at the bifurcation, at the lower part of which several have emerged, forming an eleva- tion three or four lines in height. About the orifices of the second divisions these little masses are also seen, and the whole mucous membrane of this region is deeply congested, and some- what swollen. Very few of the worms are found lying free on the mucous membrane ; almost all of them are attached to the masses or buried in them. The smaller tubes, especially those leading to the diseased portions of the lungs, are filled with a dirty brown fluid, and on squeezing any portion of the organ quantities of it can be expelled. The bronchial glands are swollen and enlarged. The spleen appears healthy. The left kidney contains a large amount of blood; otherwise looks natural. Nothing unusual in the right one. The stomach contains a few ounces of dark brown fluid- mucous membrane is pale. Large veins full. The duodenum contains a bile-stained mucus, and on pressing the gall-bladder, bile flows from the papilla biliaria. Jejunum and ileum contain a dirty black material adhering to the mucous membrane. One taenia elliptica and one ascaris marginata are found in the jejunum. Large bowel healthy. Liver firm, dark red in colour, lobules indistinct, hepatic veins full, gall-bladder contains a small amount of bile. There is a clot in the portal vein. VERMINOUS BRONCHITIS IN DOGS. 5 Brain.—Nothing abnormal about the membranes. Substance of good consistence and apparently healthy. In the following cases I have condensed the original account. Case 2.—A five months' old dog pup, which had been ill a week. Extensive pneumonic consolidation of the lungs, involving the lower part of the anterior lobe, and scattered patches in the middle lobe on the left side, and half the posteror lobe on the right. On section the solidified parts presented the appearance already de- scribed in the preceding case, and the unaffected portions are in a state of engorgement. On slitting up the trachea and bron- chial tubes much frothy blood-tinged serum escaped, but no trace of any parasites can be found either in the tubes or paren- chyma of the lungs. No ova or young parasites can be found in the blood of the cavities of the heart or of the pulmonary artery. Abdominal viscera appear healthy, though, owing to the ob- struction in the lesser circulation, the blood-vessels are engorged. A few ascarides in the intestine, and one small taenia elliptica. Case 3.—Dog pup, six months old. In the left lung there are scattered patches of pneumonia in the anterior lobe, one or two are in the middle lobe, and half a dozen, the size of marbles, closely set together in the upper part of posterior lobe. In the right lung the anterior lobe is solid in an area 3" by 1", extending along the lower free border, and through the whole thickness. Small patches occur here and there over the other lobes. In this instance the inflamed spots are smaller, and not so extensive as in the other cases. On slitting up the trachea the mucous membrane looks healthy to within 2" of the bifurcation, when it becomes swollen, dark red in colour, and thickly scattered over with the elevated granular masses noticed in the first case, attached to and in which numerous small white worms can be seen. A stream of water of consider- able force does not wash them away, but shows that each little elevation consists of a nest of the parasites. They extend to the tubes of the second order, and are specially abundant at the bifurcation itself, and about the orifices of the first tubes given off from the main bronchi. The small tubes are filled up with a frothy serum. Two of the worms are found far in the mucus. Stomach and intestines appear healthy, except the lower portion of the ileum, which is congested. In this region ten specimens of dochmius trigonocephalus occur, and furthur up in the bowel eight ascarides. § 6 VERMINOUS BRONCHITIS IN DOGS. Case 4.—A six months' old dog pup brought to the infirmary and died the next day. In the left lung the anterior and middle lobes and the lower free border of the posterior lobe are solidified. In the right lung the lower three fourths of the anterior and middle lobes, and the lower fourth of the posterior lobe, are in the same condition. Pleural surfaces involved. The posterior half of the windpipe contains upon the mucous membrane of its lower wall about a dozen small red patches, Avhich extend in the axis of the tube; some appearing like linear streaks due to the injection of a few vessels. In all of them the presence of parasites can be determined, though in some of the smaller only one is found. They become more numerous about the bifurcation and in the main bronchi, occuping chiefly the lower wall. The masses are isolated and the mucous membrance between them intensely in- jected. None are found in the second divisions of the tubes. Abdominal organs contain a good deal of blood. Mucous membrane of stomach and intestines look healthy. The large bowel contains a quantity of consistent faeces. Six ascarides in the duodenum; six specimens of dochmius trigonocephalus in the jejunum, and ten specimens of tricocephalus affinis in the ca?cum. Blood of heart and veins examined; nothing abnormal found. Case 5.—Seven months' old bitch pup. Considerable emacia- tion. Scattered areas of pneumonia throughout both lungs; not quite so extensive as in Case 4, but presenting similar characters. From an inch in front of the bifurcation of the trachea to the bronchi of the second order, the whole mucous membrane is transformed into an irregular greyish-yellow granular structure, upon which the bodes of numerous white worms can be plainly seen. Two sizes may be distinguished, one longer and of a more opaque white, which subsequent examination showed to be the female, the other shorter, thinner, and paler. In this case, even about the orifices of the third division of the bronchi, a few'nesta of the parasite can be seen. In the mucus from the smaller tubes a few of the adult worms occur, and on spreading it out on glass slips, and examining with a low power, a few ova and free embryos are seen. Blood of heart and veins contain no parasites Nothing abnormal in the stomach or intestines, a large speci- men of taenia elliptica in the latter, also a few ascarides. Case 6.—A thin, badly nourished dog pup, six months old. VERMINOUS BRONCHITIS IN DOGS. 7 Lungs present numerous patches of consolidation, involving on the right side the lower half of the anterior lobe, and a large piece of the posterior lobe. On the left side the free borders of the anterior and middle lobes for almost two inches from the margin, and a broad strip along the upper part of the posterior lobe. Trachea and bronchi healthy ; mucous membrane of the tubes in the affected parts congested, but no parasites in the membrane or in the lung tissue. Stomach and intestines appear natural; a few ascarides in the latter. Nothing abnormal found in the blood. CASe 7.—Dog pup, seven months old. The autopsy, which was made at the same time as the previous case, reveals a similar condition of the lungs, and an entire absence of any parasites either in the tubes or in the parenchyma of the lungs. Nothing unusual in the abdominal organs. The taenia elliptica and five or six ascarides in the jejunum. Case 8.—A fine, well-grown dog pup, eight months old. Had been ill a week. Lun^s contain pneumonic areas of considerable extent; in the rio'ht involving the entire apex with the dependent border, and a small portion of the posterior lobe near the diaphragm. In the left lung almost the whole of the middle lobe, and the root of the posterior, are specially affected. On opening the windpipe the discrete elevations above described upon the mucous membrane about the bifurcation are very distinct, and the worms can be seen in them. The appearance is very like that met with in Case 4, and the description need not be re- peated. No parasites in the intestines. Nothing abnormal found in the blood. The general and specific characters of the worm may be defined as follows : Strongylus canis bronchialis.—A slender nematode helminth, body filiform, the female measuring about one fourth of an inch in length, the male smaller, measuring one sixth to one eighth of an inch ; head conical, mouth simple, unprovided with papilla?; tail of female obtuse, anal and generative orifices terminal, opening by a cloaca; ovarian tube containing one row of eggs, which, in the mature species, have developed into slender-coiled embryos ; tail of the male somewhat pointed ; penis consists of a double spiculum of a yellowish-brown colour; mode of reproduction viviparous. Only occasionally, as stated above, were the worms found lying 8 VERMINOUS BRONCHITIS IN DOGS. free upon the bronchial membrane ; as a rule they lay imbedded in a localised granular swelling of the mucosa, from which portions FlG. 1.—Head of male worm. PiG. 2.—Tail of female worm, showing the young embryos. of them protruded. They could readily be pulled out with a pair of fine forceps, but a stream of water did not wash them away. In several of the cases examined (more especially Case 4) the whole mucous membrane of the affected part appeared rough and irregular, as if ulcerated, and innumerable parasites lay upon and in it. The mature females could easily be distinguished, not only by their larger size, but by the opaque whiteness of their bodies. The majority of the female worms examined were immature, and did not contain developed ova. The males were not nearly so numerous as the females. Forms intermediate between the adult worms and the young embryos (some of which, as already men- tioned, existed free in the mucus) were not met with. The occurrence in the bronchial tubes of the lower animals of nematoid worms belonging to the genus strongylus is by no means uncommon. Owing to the irritation caused by their development in the mucous membrane an inflammation of the tubes is produced, hence the affection is known by the names of parasitic or vermi- nous bronchitis, popularly called " husk " or " hoose." It is not altogether unknown in man, but very few instances are on record. Infesting the domestic animals there are three well-recognised species of strongylus: the S. filaria of the sheep and goats • S. paradoxus of the pig, and S. micrurus of the calf, more rarely of the horse and ass. In calves and lambs parasitic bronchitis often constitutes a serious and fatal epidemic, so much so that in the latter it goes by the name of the lamb disease. So far as I know no epidemic of the kind has been noticed in Canada. The species I have here described differs in several particulars from either of the above mentioned, and is most probably new to science VERMINOUS BRONCHITIS IN DOGS. 9 The origin of the epidemic must, I am afraid, like that of so many other diseases, remain obscure. We have absolutely nothing to aid us in forming an opinion on the subject. There had been no change in the locality nor in the food. The straw upon which the dogs slept was of the ordinary kind, and the usual attention had been paid to changing it and also to the general sanitary con- dition of the place. The disease broke out, too, during a spell of very severe weather, when the food left in the pans froze quickly. The course of the epidemic was short, lasting between six and seven weeks, a sufficient time, however, to destroy almost all the pups in the kennels. The mode of invasion in parasitic disease of the bronchial tubes has been, and still is, a matter of much dispute, some observers maintaining that " the ova and young parasites taken up with the food, in the first place gain access from the alimentary canal to the circulation ; " others hold the view that they pass directly from the mouth to the trachea, or that the ova are inhaled by the breath. The former view is the one most generally enter- tained, and it is urged in its favour that the presence of the worms has been determined in the cavities of the heart and in the blood- vessels, as well as in the intestines. Now, in the epidemic under consideration I think this view does not meet the case. Supposing the young embryos to have been ingested and to have gained access to the branches of the portal vein, they would then be carried to the right side of the heart, and from thence to the lun«s, by the pulmonary artery, the capillaries of which ramify in the lung substance alone, a situation in which the parasites did not occur. To get to the bronchial mucous membrane they must be returned by the pulmonary veins to the left side of the heart, enter the aorta, and pass out by the small bronchial arteries which supply the tubes—an exceedingly round-about and some- what improbable route. It is to be remembered that young strongyles have been found capable, like many other nema- toid worms, of reviving on the application of moisture after a dessication of a month or more, and even after immersion in spirits of wine, and solutions of corrosive sublimate and alum (Williams), so that their chance of survival under adverse circum- stances is unusually good. It seems quite as reasonable to suppose that the dried embryos were inhaled with the breath, and, lighting in the mucous membrane, found suitable conditions for development. The position of the parasites about the bifurcation of the trachea, at the angles of division of the main bronchi, and most abundantly in the lower wall of the tubes, just the localities 10 VERMINOUS BRONCHITIS IN DOGS. where small particles would be most likely to lodge, favours an infection through the air rather than by the blood. The negative evidences in the heart and blood-vessels do not go for much either way, as the examination in all the cases was made after the invasion of the parasites, and consequently at a time when they could scarcely be found in the circulation. It is a somewhat remarkable fact that verminous bronchitis prevailed to a much greater extent, and is more fatal in young animals than in adults. Thus lambs and calves are the chief victims in epidemics of " hoose," whereas it is only occasionally that adult animals succumb to the disease. In lambs the worms are usually found in the bronchial tubes, while in sheep they are more commonly encysted in the lung tissue itself, where they do not appear to cause much irritation. It seems to me that in the anatomical peculiarities of the lungs in young animals we have an explanation of the fatality of the disease among them. If the bronchial tubes of a young animal be compared with those of an adult they are seen to be softer, much less rigid; the mucous membrane is lower, not so thin, nor so closely attached to the tissues beneath. Hence it happens that in inflammation of the tubes from any cause, swelling and tumefaction of the mucous membrane readily occur, and constitute elements of danger which are directly proportionate to the calibre of the tubes attacked. In the cases above reported the swelling of the membrane in the larger tubes was considerable, and, though not sufficient to prevent the access of air, must have interfered greatly with the expulsion of mucus from the smaller tubes, not only by decreas- ing and narrowing the orifices of exit, but also by destroying, over an important area, the ciliary action so useful for this purpose. The same difference is met with in human practice. Ordinary acute bronchitis in the adult is not at all a dangerous affection, while in young children it is the reverse ; and for the very reason that in them the bronchial mucous membrane swells easily, and there is not the same expulsive power to enable them to get rid of the mucus which, in consequence, accumulates, and may cause collapse or inflammation of the lung tissue. In the " lamb disease " death occurs from asphyxia, caused by the collection of mucus in the tubes. I have no records at hand of the state of the lung tissue in these cases, whether it is in a condition of collapse or of inflammation; probably the latter, for I see the expression ver- minous pneumonia," used by some authors. With reference to the pneumonic condition of the lun^s of the dogs in this epidemic, it will be remembered that in three of VERMINOUS BRONCHITIS IN DOGS. 11 the post-mortem examinations the inflammation of the lungs was found without the occurrence of parasites in the bronchial tubes ; the pneumonia being quite as extensive as in the cases accom- panied with strongyles. I must confess that this circumstance has puzzled me not a little, and I see no very satisfactory expla- nation of the fact. It appears natural to refer the diseased con- dition of the lung substance in the parasite cases to the accu- mulation of the mucus in the smaller tubes producing collapse of the air cells in certain areas, which subsequently became in- flamed— a sequence of events sometimes observed in jchildren. The appearance of the lungs in several of the cases corresponds with this view ; for the pneumonia was lobular, affecting small and isolated portions of the lung tissue. > CASE OF ANEURISM OF THE HEPATIC ARTERY MULTIPLE ABSCESSES OF THE LIVER. GEORGE ROSS, A.M.. M.D., Pkokk-sok ok Clinical Medicine, McGill University, Attending Physician to the Montreal General Hospital. WILLIAM OSLER, M.D , L.R.C.P., Lond. Professor of Institutes of Medicine, McGill University. (Read before the Medico Ohirurgical Society of Montreal.) {Rtprinted from Canada Medical and SuRcrcAL Journal, July, 1877.) PRINTED AT THE "GAZETTE" PRINTING HOl'SI 1877. CASE OF ANEURISM OE THE HEPATIC ARTERY WITH \ MULTIPLE ABSCESSES OF THE LIVER. i BY GEORGE ROSS, A.M., M.D., Professor of Clinical Mkdjoine, McGill University, Attending Physician- 10 thk Montreal General Hospital. AND WILLIAM OSLER, M.D., L.R.C.P., Lond. Professor of Institutes of Medicine, McGill University. (Read before the Medico-Chirurgical Society of Montreal.) {Reprinted from Canada Medical and Surgical Journal, July, 1877.)* PRINTED AT THE "GAZETTE" PRINTING HOUSE 1877. ANEURISM OF THE HEPATIC ARTERY. (a) Hepatio artery, (b) right branch mainly involved, (c) left branoh, (d) gas- tro-duodenalis, (e) cystic arteries, (/) occluded branches of right trunk. ANEURISM OF HEPATIC ARTERY; MULTIPLE ABSCESSES OF THE LIVER. BY GEORGE ROSS, A.M., M.D. Professor of Clinical Medicine, McGill University, Attending Physician to the Montreal General Hospital. — and — WILLIAM OSLER, M.D., L.R.C.P., Professor of Institutes of Medicine, McGill University. (Read before the Medico-Chirurgical Society of Montreal.) Aneurism of the hepatic artery being of such very rare occurrence and the case which we are about to relate presenting in addition some remarkable pathological features, we are led to believe that it will be found of considerable interest. . For the notes of the case we are indebted to Mr. John Brodie, ward clerk. W. H, set. 21, single ; height 5 feet ll£ inches; weight, about 140 lbs, — was admitted into the Montreal General Hospital on the 8th of November, 1876, complaining of pains in the right side and great weakness. The patient was born in Wisconsin, U. S., and lived there until about two years ago, since which time he has resided in this city. His family history, as far as could be ascertained, is good. Has never been ill with the exception of small-pox, and a mild pneumonia of the left lung. Has never had dysentery nor 4 ANEURISM OF HEPATIC ARTERY. piles, nor any abdominal or rectal trouble of any kind. Has always been of extremely temperate habits. His present illness began, he says, about the 1st of Septem- ber last, with what he describes as a severe cramping pain in the stomach, which began in the morning and continued all day. At 4.30 p.m. of that day he had a violent rigor, lasting about twenty minutes. This was followed by high fever and perspira- tion. Similar chills recurred, he says, with great regularity, every second day for five or six times, and then ceased after he had taken some medicine from the Hospital Dispensary. At this time his appetite became poor, he felt weak and was very low- spirited, and observed that his skin assumed a sallow colour- Ever since he has been gradually getting weaker and losing flesh pretty rapidly, and the sallow tint of the skin has been steadily increasing in intensity. There has also been almost constantly present a dull, aching pain in the right side over the region of the liver. Slighter rigors, followed by fever and some perspiration, have also occurred several times at irregular intervals. Present Condition.—Much emaciated, somewhat anaemic, but the whole skin of a dirty, dingy, sallow hue, without any jaundice,—the sclerotic clear, and not yellowish, There is a very peculiar, pungent, somewhat feculent and extremely disa- greeable odor exhaled from the surface of the body. There is slight fullness of the right hypochondriac region which is also somewhat tender upon pressure. Liver.—Dulness extends from the 4th interspace to one inch below the margin of the ribs. The belly is full and tumid, and tenderness is also found on pressure over the epigastrium. Splenic dulness not increased. Tongue slightly furred, rather dry, and with red edges. Bowels have been, and still are, considerably relaxed, the motions being light-coloured and especially offensive. Urine, sp. gr. 1019, high-coloured, but containing neither bile pigment, albumen nor sugar. Heart—Situation and sounds normal, pulse 116. Lungs. Resonance and breathing normal throughout, except at the base of ANEURISM OF HEPATIC ARTERY. 5 the right lung where there is an area of dulness with enfeebled respiration. Temperature 105Q F. Ordered quinine gr. xx each evening. Nov. 11th.—Has not complained much of the pain. Disagree- able odour from the body very marked. Bowels are regular, but motions are ochre-coloured and offensive. Tongue clean. A dull red flush on cheeks especially in afternoon. Has occa- sional slight epistaxis. Temperature has ranged between 102°F. and 103° F. 16^A.—Is getting weaker but is quite cheerful, and feels well. Tongue moist and clean. Takes nourishing food very well, and bowels remain regular. Never vomits. Temperature continues equally high, always rising 2° or more in the evening, followed by sweating which is sometimes very profuse. This usually commences at 6 p.m. Urine 43 oz. sp. gr. 1022. No bile pig- ment, albumen or sugar. 22>rd.—The volume of the liver has considerably increased, .and, owing to the progressive emaciation, bulging of the lower ribs on the right side has become quite apparent. Dulness ex- tends from the top of the 4th rib to two inches below the margin of the ribs. The lower edge of the liver cannot be felt owing to the fulness of the abdomen and its tender condition. Pain on pressure over liver region and epigastrium increased. His strength is failing fast, and the sallow colour has become deep- ened. The odour from his body has been so offensive in the ward for some time that the House Surgeon has been obliged to em- ploy spongings with carbolized solutions, and disinfectants round the bed. He lies almost continuously on his back, occasionally turning slightly towards the right side, but any attempt at turn- ing on his left side is accompanied by severe pain and a feeling of a dragging and weight in the region of the liver. The superficial veins on the right side of the chest are very large and prominent. Ordered linseed poultices over the liver. 25th.—Tenderness less. Hepatic dulness increased in area, uneasuring 8 inches vertically at the line of the nipple. No localized fulness or redness of the skin or fluctuation to be found 6 ANEURISM OF HEPATIC ARTERY. anywhere. The enlargement of the organ is very general and uniform. Pulse 128, very small and feeble. Temperature continues high with evening perspirations. Is remarkably cheer- ful, saying he feels well but weak, although he suffers a good. deal of pain. Ordered acid nitro-mur. dil. Tr. calumb., a a oss ter die. 29th.—Pain and tenderness low down on the right side, Excessive pain is caused by the slightest change of posture. Lies constantly on the right side. Pulse 130. His diet throughout has been of a most nourishing kind. Milk abundantly, beef-tea, eggs, wine, &c. Dec. 3rd.—This morning there occcurred a temporary col- lapse, marked by a rapid fall of the thermometer to a remarka- bly low level, 94.8°. F., accompanied by great prostration and a cold sweat. In the evening the temperature rose to 102.4.° F., and during the night great pain was felt in the left iliac region, which was tender. Ordered an opiate, and a small blister to this region. Gth.—Is rapidly sinking. The signs of effusion in the right pleura, hitherto stationary, have in the last few days, rapidly extended, and there is now dulness over the lower two-thirds of that side, with absence of breathing, and an amphoric jiote beneath the right clavicle. 7th.—Died at 6.00 a.m. Autopsy, 31 hours after Death. Rigor mortis present. Skin of a dirty-brown colour. In the abdomen about 22 oz. of yellow turbid fluid. In the right pleural cavity about 20 oz. of similar fluid. Right lung collapsed.. The pleura covered with a thin layer of greenish-yellow lymph. On section, the lung is dark, airless and sodden. Left Lung. On the visceral layer of the pleura, especially behind, are numerous small ecchymoses. On section, organ contains much blood, i3 firm, and only slightly crepitant. Heart normal. Kidneys rather pale, cortex swollen, and malpighian tufts injected. Spleen, weight 445 grms. (14 oz), adherent to the stomach. Organ soft. On section dark and congested.. ANEURISM OF HEPATIC ARTERY. 7 Intestines normal. No trace of ulceration in the large intestine. Bladder and prostate, normal. Liver, 4879J grammes, (lOf lbs). The peritoneum around it in many places showing signs of inflammation. The left lobe intimately adherent to the stomach by a thick layer of firm yellowish-coloured lymph. The right lobe also cemented to parts in its neighbourhood by lymph of a similar character. A small amount is also observed on the descending colon, but the general peritoneal surface is not affected, the serous covering of the intestines being clear and glistening. The liver itself retains its normal shape, the upper surface is smooth and not adherent. Towards the right border a yellowish-coloured swelling is evident which is perceptibly fluctuating. Other less distinct yellowish spots are seen scattered over the organ. To the touch the upper and back part of the right lobe is exceedingly soft and fluctuat- ing. On the under surface many yellowish-white nodules are apparent, some large, others quite small, all distinctly fluctuat- ing. A similar one of large size is apparent on the under surface of the left lobe. A transverse incision through both lobes reveals the fact that we have to deal with a diffuse suppurative hepatitis. An immense quantity of yellowish-white, custard-like pus flowed out. The right lobe is completely honey-combed by a series of small, closely united abscesses, ranging in size from a marble to a walnut. The septa between these absceses are composed of a dark-red tissue. Most of these small abscesses communicate together; some have merged to form larger ones. They all possess distinct lining membranes which are frequently stained with bile. The left lobe is in a similar condition, and in both the abscesses extend throughout the thickness of the organ. Thus, the only portions ot liver-substance which are found comparatively free are the lobus quadratus and that portion of the organ lying immediately above and a little to the left of the gall bladder. These parts on section are of a dark colour, lobules distinct, small bile vessels very evident. The gall- bladder is small, contains about three drachms of a clear, some- what viscid secretion. On pressing it and along its ducts no fluid could be forced out at the papilla biliaria. It was with 8 ANEURISM OF HEPATIC ARTERY. much difficulty that a probe could be passed along the cystic duct, owing to an unusual number of irregular folds of its mucous membrane which were evident when the duct was slit up. The common bile duct itself was patent, the mucous membrane of its upper two-thirds stained with bile. There were no clots in the superior mesenteric, gastric, or splenic veins. On slitting up the portal vein itself, a small abscess was. found to project into the calibre of one of its right divisions. The tissue in the neighborhood of these main divisions was infiltrated with pus. A firm nodule was felt at the portal fissure and mistaken at first for a bunch of lymph glands. Section of this, however, showed it to be distinctly laminated, and careful dissection of the part revealed the existence of an aneurism just at the bifur- cation of the Hepatic Artery, but occupying chiefly the right "branch, (see plate.) The dilatation begins immediately beyond the gastro-duodenalis, (c?) and extends for about 3 inches as a somewhat conical swelling. The left hepatic artery (c) arises from the obtuse end of the aneurism and is unaffected. At its thickest part its circumference measures 3 inches. For 2\ inches it passes to the right and gives off two branches if) which appear occluded, then turns at right angles and passes backward for 1\ in., towards the posterior border of the liver, terminating by a conical extremity which is continuous with the main branch of the artery. The arteries of the body had been injected, and the red mass is found in the trunk of the hepatic before its bifurcation, in the gastro-duodenalis, and the left hepatic branches, all of which are full and tense. The hepatic artery appears to enter the aneurism about \ of an inch from the obtuse end, the gastro- duodenalis and left hepatic being given off apparently from the ■dilatation itself; and on slitting up the hepatic artery it appears at first sight as if these were its only branches, and that its com- munication with the aneurismal sac had become obliterated. Care- ful inspection, however, of the lower and posterior wall reveals a small canal, the calibre of a hypodermic needle, which leads ■directly into the sac. The aneurism being opened by a longi- tudinal cut on the upper surface, it is seen that the anterior third, comprising the rounded end, is completely filled with firm ANEURISM OF HEPATIC ARTERY. 9 ■decolourized laminae of fibrin, concentrically arranged. The middle third of the sac contains semi-coagulated blood, and red injection mass, after emptying which there is seen a cavity about the size of a small walnut. This is in communication with the hepatic artery by the small canal already referred to, which passes for rather more than half an inch through the fibrinous laminae of the anterior end. Two small branches, both containing injection pass from the cavity, one the cystic, (e) going to the gall-bladder, the other a somewhat larger branch, passing to the central part of the organ. The sac is lined with sheets of fibrin, which, at the under part were thinner than elsewhere, and at this point the blood has infiltrated the proper coats of the aneu- rism, which, in consequence, look reddish black. The terminal portion of the sac lay chiefly in the substance of the right lobe, surrounded by suppurating hepatic tissue, which had to be dissected away to expose it; and on section the cavity is found almost completely obliterated by fibrinous laminae, which in the centre are softer, and not so colourless as the other end of the sac. No direct passage could be traced through this from the central cavity, and the main branches given off from the aneu- rism are found empty, and at their commencement plugged with fibrin, which in several extends as a thin sheet along the intima. The condition appears to be one of simple aneurismal dilata- tion of the vessel, the walls being thin, slightly roughened on the interior, but not markedly atheromatous. The trunk of the hepatic artery itself looks healthy, and there are no evidences of general vascular degeneration. Remarks.—Aneurismal dilatation of the Hepatic Artery would appear tobe of rare occurrence, the chief reason, of course, being that its main cause—atheromatous degeneration—is very seldom met with in this situation. Embolism of this artery Frerichs has never seen—the situation and mode of giving off of the vessel being such as to hinder the entrance therein of foreign substances from the stream of the aorta. One single case of the kind has been recorded by Virchow, where an hepatic abscess followed embolism from a gangrened lung. The same author (Frerichs) alludes to four, or possibly five, 10 AUERISM OF HEPATIC ARTERY. as the only recorded cases of Aneurism of the Hepatic Artery. They are those of Ledieu, Stokes, Sestier, Wallmann and Lebert. In the case of Ledieu, the patient died of some pul- monary complaint, and had never had any symptoms of hepatic disease. There was found, just before the giving off of the pyloric branch, on the hepatic artery, a small hard tumour the size of a hazel nut. It was entirely composed of firm laminated fibrin, and had completely occluded the main artery. The case of Sestier was also obscure. There had been " symptoms of some chronic painful affection of the stomach." The right branch of the vessel was found occluded by a small aneurism filled with clots, and the gall-bladder was gangrenous. In Wallmann's patient—a female—there was an account of attacks of violent pain in the upper part of the abdomen, coming on after intervals of several days, gradual loss of strength, and emaciation. There was enlargement of both liver and spleen» No ascites ; no fever. Then there supervened obstruction of the ducts with perceptible fulness of the gall-bladder, and very deep jaundice. She was believed to be suffering from gall- stones. Then fever, abdominal tenderness, collapse and death. A large aneurismal tumour was found in the situation of the lesser omentum. It was the size of a child's head, and showed a rent communicating with the cavity of the abdomen. Lebert's case was accompanied by severe pains in the pit of the stomach, followed after a time by haematemesis and melaena. Vomiting was persistent, and the patient soon died. The aneu- rism involved the main trunk of the vessel, and communicated by a fistulous opening with the gall-bladder, by which means the blood had found its way into the duodenum and stomach. From a relation of these cases Frerichs sums up as follows the clinical features resulting from this lesion: " The symptoms to which aneurism of the hepatic artery gives rise are accordingly of a three-fold nature. In the first place there is the tumour, which is sometimes remarkably laro-e and displaces the liver; secondly, there is the neuralgic pain, pro- duced by pressure upon the hepatic plexus of nerves ; and lastly there is jaundice caused by compression of the bile ducts. The ANEURISM OF HEPATIC ARTERY. 11 fatal termination in most cases takes place under symptoms of internal haemorrhage." We are inclined, therefore, to look at the record of the present case as of considerable importance, inasmuch as it clearly shows that besides, or even without, any of the symptoms mentioned by writers as accompanying aneurism of the hepatic artery, it may actually institute an entirely different series, — those namely of acute suppurative hepatitis of a diffuse character. The case as it came under observation was one presenting the marked characteristics of the latter disease, and every possible source of contamination of the portal system which might have given rise to it was interrogated in vain. Of course, we need hardly say that the real cause was entirely unsuspected, nor do we see but that the diagnosis of the aneu- rism was truly impossible. In the future, however, we must admit, in cases owning no other evident cause, that hepatic aneurism may be the starting point of acute hepatic abscess. Among the many interesting points in connection with this case, the causation of the multiple abscesses takes the front rank ; not only because in this one alone among the recorded cases was the fatal termination due to a suppurative hepatitis, but also on account of the extreme rarity in the human subject of opportunities of studying upon this organ the effects of disease of the hepatic artery. Taking for granted, as from the careful examination we may justly do, that the portal system did not in this instance furnish the materies morbi, we have to consider the consequence of total obliteration of the hepatic artery, or of its main branches, and also the effect of small emboli, in the form of particles of fibrin, plugging its terminal twigs. It will be necessary first to refer briefly to a few anatomical and pathological points in connection with the blood supply of the liver. This, as in the lungs, is two-fold ; the portal vein min- istering solely to the functions of the gland, the hepatic artery chiefly to its nutrition. The ultimate branches of the portal vein ramify at the periphery of the lobules, forming the inter- lobular vessels, from which numerous capillaries pass into' the interior, and finally converge to the centres of the lobules, as 12 ANEURISM OF HEPATIC ARTERY. the ultimate radicals of the hepatic veins. The hepatic artery furnishes blood to the bile ducts, portal and hepatic veins, and the connective tissue of Glisson's sheath. Its capillaries empty their blood by small venules into the interlobular veins. Hence, remembering this distribution of the hepatic artery, it is easy to understand how that in cases of thrombosis of the portal vein, even where the obstruction is complete, the functions of the organ may be maintained, and both bile and glycogen secreted ; for the capillary plexus of the lobules continues to receive through the interlobular veins the blood which has been emptied into the latter from the venules of the hepatic artery. The nutritive blood serves as a substitute, acts vicariously, for the functional. It has been maintained, and the statement passes current in the text-books, that the converse of this is true, viz: that the portal blood can replace the hepatic, the functional act for the nutritive. This view is based on experiments made upon the lower animals. Schiff states that in the cat the func- tions of the liver are performed just as well after ligature of the hepatic artery as before ; and Betz found that in the dog, after tying the trunk of the hepatic and all the collateral branches, no important alteration took place either in the structure of the liver or in its secretion. Cohnheim and Litten have shown, however, in a very impor- tant paper on " Disturbances in the Circulation of the Liver," (Virchow's Archiv. May, 1876), that in experiments on dogs arterial blood still reaches the liver even after ligation of the hepatic, the coronaria ventriculi, and the gastro-duodenalis, owing to the very extensive anastomoses and connections of these vessels. In the guinea pig, on the other hand, the supply of arterial blood can be completely shut off, either from the whole organ or from individual lobes. In the former case the operation is always fatal within 24 hours, and even in this time important changes are found to have to have taken place in the or^an. These are all the more marked if, instead of ligating all the arteries, only the one going to the extreme right lobe be tied. The result is an entire necrosis of the portion of the liver sup- plied by the ligatured artery, and in every instance the animal died within two days. ANEURISM OF AEPATIC ARTERY. 13 Cohnheim states that pathological proof of the correctness of this view is as yet wanting, but we are inclined to believe that by this case the deficiency is supplied; for we think the sup- puration of the organ best explained on the view, that the shut- ting off the supply of blood, either by the gradual occlusion of the aneurism by clots,or by the quicker process of emboli convey- ed away from the interior of the sac, produced numerous areas of necrosis, which subsequently became, by inflammation and a sequestering suppuration, converted into abscesses. It is impos- sible to determine, in the absence of any positive evidence, whether the process resulted from emboli or simply by the gra- dual obliteration of an important blood channel; and in any case there are certain difficulties which will occur to the minds of many in the view which we have suggested. There are at least two cases on record of total obliteration of the artery, without consecutive suppuration, one of which was from aneurism. Still, this, if occurring gradually, and not involving the pyloric artery, need not necessarily, as the above-mentioned experiments prove, deprive the liver of arterial blood. There is no reason to suppose that the obliteration in the case before us did not occur slowly, for the fibrinous laminae, especially at the anterior end, were firm and tough. Again, on an embolic theory it might be urged that in this instance the emboli, consisting of fibrinous shreds from an aneurismal sac, should have produced simply mechanical effects, infractions, and not, as in the case of emboli proceeding from necrotic or suppurating foci, abscesses. Mechanical emboli do, however, sometimes produce suppuration,, and in the liver might do so by causing death of the structures supplied by the obstructed arteries, viz: the portal vessels, bile ducts and connective tissue of Glisson. In the present case, supposing the process to depend on emboli, there would be arterial blood enough sent through collateral branches to furnish material for an active suppuration about the necrotic centres. Altogether, we think the embolic theory meets the case better than any other. We must remember, too, that the disease wm not rapidly fatal, but came on slowly, lasted five weeks or saore, and it is not unlikely that during time that much of 14 ANEURISM OF HEPATIC ARTERY. the fibrin was deposited, and the obliteration of the distal end of the aneurism took place. This is rendered still more proba- ble by a consideration of the condition of the left hepatic branch, the commencement of which is involved in the aneurism, but which now, owing to the filling of the proximal end of the sac with fibrin, appears to be almost the direct continuation of the main trunk. In fact, for a short distance from the bifurcation, the upper wall of the left branch is made up of condensed fibrin. which is groved by the blood chanel. This explains, too, the occurrence of the abscesses in the territories supplied by the left branch. The almost entire obliteration of the obtuse end of the sac occurred, most probably after the mischief had been started by the escape of emboli. The appearance of the abscesses adds further support to this view. None of them looked recent or contained shreds of necrotic liver tissue, but all were filled with a creamy pus, and had walls lined by definite pyogenic mem- branes. We have no clue to the origin of the aneurism itself. The age of the patient, and the absence of arterial degeneration else- where, are almost sufficient to exclude atheromatous degenera- tion as a cause, and the walls of the sac appear thinned but not evidently diseased. Of other agencies capable of producing aneurism, especially of smaller vessels, embolism is the most important, and, even in the absence of valvular disease, and remembering the unfavorable position of the hepatic artery for emboli, we are inclined to regard it as the most probable cause. CASE OF |}rcr0re$£itn} JJenimons J [iKttttia (IDIOPATHIC OF ADDISON.) BY WILLIAM GARDNER, M. D.. Professor op Medical Jurisprudence, McGill University ; WILLIAM OSLER, M.D., L.R.C.P . Lond., i Professor of Institutes of Medicine, | McGill University. Reprinted Jrom Canada Medical and Surgical Journal, March, 1877. Pontral: PRINTED AT THE "GAZETTE" PRINTING HOUSE. 1 ' f CASE OF jta>aw$*fo4 ftt mm %mwk (IDIOPATHIC OF ADDISON.) WILLIAM GARDNER, M.D., Professor op Medical Jurisprudence, McGill University ; WILLIAM OSLER, M.D., L.R.C.P. Lond., Professor op Institutes of Medicine, McGill University. Reprinted from, CAnada Medical and Surgical Journal, March, 1877, SJtoirtml: PRINTED AT THE "GAZETTE" PRINTING HOUSE. A CASE OF PROGRESSIVE PERNICIOUS ANMIA. (IDIOPATHIC OP ADDISON.) The following case occurring in the practice of Dr. Gardner, is recorded as a contribution to the literature of a disease, rare, but by no means new, in any sense, concerning the pathology of which we have still a good deal to learn, and concerning the succesful treatment of which we as yet know nothing. G. A., set. 52, a native of England, employed in a spike fac- tory, first came under observation on the 5th November, 1876. He is a thin, spare, moderately well-built man of average stature, and with gray hair and beard. He is one of a large family, all of whom, except some who died in infancy, are now alive. His mother was very subject to diarrhoea. All of the family have had at one time or another serious illnesses, which, however, in their nature, have no bearing on the present case. Two or three members of the family have had a tendency to bleeding at the nose. 0 DRS. GARDNER & OSLER. At the age of between six and seven, shortly after coming to Canada, he had a long illness of five or six months duration, the nature of which, beyond the fact that it was attended with fever of remittent type, could not be ascertained. After recovering from this illness, he continued to be very healthy and active, suffering from little except somewhat frequent, slight, and easily-controlled bleedings from the nose. He never had had free bleeding from slight wounds. He was, however, subject to occasional attacks of diarrhoea. During the last few years he had occasional attacks of lumbago, and pains in some of his joints. None of these complaints prevented him for more than a few days from continuing his employment, which, until within some months previous to his being laid up, involved a great deal of muscular exertion. About five years ago he lost, within three months, the only two sons of his family, and his friends assert that, although he did not display much emotion, he took the bereavement very much to heart, and that since then his health has greatly failed, that in particular he has become weaker and lost colour. Nearly two years ago this became so decided, that his friends induced him to go away for change of air. He accordingly went to Toronto on a visit to a sister. During the first few days he felt better, but after exposure to cold and wet he was seized with an illness, setting in with rigors, and attended with cough, bloody sputa, and delirium. This illness lasted a fortnight, and was called by his medical attendant congestion of the lungs. Ever since this illness he has been gradually growing paler and weaker, and liable during the summers, especially that of 1876, to frequent diarrhoea, never very severe, but rather constant. He would often have in the morning one or two loose motions, and during the day have no further trouble from it. The symptoms of which he specially complained were weakness, attacks of shortness of breath, when he walked in the cold air, especially if he faced a wind, and diarrhoea,__ five or six motions in each twenty-four hours. Notwithstand- ing these symptoms he had been attending regularly to his occupation, which, however, did not involve much muscular PROGRESSIVE PERNICIOUS ANAEMIA. 3 ■exertion. At this time the most striking feature of his case was a remarkable waxy pallor of the skin and mucous membranes, and a pearly appearance of the white of the eyes. He is some- what deaf; this he attributes to his occupation in a noisy workshop. Pulse rather more frequent than normal; temperature normal. Appetite by his own account and that of his friends, is good— he is able to eat meat; suffers no distress after food. Sleeps very soundly, and sleeps a great deal, much more than previous to the failure of his health. If he sits down and is let alone he is sure to go asleep. Is compelled to be up two or three times each night to make water. Urine very highly coloured ; quantity in twenty-four hours thirty-four to forty ounces ; specific gravity varied from 1012 to 1016 at different times ; no albumen ; no sugar ; no bile pigment; no tube casts. Complains of some numbness of his fingers, hands and fore- arms ; has difficulty in buttoning his clothes, or in using his tools. Complains of a throbbing, rushing sensation in his temples. Says that he has suffered from decided diarrhoea for rather more than a month, but the number of motions in each twenty four hours has not exceeded five or six. They have been painless and free from blood. Physical examination of the chest reveals nothing abnormal. The superficial cardiac dulness is normal in extent; the apex-beat natural in position ; heart-sounds not specially changed—the first sound perhaps less accentuated than normal. There is a distinct bruit in the vessels of the neck and upper part of the chest. The spleen is normal in size, or at all events not enlarged ; the liver not enlarged. The most careful examination reveals nowhere any pigmenta- tion or bronzing of the skin. There is not the slightest evidence of enlargement of any of the superficial lymphatic glands. The symptom of which he complained most was the shortness of breath, which, as already mentioned, came on when he attempted to walk facing a wind, and was so urgent as to compel him to stop for a minute or two till he recovered his breath. 4 DR^. OARDNER & OSLER. The liq. ferri pernitratis was prescribed in doses of fifteen minims in a wine glassful of water three times a day, and also a diet from which vegetables and fruits were to be excluded. At the end of a week he returned to say that his diarrhoea had almost ceased, and that he fancied himself a little better. As. on the previous occasion, he had walked from his house—fully three-quarters of a mile. There was no other change to note in the symptoms. He continued to come regularly at intervals of a week for the next three weeks. During this time the diarrhoea had entirely left him ; he was, he said, eating fairly, yet he was growing steadily weaker. The numbness of the fingers, hands and forearms was more marked, the difficulty in buttoning his clothes greater, the throbbing and rushing sensations in the head more distressing and the drowsiness more troublesome. A loud systolic bruit, much intensified by exertion, had developed in the region of the heart, loudest at the base, but heard also at the apex. The murmur in the vessels of the neck had become exceedingly loud. At this time there was no oedema of face or ankles. The attacks of dyspnoea had been much mitigated by wearing a respirator over the mouth on going into the cold air. He continued to take the pernitrate of iron during the first three weeks, but the only effect noticed from its use, if, indeed, it deserves the credit, was the cessation of the diarrhoea. The ammonio-citrate was then given instead for the next two weeks, but without the least benefit. Cod liver oil was next prescribed, but it disagreed so markedly that it was discontinued at once. He had not been seen for a fortnight, when, on the 29th Decem- ber, a message was received asking that he should be seen at his house. There was little change to note in his condition, other than an intensification of the symptoms previously noted. The pallor was more intense, the weakness greater, the drowsiness and deafness more marked, but in addition there was slight oedema of the ankles and eyelids. Yallet's pills were now prescribed and taken for a week, but without the slightest benefit, as he continued to grow steadily weaker and worse, being scarcely PROGRESSIVE PERNICIOUS ANAEMIA. 5 able to leave his bed. On the evening of the 11th January of the present year, an urgent message to see him was received. On reaching his house it was found that on being assisted out of bed to make water, he had had an attack, apparently syncopal in its nature, and that at times, especially when left to himself, he was rambling and incoherent. He, however, answered questions correctly. He was very restless; pulse 110, temperature 102°. He had also been vomiting. Jan. 12th.—Noon—Temperature has fallen to 101°. Other symptoms as at last report. Dr. Howard, Professor of Medi- cine, McGill University, saw him in consultation at this visit, and fully concurred in the diagnosis. At 10 p. m. the pulse was 105 and the temperature 97*5° Retention of urine, requiring the use of the catheter. Urine very high-colored, red-brown, acidity normal, no albumen, sugar or bile-pigment ; specific gravity, 1016. Jan. 12>th.—11 a. m.—Pulse 98, temperature, 973°. Not so restless, still incoherent; vomits everything; catheter has to be introduced regularly. Jan. 1-ith.—Died at 3 a. m. The blood examined during life presented the following appearances in a specimen obtained, in a capillary tube, fifteen hours before death, and examined without the addition of any reagent, 30" after withdrawal. (Hartnack, No. 9 im. and Oc. 3.) About one-half of the red blood corpuscles run together to form rouleaux. The majority of them appear of large size, but do not present the characteristic round contours of these bodies ; many are ovoid, others lozenge-shaped, or of various forms, with irregular projections and processes. Isolated corpuscles look of the natural pale yellow colour, but the alternating light and dark centre with the change of focus is not so distinct as usual. On touching the top cover and causing them to roll over, many do not present the biconcave appearance, but look thin and flat- tened out. A limited number are crenated. In each field -certain small round red corpuscles are seen, sometimes as many as six or eight. They are spheres, not biconcave, of 6 DRS. GARDNER & OSLER. a pale yellow colour, occasionally crenated or irregular in form. The measurements of some of the coloured elements are given below (Hartnack No. 16 im. ), from which an accurate idea is obtained of the remarkable discrepancies in size. About forty measurements were made of corpuscles taken at random in two or three specimens obtained a few days before death. Of these one was r&W by WiV\ being somewhat elongated. Five ranged from r^sn" to mW, these being the extremes. In twenty-two the range was from ^ota" 4*W to In this group the usual looking red disks occurred. In five the diameter varied from between y^ta" and roV) Small round red cor- puscles, non-nucleated, from one-quarter to one-half the size of ordinary corpuscles, and similar in appearance to the small forms seen in the blood. They occur most numerously in the marrow of the fibula, where they form fully one-fourth of the coloured corpuscles. In the sternum and ribs they are not so abundant, though occurring in each field. As described in the blood itself, they do not appear to be biconcave disks, but spheres. The colouration is quite as intense as in form a, and a few were observed to be crenated. (3) Nucleated red corpuscles, the " transitional" forms of Neumann, which are numerous in the sternum and rib, less so in the fibula, while in the clavicle and vertebra they occur scantily, or, owing to the general decolourization of the red corpuscles in these bones, are seen with difficulty. As shown by the measurements given below,they are as a rule larger than ordinary blood corpuscles, but present, like them, a perfectly homogene- 12 DRS. GARDNER & OSLER. •ous coloured stroma, in which a finely granular nucleus is imbedded. They are spheres, not biconcave, as a rule round, though frequently irregular in outline, or with one end pointed and prolonged. The intensity of the colouration in most cases equalled that of the ordinary red corpuscles, in some instances being deeper, in others not so marked. The nuclei are either round or elliptical, and occupy from one-quarter to one-half of the body of the cell (see measurements). They are solid, granular, and inside the corpuscle look coloured, though not so •deep as the surrounding substance. The presence of nucleolus could not be determined, The position in the cells is variable ; in specimens examined within a short time after the post-mortem they appeared to be chiefly centric, but in preparations taken the next day very many of them had become quite peripheral, while others had protruded almost through the corpuscle, when it could be clearly seen that the nucleus was colourless. In several instances the nuclei are seen to be entirely outside the cells, though remaining attached to them. In this condition they look not unlike the small lymphoid marrow cells, and it is only the large size of the corpuscles to which they adhere, and the fact that in the same field others may be seen half-way out, that enables a correct opinion to be formed. In three or four instances dumb-bell-shaped nuclei were noticed. Cells with two nuclei were not uncommon, and instances with three and four were observed. As remarked above, the nucleated red forms are numerous in the sternum and rib, six to eight being seen at once in the field of the No. 9 im. and 3, while in the fibula not more than three or four were noticed in any single field. In fifteen measurements of these forms, eleven were above the roV ; five being -nW- The following measurements are of three corpuscles with their contained nuclei:—(1) ttV*" by «W ; nucleus ^"by y*W. (2) WoV by *-3Vt"; nucleus M' by ttoW. (3) Wst" by t-.V ; nucleus ^V by ^W". A good idea of the irregularity in outline of these corpuscles and the slightly elliptical character of the nuclei may be gathered from the above. (4) Cells containing red blood corpuscles. These are very PROGRESSIVE PERNICIOUS ANJEMIA. 13 abundant in the marrow of the vertebra, three or four occur- ring in the field at once, and containing from five to six red corpuscles, the colour and outlines of which in most cases are preserved. In the sternum and rib they are not nearly so numerous ; in the fibula and clavicle they were not observed. (5) Myeloplaques, of which one or two only were met with in the marrow of the sternum and rib. Neither in the shaft nor epiphysis of the fibula could these forms be determined. (6) Fat cells, which are present in marrow of the clavicle in small numbers, absent in the sternum, vertebra and rib. In marrow from the fibula an oil-drop is occasionally met with in the field, but here also they are almost entirely absent. (7) The octahedra crystals, first described by Charcot, and which always occur in the marrow from twelve to thirty-six hours after death. Remarks.—Apart from the clinical features and general pathological appearances of the above case, which show it to be an exceedingly typical one, there are two points of special interest, viz., the appearance of the blcod, and the condition of the bone marrow, both of which are deserving of a few com- ments. Prof. Eichorst has drawn attention in a short note* to the presence in the blood of patients suffering with pernicious anaemia of exceedingly small red corpuscles, which he regards as pathognomonic of the disease, and affording a valuable diag- nostic sign, being present in all of his cases, seven in number. The following are his own words : " Some of the red globules are of normal size, but very pale and have lost their tendency to form rouleaux, others scarcely attain £ the diameter of a normal, perfect corpuscle, so that they look like small drops of fat tinged red, and have not their bicon- cave appearance." Towards the latter stages of the disease he states that they increase, so that before death they may equal in number the common forms. The histological examination, both before and after death, • Centralblatt f. die. Med. Wissen. June 24th, 1876. 14 DRS. GARDNER & OSLER. and the measurements above given, show that in this instance the blood did contain an unusual number of small coloured elements, and is so far confirmatory of Eichorst's statement. Though not abundant, they were quite numerous enough to attract attention, and offered a striking contrast to the other red corpuscles about them, many of which were large, flattened out, and less biconcave than usual. A great variation in size was noticed in all the specimens examined, and range as given in the measurements, from r«V to ^oW" must be regarded as very remarkable. That these tiny elements are red corpuscles there can be no doubt, as with No. 16 Hartnack (l-36th) they appear homogeneous, of a pale yellow colour, and, like the larger forms, are sometimes crenated. In the third case reported in Dr. Howard's paper on the subject,* the blood of which one of us (Dr. 0.) had an opportunity of examining in the spring of 1875, the note on the appearances of the blood is as follows: " There is a somewhat unusual variation in size among the red corpuscles, many of them scarcely measure the roWtb part of an inch in diameter. The white corpuscles also present slight variations in size and are more granular than normal. Max Schultze's granular masses are abundant." Cohnheim, in a case which will be more fully referred to hereafter, states that the presence of the small blood corpuscles was established. Quinckef also speaks of the inequalities in the size of the red blood cor- puscles, many of which were small and round. In three of his cases these smaller forms presented great irregularities in con- tour. These are, I believe, the only positive observations on this point. On the other hand, there is a note by Prof. Grainger Stewart of Edinburgh.$ in which he states, that the blood in two cases of pernicious anaemia, under treatment at the time, did not present the small red corpuscles described by Eichorst. Among recent cases in which the blood was carefully examined, * Eead before the International Medical Congress at Philadelphia, and being published in the forthcoming Report. f Volkmann's Sammluug Klinischer Vortrage, No. 100., translated in Medical Times and Gazette, Oct. 14th, 1876. t Brit. Medical Journal, July 8th, 1876. PROGRESSIVE PERNICIOUS ANAEMIA. 15 and no mention made either of small forms or great variations in size are those of Pepper,* Scheby-Buch,f Pye Smith,:}: Lepine.§ Bradford,|| in his case, made a most careful examin- ation of the blood, and reports not much variation in size, but that all are rather smaller than usual. In Ferrand's case^[ many of the red blood corpuscles were larger than normal, no mention is made of any diminution in size. In Bradbury's case** the red corpuscles were larger than normal, pale, and exceedingly irregular in shape. No small forms were noticed. Burgerff did not notice any great variations in size, but a peculiar paleness about them. Immermann^ makes no men- tion of alterations in form or size in the red corpuscles. The presence of very small red disks in healthy blood is not common, still, one of us (Dr. 0.) has occasionally measured forms not *&Voth of an inch in diameter, both in his own and in the blood of other quite healthy individuals. Laptschinsky§§ has also found these small corpuscles in the blood of patients with various febrile affections, and speaks of them as being numerous, about J the size of ordinary red corpuscles, some having an intensely red colour, whilst others are pale. In the blood from the above reported case, drawn in capillary tubes, and not examined until some hours after, many of the red corpuscles appear as deeply coloured spheres, slightly smaller than natural. This is a physical alteration, resulting apparently in a change from a disk-shape to a sphere, with, perhaps, a condensation of the corpuscle. These forms were not present in perfectly fresh blood, but could be seen in the slide six or eight hours * Amer. Journal of Med. Sciences, Oct. 1875. t Deutches Archiv. f. Klin. Medicin, April, 1876. t Virchow's Archiv. Bd. 65. hft. 4. Dec. 1875. § Bulletin General de Therapeutique, 30 Julliet, 1876. || Boston Medical and Surgical Journal, May, 1876. if Bulletin General de Therapeutique, Dec. 15, 1876. •* Brit. Medical Journal, Dec. 30, 1876. ft Berliner Klin. Wochenschrift, No. 33, 1876. tt Ziemssen's Handbuch der speciellen Path, and Therap. Dd. xiii. Art. Pro. Pernic. Anaem., 1875. §§ Centralblatt f. d. Med. Wissen. No. 42, 1874. 16 DRS. GARDNER £ OSLER. after mounting. It is interesting to remark with reference to the large corpuscles, that Hayem* states that during a long course of iron—just such as this man had been subjected to— the red disks undergo an increase in volume. Until we possess more definite knowledge than we do at pre- sent of the variation in size of the red corpuscles in constitutional and febrile diseases, it would be hasty, from the limited number of observations, to conclude that the presence of the small coloured corpuscles is pathognomonic of, or even affords a positive diag- nostic sign in, progressive pernicious anaemia. It remains for subsequent observors to note accurately the size of the red corpuscles in this disease, and it will not be long before we are in a position to arrive at a satisfactory conclusion on this inter- esting point. In a disease like pernicious anaemia, which after death is is not characterized by any important lesion in the viscera or glands, it was natural that attention should be directed to the bone marrow, a structure now ranked among the blood-forming organs, and which in leukaemia, and pseudo-leukaemia (anaemia lymphatica, or Hodgkin's disease) has been found remarkably altered, so much so that myelogenous forms of both have been described. With the two affections just named the one in ques- tion is closely allied, and in its clinical features almost identical. From the splenic and lymphatic forms of both, it is distinguished by the absence of enlargement of the spleen and lymphatic glands, and additionally from leukaemia by the failure of any increase in the white blood corpuscles. In those rare cases of leukaemia, where the disease is confined to the bone marrow— myelogenous form—the only distinguishing feature is the excess- ive number of colourless corpuscles in the blood, with, perhaps, tenderness over the affected bones (Mosler). Immermannf quotes a case in illustration of this. In the still rarer cases of myelogenous pseudo-leukaemia, where the affection is uncomplica- ted with disease of the spleen or lymphatic glands, a differential diagnosis would be impossible, (compare the remarkable cases * Bulletin General de Therapeutique, Dec. 15th 1876. t Loc. Cit.p. 651. PROGRESSIVE PERNICIOUS AN/EMIA. 17 given by Wood*). It is not to be wondered at that some writers (Immermann and Jaccoudf) should hint at the identity of the two diseases, or that Pepper, encouraged by the appearance of the marrow in one of his cases, should state that progressive pernicious anaemia was " merely the simple medullary form of pseudo-leukaemia.'' The evidence of an implication of the marrow in this disease rests upon the following reports: the first case in which it was examined was one of Pepper's, in which the marrow of the radius and sternum was " made up almost entirely of small granular cells." Passing over a case observed by Fede,$ and recorded as one of pernicious anaemia, but which ought to be regarded as a well-marked myelogenous pseudo-leukaemia, the next observation is by Scheby-Buch,§ in one of whose cases the marrow of the radius was pale red in colour, and contained numerous cells like white blood corpuscles, and very few red corpuscles or fat cells. In Lepine's|| case nothing unusual was found. Burger^ states that there was no affection of the marrow in his case. By far the most extended account of the changes in the marrow in this disease is that given by Cohnheim in a letter to Virchow.** The following is a summary of the appearances described : Marrow of all the bones intensely red ; fat almost entirely absent. Microscopically there were (1), ordinary marrow cells of various sizes, some small and lymphoid in character, others large and with vesicular nuclei; (2.) coloured elements in almost equal number, of these the common, biconcave, red blood corpuscles formed a decided minority, while the number of red non-nucleated corpuscles of various dimen- sions was very evident. The smallest of these had the diameter of normal red blood corpuscles, the largest were more than * Am. Journ. of Medical Sciences, Oct. 1871. f Nouv. Diet, de Med. et de Chirurg. Leucocythemie. X Quoted in Centralblatt; f. die. Med. Wissen., Oct. 16th, 1875. % Loc. tit, II Loc. cit. * Loc. cit. No. 34, 1876. •• Virchow. Archiv. Bd. Ixviii, Hft., 2. Oct. 26, 1876, 3 18 DRS. GARDNER & OSLER. double the size of colourless blood corpuscles, and between them forms intermediate in size. (3.) Nucleated red cor- puscles in great abundance, and of various sizes, the majority equalling in size the smaller of the true marrow cells. The blood examined after death was also found to contain a few of the nucleated red corpuscles. In Quincke's article no details are given, and this part of the question is disposed of with the remark: " The marrow of the bone showed no abnormality." In Bradbury's case, the red marrow from the right tibia looked natural, and was made up almost entirely of granular spheroidal cells, like white blood corpuscles. In that from the sternum the cells were much larger, and red globules more abundant. Coloured corpuscles were not numerous. These are the only facts for and against the view that perni- cious anaemia is the medullary form of pseudo-leukaemia. The general statement of Quincke, and the more definite ones of Lepine and Burger, are not very satisfactory, as no details are given ; still, they must be accepted as negative evidence. It may be held with Bradbury* that the changes in the marrow of the sternum and radius in Pepper's case were scarcely sufficient to indicate serious disease of that structure, as only the normal elements were found, though in the radius in slightly increased numbers, and the same may be said of Scheby-Buch's case. In Cohnheim's case and our own the constitution of the medulla was altered, and, in addition to ordinary marrow cells, it contained lymphoid corpuscles, embryonal forms,! and red blood corpuscles of various sizes. The detection, too, in both, of the embryonal forms in the blood, though in quite insignificant numbers, places them apart from the others ; and on these grounds they alone are strictly comparable with myelogenous leukaemia. Indeed, the question at once arises whether we have not to do here with * Loc Cit. t In a recent note in the Archiv. f. Mikroscop. Anatomie, Bd. xii. p. 796 Neumann expi'esses a wish that the term <« transitional," as applied to the nucleated red corpuscles, should be dropped, as involving an hypothesis about their origin, advanced rather too confidently by him. He would substitute the term " embryonal" of " developmental" form. PROGRESSIVE PERNICIOUS ANEMIA. 19 an uncomplicated case of medullary pseudo-leukaemia, similar to one of those described by Wood*. A consideration of the symptoms will not help us, and the remarkable admission must be made, that while the ante-mortem diagnosis of pernicious anaemia was correct, a post-mortem one of pseudo-leukaemia might be equally so. The absence of these changes in the marrow in the cases of Quincke, Lepine, and Burger proves that the disease in certain cases is independent of any affection of this structure ; and we must either regard implication of the marrow as an accidental complication, having but little to do with the cause or progress of the disease, or refer all cases in which it is met with to the cate- gory of myelogenous affections. .Can the state of the marrow be regarded as an accidental complication, a secondary change, depending on the grave constitutional disease ? Our knowledge of the condition of this tissue in disease is not at all complete, and the only observations at hand on the subject are the following: Neumannf met with great hyperplasia of the marrow in a case of Addison's disease. Wood, in a paper already referred to, says, that he has " made a number of examinations of long bones taken from patients dead of various chronic diseases, and never, except in a single case, found any abundance of the leucocytes;" and this was probably a case of leukaemia. In 14 examinations made by Dr. Osier of the marrow of the long bones, obtained chiefly from chronic Hospital cases, in only one was there found hyperplasia and marked alteration in its constitution; and in this instance there is a strong proba- bility of the case belonging to the group under consideration. Altogether, the few facts we have are opposed to the view that in chronic diseases, accompanied with anaemia and wasting, hyperplasia of the marrow of the long bones occurs as a secon- dary change. CohnheimJ writing to Virchow, on his case, says, " You will • Loc. Cit. p. 293. t Quoted in Quarterly Journal of Microscopy, 1871. X Loc. Cit. p 382. 20 DRS. GARDNER £• OSLER. certainly agree with me in taking for granted that the above described condition of the marrow stands in intimate connection with the fatal disease of the patient. That in this affection (progressive pernicious anaemia) we have to deal writh a pro- found disturbance in the constitution of the blood all observers are at one ; and, on the other hand, it can at present be no longer doubtful that an important disease of the marrow must have a serious influence on the composition of the blood." With this statement we concur, and are inclined to regard the affection of the marrow in our case as the fons et origo mali. Our best thanks are due to Dr. Howard, of McGill University, who in his lectures has long taught the existence of Addison's idiopathic anaemia, and who kindly allowed us to have access to the manuscript of his paper on the subject. INTRODUCTORY LECTURE ON THE OPENING OF THE FORTY-FIFTH SESSION MEDICAL FACULTY MoGILL UNIVERSITY OCTOBER 1st, 1877. V WILIJAM OSLER, M.IX Professor of the Institutes 'of Medicine. (Uonttjeal: DAWSON BROTHERS, PUBLISHERS. 1877. INTRODUCTORY LECTURE ON THE OPENING OF THE FORTY-FIFTH SESSION MEDICAL FACULTY MoGILL UNIVERSITY OCTOBER 1st, 1877. BY william: osler, M:.r>. Professor of the Institutes of Medicine. y GRontneal: DAWSON BROTHERS, PUBLISHERS. 1877. PRINTED AT THE OFFICE OF THE "GAZETTE," MONTREAL. INTRODUCTORY LECTURE. Gentlemen of the Faculty,—The duty of delivering the introductory lecture has this year fallen to my lot, and however opinions may differ as to the necessity or advisability of beginning the session with such an address, there can be no doubt of this—that it affords an opportunity, rarely given, of offering to the assembled students words of welcome, advice, and encouragement — an opportunity, the responsibilities of which come home to one with the thought of these young and eager lives just entering upon the serious work of life, and to be influenced for weal or woe, perhaps by what the Introductory Lecturer may say, and most certainly by what we as a Faculty do. Students of Medicine,—My first duty, then, is to bid you on behalf of the Medical Faculty a hearty welcome ; and I do so most sincerely, feeling sure that I express the sentiments of every one of your teachers when I say that you come now into the society, not of mere Professors who will lecture at you from a distance, but of men who are anxious for your welfare, who will sympathize with your difficulties, and also bear with you in your weaknesses. I can offer no better welcome than to tell you this. I see among you many with whose faces we are all familiar, who return, and not for the first time, to these benches. To such, words of welcome are superfluous ; I will only say we rejoice to see you back, we trust with refreshed bodies and invigorated minds, to pursue the work of the session. To those of you who for the first time occupy seats in this class-room the 4 occasion is a memorable one, to which I trust you will look back in after years with exceeding pleasure as the starting point of a career of usefulness and honour. For you we have a special sympathy. Look upon us as elder brothers to whom you can come confidently and fearlessly for advice in any trouble or difficulty. On such an occasion as the present it is natural that you should expect to hear from me something about the profession of your choice, its position, the prospects it holds out to you, and the relation that you as students bear to it. Probably there are few among you who could give a very logical explanation of the causes which induced you to adopt this in preference to other callings ; with one it has been the influence of a friend; with another, perhaps, hereditary predisposition ; with a third a sud- den inspiration ; with another that innate enthusiasm for the science which is akin to the natural gift that makes of one man an artist, of another a musician, an inborn natural fitness for that special work and no other, which the man's surroundings, whether fostering or adverse, can neither give nor take away. From these last arise our greatest men ; for others it matters little in what way the impulse has come, so long as the feeling now thoroughly possesses you, pene'trating every fibre of your being, that this above all others is the profession you can most heartily embrace. If, however, any man of you here enters upon it with the idea that it will do as well as another, that other will most probably be better for you. Lukewarm- ne33, bad enough at any time, is simply fatal at the beginning of a life-long career, when it usurps the place of that enthu- siasm that should bend the man's whole nature to serve him willingly in the work that he has chosen. In addressing a few words to you on the position which the medical profession at present holds, I must admit that different men hold very opposite views on this point. Some will tell you that the profession is underrated, unhonoured, under- paid, its members social drudges—the very last profession they would recommend a young man to take up. Listen not to these croakers ; there are such in every calling, and the secret of their 5 discontent is not hard to discover. The evils which they deprecate, and ascribe—it is difficult to say to whom—in themselves do lie,—evils, the seeds of which were sown when they were as you are now ; sown in hours of idleness, in inatten- tion to studies, in consequent failure to grasp those principles of their science without which the practice of medicine does indeed become a drudgery, for it degenerates into a business. I would rather tell you of a profession honoured above all others ; one which, while calling forth the highest powers of the mind, brings you into such warm personal contact with your fellow-men that the heart and sympathies of the coldest nature must needs be enlarged thereby. For consider the practical outcome of all the knowlege you gather ; the active work for which your four years' study is a preparation. Will not your whole energies be spent in befriending the sick and suffering ? in helping those who can- not help themselves ? in rescuing valuable lives from the clutch of grim disease ? in cheering the loving nurses of the sick, who often hang upon your words with a most touching trust ? Ay ! and in lessening the sad sum of human misery and pain by spreading, as far as in you lies, the knowledge and appreciation of those grand laws of health transgressed so ignorantly and yet avenged so fatally ? It cannot be denied that, (excepting the clerical profession, the members of which, in this country at least, can seldom look for the fruit and reward of their labours on this side Heaven), there are fewer great prizes open to the medical man than to others from whom along and special training is demanded. He is not raised to command his fellow-men; his name is not im- mortalized in history and song like those of the gallant veterans who wear her Majesty's uniform, and risk their lives for their country and their Queen ; he does not sit among the judges of the land ; the high places of brilliant statesmanship are not for him ; while the world at large can reward him with little beyond a successful practice in which every dollar that he earns repre- sents its equivalent in hard continuous work. But while the soldier and the statesman win honour and fame, the family physician will draw to himself the love and gratitude of manifold 6 hearts ; he will have no enemies, martial or political; and his labours if directed by a wise and prudent skill, will be for the welfare and benefit of all. Such honours as are open to him lie chiefly within his own profession and the small circle of the scientific world. Among these his name may be as a house- hold word, his opinions may be quoted as conclusive, his writings become standard works ; and these honours are very real and very satisfactory. I need only quote such names as Harvey and Hunter, Jenner and Virchow, to show you what I mean. But let the student remember that while influence or party may advance a man in other professions above many suoerior to- himself, the hero in medical research must wholly depend upon his own deservings. To take a foremost place in the wary and critical field of science he must excel. And these remarks naturally bring me to a consideration of the state of the profession in this country. Though not so ad- vanced in the scientific departments as in the older countries of Europe, yet I think the condition is one for congratulation, for in practical work and in the average of attainments the members of the profession in Canada yield to those of no other country; and this is what should be desired, for general professional excellence brings about the greatest good to the greatest number. For this we have largely to thank that wise conservative spirit which directed the founders of our medical institutions, and which has ever since remained with the promoters of medical legislation in this country. While across the border the stan- dard of qualifications has been gradually retrograding, and not until now, upon the chaos which resulted from the Free Trade principle applied to medicine, is the light breaking and with it glimpses of a future full of hope, the people in Canada have enjoyed the benefit of a uniform medical curriculum, modelled after that adopted in Great Britain, to which all students have had to conform—a benefit which many of our citizens fail to appreciate, having had no practical acquaintance with the opposite condition. Early in the history of this country, before the establishment of universities, the medical men found it necessary for their own protection to organize, and to obtain 7 powers from Government to inspect and verify the degrees and diplomas of persons wishing to practice, and also after a suitable course of study to examine men for their license. With the establishment of medical schools these organizations became, to a large extent, mere registering corporations, though still possessing the power to examine, and to grant licenses. Latterly, however, owing to the increase in the number of medical schools, and the consequent latent distrust in the profession that undue rivalry between these might, as in the United States, lower the standard of attainments, there has been legislation to take in part or altogether from the universities their power of granting the license to practice together with the degree. In the Provinces of Quebec and Ontario the changes are in different stages of development. In the former the first step only has been taken, and while the preliminary examination has been removed from the hands of the universities the power to practice still accompanies the degree on its regis tration. The recent Act of the College of Physicians and Surgeons of the Province of Quebec, while modifying the Constitution of that body to some extent, influences medical education in two ways : 1st, by requiring all students belonging to this Province to pass the matriculation examination of the College, and to spend four subsequent years in the study of medicine, the first session to be attended immediately after the matriculation examination, the standard of which has also been somewhat advanced, French and Literature being now compul- sory subjects ; 2nd, in nominating visitors to see that the colleges do their work faithfully, and that the examinations are conduct- ed properly. This latter is, in my opinion, a weak point in the recent legislation, but as it is probably only temporary there is less cause for regret. Passing on to consider the more devel- oped system in connection with the profession in Ontario, incorporated as the College of Physicians and Surgeons of that province, we find there that colleges and schools of medicine are merely teaching bodies, the power to grant license to practice being vested solely in the Council of the College, and obtainable only by examination. So also the preliminary 1 s examination of that body is compulsory upon all medical students of that Province. Opinions differ very much regard- ing the Ontario Medical Council, and it is not to be denied that as a body the members have laid themselves open to criticism, but no one can question that its existence is fraught with much good to the profession, and that it has influenced medical education very beneficially and may do so yet more. In the establishment of annual examinations, they have, I think, conferred a boon upon the students, which the students, I am sorry to say, have been slow to recognize. I would urge upon the Ontario men among you to conform in all particulars to the laws of your Province, for you may rest assured of this, that you will have no sympathy from us in any attempts to evade them. Thus the men among you who neglected to present yourselves for the first annual examination last spring, felt aggrieved when the Council determined that your obstinacy should cost you a year. I had letters from several of you expecting sympathy, but you came to the wrong quarter. Breakers of the law must abide by the consequences : though I believe in this instance, as it was the first offence, the Council will permit you to take both the 1st and 2nd year's examination next spring. In the other Provinces of the Dominion the old system is still in force, and the profession has not such control over its educational matters as in Quebec arfd Ontario. It seems a pity that a central examining board could not be established for the whole Dominion, but there are serious difficulties in the way, difficulties which I do not think will in this generation be overcome. The best we can hope for will be central examining boards for each Province, a uniform curriculum, a uniformly high standard of examination, and general reciprocity. Turning from these matters of medical politics, let me try to answer the question which has, I am sure, come to each one of you more than once in the past few days, " How shall I best occupy my time ? " To answer this [ take to be one of the chief uses of such a lecture as the present. To those of you who now begin the study of medicine this is an all-important 9 period, for what you do this session will probably be an index of what you are capable of doing, and will certainly have a great influence upon your college career. Five subjects will mainly occupy your attention : anatomy, physiology, chemistry, materia medica and botany. The three first constitute the frame-work of medical science, a portion of which must this session be put together,—and allow me to indicate how much. In anatomy you should confine your attention to mastering the bones, ligaments, and muscles, their general arrangement, individual peculiarities, and mutual relations. Do not attempt to do more, but try to accomplish this. Three extremities, at least, should be dissected, which, with the lectures, ought to give ample opportunities for mastering your work in this branch. In physiology you must learn the constituents or components of bones, muscles, and the other textures of the body ; the nature and properties of food, and how it is digested ; about the blood, the manner of its circulation, and the method of its purification. In chemistry you must master the principles of heat, light, and electricity, and the non-metallic elements. In materia medica, strive to see and handle all the drugs you can, find out what they are made of, and get a notion of the dose of each. Ignorant as you are of disease, a knowledge of their application will be more suitable later on. Botany will be useful to you chiefly as an introduction to materia medica; it is thought necessary that ^ou should be fully acquainted with the structure and organization of plants the better to appreciate the medicinal virtues of certain of them. Do not, however, regard it, as I have found in the past three years many men do, as the essential subject to be studied in your first session, to the neglect of more strictly professional work. Those who like can take up the structure of animals, zoology and comparative anatomy, instead of botany ; and I have been surprised that so few men do so, for the grasp of principles obtained in a careful study of the form and nature of animals, and the bearing of this upon human anatomy and physiology, is more valuable, in my opinion, than the benefit derived in the study of materia medica from a previous course of botany. 10 One thing, however, do not attempt—to take both ; you have not time for that. Shall you attend lectures in any of the final branches during your first year ? Most emphatically, No ! It would be as reasonable to ask men to listen to lectures in German when they did not know the language. Some of you, however, having studied a year with a physician, purpose spending but three years in college work, and then you must needs take one or two of the final branches in your first session. If you have been diligent in the preparatory year you may appreciate them, but otherwise it will be so much time wasted. The question whether the first year student should see hospital practice is different, and one upon which there is less agreement; some believing that he should defer this until the second session, others that he should begin at once. I hold with the latter. An hour spent daily in the out-door department of the hospital in attentively watching the examples of disease brought in will do much, especially if combined with a little instruction, towards educating powers of observation in a student, and giving him a general idea of the names and appearances of many maladies ; while every one of you can learn within the next six months to detect fluctuation in an abscess, and how to open it; to recognize crepitation in a fracture ; and to master many other little practical details, which you cannot know too soon. My advice to you then on this point is, attend the out-door department of the hospital when you can ; the time, from 11 to 12.30, is very convenient, except when you have dissecting to do in the morning. From these remarks you will see that a full programme is prepared for you, and it is for each one of you to set about the task with energy and determination. Gradually those difficulties will vanish which at first appeared insuperable. I remember well, when beginning the study of medicine—it is but ten years ago—with what enthusiasm I took my Gray's Anatomy and attempted to master the structure of one of the cervical vertebrae, and though I succeeded in making a little headway, yet the matter seemed so difficult—the bones were 11 indeed very dry—and, turning over the leaves of that ponderous volume, the subject of anatomy appeared so vast, that my heart sank within me and I felt despondent. You will also have moments when the way appears rugged and the out-look dark, but never fear ; others have succeeded in the face of the same difficulties, and with patience and perseverance you will do so too. Banish the future ; live only for the hour and its allotted work. Think not of the amount to be accomplished, the difficulties to be overcome,, or the end to be attained, but set earnestly at the little task at your elbow, letting that be sufficient for the day ; for surely our plain duty is " Not to see what lies dimly at a distance, but to do what lies clearly at hand." To the second, third, and fourth year men among you, I need not enter into the details of the work required in your respective classes. I will only mention here that both materia medica and chemistry may now be passed at the end of the second session, and I would earnestly advise the second year men to take advantage of this. Those who feel competent can present themselves for the practical anatomy examination, so that in this year you will only have chemistry, materia medica, clinics, and, perhaps, one final lecture to take, which will be quite enough if attended to properly. Second year men, as a rule, take too many lectures ; this is a great mistake. Four lectures a day are as many as the student can well digest. And now let me add a word of advice on the method of study- ing. The secret of successful working lies in the systematic arrangement of what you have to do, and in the methodical performance of it. With all of you this is possible, for few dis- turbing elements exist in the student's life to interrupt the allot- ted duty which each hour of the day should possess. Make out, each one for himself, a time-table, with the hours of lecture, study, and recreation, and follow closely and conscientiously the programme there indicated. I knoAV of no better way to accom- plish a large amount of work, and it saves the mental worry and anxiety which will surely haunt you if your tasks are done in 12 an irregular and desultory way. With too many, unfortunately, working habits are not cultivated until the constraining dread of an approaching examination is felt, when the hopeless attempt is made to cram the work of two years into a six months session, with results only too evident to your examiners. The science and art of medicine is progressive ; therefore, colleges and teaching bodies, representing as they do the embo- diment of it, must progress with it and that on several lines. Not only must the results of practical and scientific labour in the different departments be incorporated in the lectures, so that in every subject the teaching may keep pace with the times, but new and better methods of instruction and examination must be adopted, and many other improvements made which shall be for the benefit of the student. At this more than at any other time within the past fifty years the leading minds in the profession are occupied with the subject of medical education, and there is an almost universal feeling that in many quarters reform is needed. It is probable that the next decade will see radical changes in the modes of tuition, while practical work will be introduced more and more largely into every department. With all beneficial reform the Medical Faculty of McGill University will sympathize, asking her students to participate therein, believing not in stereotyped forms but in steady onward progress, convinced that— " On our heels a fresh perfection treads, ........ born of us, Fated to excel us." To some recent changes I would briefly call your attention; and first to the practical examinations in anatomy. Though it has always been customary for the Demonstrator to test the knowledge of the student on the subject, and while the oral part of the primary examination was made more or less practical, yet it was felt that something more might reasonably be expected of you. Therefore, examinations in practical anatomy have been established, modelled after those of the Royal College of Sur- geons, England. Nothing will give you greater confidence when you enter upon practice than an intimate acquaintance 13 with anatomy, and that you can obtain to perfection in our dissecting room. The advantages in this branch are very great; remember that we shall look for proportionate effort on your part. Practical examinations will also be held by the clinical professors in medical and surgical anatomy. Attendance upon the lectures in hygiene is now compulsorv. From 1871, when the course was established, the Faculty felt that, notwithstanding the importance of this subject, they could not reasonably add it to the already numerous compulsory studies. This, however, has now been done, and being a depart- ment of medical science so necessary to the well-being of society, dealing as it does so largely with the prevention of disease, there is no cause for regret in this action on the part of the Faculty, save that it binds an additional burden on backs already well laden.—still it is one which if rightly treated will not be hard to carry. The abolition of Theses is a change which, I am sure, you will all appreciate. They Avere relics of the past, and though for- merly they might have been an important means of ascertaining a man's capacity and judging of his fitness for a degree, this is now done in other and more effective ways, and the Thesis had degenerated, as a rule, into a very inferior medical essay quite devoid of origiuality. At universities where the degree of Bachelor of Medicine precedes the Doctorate, the writing of such an essay "for the latter appears reasonable, but where, as at McGill, the M. D. is granted at once, it is superfluous. One regret goes with it. " Defence of Theses " is no more—a day regarded by candidates with very mixed feelings; an uneasy nervousness about one's own effort, and the criticisms it would call forth ; and a natural curiosity to hear the comments upon the productions of brother students. The day, as a rule, was productive of little good, for the Theses were rarely defended and the best that can be said about it is that it was sometimes a pleasant gathering. Many a joke has been made, and much laughter excited over the mistakes of unfortunate competitors, but occasionally a sensitive spirit has been unintentionally bruised, and has left us with feelings of bitterness which would 14 long mar that pleasant and affectionate remembrance of hia university life which we would fain have each one of you carry with him to the end of his days. At the hospital the attendance is increased to eighteen months, while very important changes have been made in the clinical department whereby the method of teaching has been more systematized. Instead of having clinical Medicine daily for the first three months of the session and clinical surgery in the last arrangements have been completed under which the two classes will be carried on simultaneously throughout the six months' course, the class taking clinical medicine and clinical surgery on alternate days, having in each subject one lecture weekly in the theatre and three demonstrations at the bed-side. You will find this plan greatly conducive to your advancement, and I look upon it as a strengthening of what has always been a strong point in this school, a point upon which the reputation of any school must mainly depend, viz : the effectiveness of its clinical teaching. And further, it is no longer taken for granted that you will compound medicines during the summer months either at the hospital or with your preceptors, but you are compelled by law to spend at least six months in so doing, and to present a certifi- cate for the same before qualifying for your degree at the university. And lastly, the amount of material at our command will enable us to extend the pathological teaching of the school. The system Ave have followed heretofore was good but incomplete. It is impossible properly to instruct students how to perform post- mortems and at the same time to demonstrate fully to them the lesions met with. I purpose this winter establishing a weekly demonstrative class, in imitation, however feebly, of the course conducted by Virchow in Berlin, in which the material collected may be made thoroughly instructive to the final men among you. Pathology is the ground-work of clinical medicine, and if you wish to obtain a true insight into disease never neglect an opportunity to see and handle its effects on the various organs and tissues of the body. 15 I trust the Medical Society, established during the past sum- mer session, will receive your hearty support. To those of you who take advantage of it the benefit will be inestimable. It affords opportunities Avhich after graduating you can never have of learning how to prepare papers and to express your ideas correctly, while it is also a training in the difficult science of debate. To a man who has made his start in life, who having chosen his path is now following it day by day, there is something heart-stirring in the sight of a number of young men, such as those who are gathered here, just entering on the race which they will run with such varied poAvers, with such different results, in the busy arena of the world. For he knows that on such an occasion their hearts must be seething with thoughts of the future and of all that it may be to them. What high hopes swell the breasts before him ! What earnest resolves are hidden behind the brave young faces ! What steadfast aims are set as the goal which shall reward the worker for each " passionate bright endeavour " that he makes ! Surely such thoughts are to each man among you as a trumpet-call, summoning the young recruit to fall into his rank on the battle- field of life. And further, like some soft, familiar melody running through the clangour of martial music, the thought of home must needs mingle with all others, till the student's fondest hope is the hope that he may be the pride of those who have cherished him from his childhood ; his firmest resolve the resolve to do nothing unworthy of their trust in him ; his holiest ambition to satisfy their loving desires for his welfare and advancement. To the younger ones in such an assemblage as this, who are but just entering on college life the new sense of liberty must be paramount. No longer subject to the narrow rules of school-boy days and to the penalties that enforce them ; released from the gentler, but no less real, restraints of home ; bound only by the laAvs of his Alma Mater, Avhich demand little from him that he would not willingly give, the youth feels himself for the first time his own master, and the sense of freedom rouses the growing 16 manhood within him and gives impulse to that self-reliance and independence of action that in after years brace the man for the deeper responsibilities of life, when the power to choose is no longer a delightful novelty, but an anxious care. So much for the inspiriting feelings which animate the student at the beginning of a fresh course ; but I am sure many can bear me out in saying that thqse are not all. The fear of failure underlies every effort, and this fear must be specially present to those who run the competitive race of a university career, in which a man naturally desires, not only to reach the standard which shall secure him his degree, but also to take a high place among his fellows. This fear of failure abides with some, paralyzing their energies and growing more burdensome as time wears on and their test day is near. But let the student take courage ; for though in the nature of things only one man can carry off the highest honours, I doubt if there be one among you who cannot come out well at the end of the session if he will only work as he ought. Remember, moreover, that: " E'en when the wished end's deny'd, Vet while the busy means are ply'd, They bring their own reward." Looking round upon you all I feel no doubt that the majority are resolved to make good use of their time, to study in,earnest, and to take a creditable stand in those examinations which in a few months will test the work of every one of you. How comes it then that so many fall away from such good intentions ? Why is it that some barely pass who should come out with flying colours ? Why do others fail altogether ? Not, as a rule, from want of mental capacity; not from a lack of the bodily stamina necessary for a course of severe study ; but rather from a failure in steadfast perseverance. Men begin well; they are diligent in their attendance at lectures, they throw their hearts into their practical work, they read early and late; but after a time the old temptation comes over them, a temptation as old as human nature itself, one that assails every age and every path in life, the temptation which the old Israelites felt when 17 " The soul of the people was much discouraged because of the length of the Avay" Men get tired of continuous study, their hearts grow sick under the monotonous daily grind. The more buoyant spirits feel their youth and health strong within them, they relax their rules, they go into society, they begin to spend their evenings in ways more pleasant than in the dry digestion of books ; the hard bit of reading is slurred over, the looking up of the lecture notes is put off. " What matter," they think, " it can soon be made up." And so the man becomes an idle man, half-hearted in all that he does, and the grand powers within him lie fallow for want of that earnest per- sistent exercise of them which alone can bring out their latent strength and make the student all that he might be. But it would not be fair to attribute all failures to this cause. There are some men who fall short, not so much from want of application as from lack of hopefulness. They do not remember their reading as they wish ; they do not grasp scientific principles as they expected ; difficulties thicken ; they grow someAvhat bewildered with the extent and variety of knowledge required, and at last give up in despair that engrossing effort which alone can carry them through. " What is the use," they say, as they shirk the harder points, and lay the blame on the system of instruc- tion which should fall on their want of confidence in themselves. These are commonly men of no brilliant talent, yet their brains would serve them faithfully enough if they Avould only put forth mettle. Let such believe the truth that fair average abilities, well used, often carry their owner above the heads of abler men— the genius rarely makes a successful practitioner ; but the careful hard-working student who feels that he must grind up his subject with plodding pains Before he can make it a part of himself, and who acts on this impression, develops the elements of life-long success during his academic course. To each of you, gentlemen, I would give the same advice. This feeling of disgust and weariness in study, this disheartening sense of Avant of progress, is natural; be prepared for it, meet it like a man; the mere effort will draw out the energy you hold in reserve, and you may find, perchance, as many a student has 2 18 found before you, that the duties taken up with distaste become attractive in the doing of them, if only from that sense of vic- tory over the lower self within us which is, I suppose, one of the most exhilarating and comfortable feelings that any man can possess. Never lose sight of the end and object of all your studies; the cure of disease and the alleviation of suffering. Some of you will soon be placed in the chamber of the sick, by the bed-side of the dying, and the issues of life and death may be in your hands. Think of this now, and while you have time use your talents aright. Your lives will be a constant warfare against a common enemy, implacable, often irresistible, who spares neither age nor sex, and who, too often, as the memories of the past week remind us, turns and bitterly avenges the victories of those who have many a time snatched victims from his grasp. Gentlemen, our meeting to-day is a sad one, for sorrow is in all our hearts. One * who had endeared himself to us all has passed to that shadow land, which sooner or later awaits each one of us. Stricken down in the flower of his manhood, checked almost at the outset of his professional labours, it is inexpressibly sad that this fine life, so hopeful, so full of promise, should have been thus suddenly removed. This day week his cheerful, honest face was seen in the hospital wards—to-day the mourners follow his body to the grave. I need not recount to you who have appreciated his uniform kindness in the hospital his many good qualities, nor need I speak of the talents to which our university awarded her highest honours; I will rather dwell upon the deep regret of the profession at the loss of one whom we were proud to number among us, and ask the students to imitate that zeal and faithfulness which marked his short career, and which will long make his memory beloved and honoured among those he served. In conclusion, gentlemen, let me urge upon you all to work diligently in the pursuit of that thorough knowledge of the science of medicine, which alone will make the practice of it satisfactory. And above all things do not regard the profession * Dr. Cline, House Surgeon, Montreal General Hospital. 19 as a mere means of earning a livelihood, and so enter upon it simply as a business. It is indeed a pitiable sight to see a medical man neglectful of the higher interests of his profession, and given over wholly to the pursuit of wealth. Remember, you enter upon a glorious heritage ; you will reap where you have not sown, and gather where you have not strawed, and the knowledge which it is your privilege to-day to acquire so easily has cost others much. We are all of us debtors to our profession : let us then, being mindful of those that come after endeavour to add our little fragments to the pile. And now, remembering that we have other duties towards you than teaching the details of your profession, I would on this occasion earnestly impress upon you the necessity of living upright, honest, and sober lives. The way of the medical student is beset with many temptations, and too often the track he leaves is marked by as many lapses; a zig-zag path, " To right or left, eternal swervin'." Above all things be strictly temperate. I will not say that you are in duty bound to give up the use of stimulants altogether —though my own convictions on this point are very strong,— but this I do say, that the slightest habitual over-indulgence is as the small flaw in some dyke that forms the barrier to a mighty flood, which widening that flaw day by day, sooner or later drowns every fair promise and brings inevitable ruin. To the thoughtful among you the speculative aspect of mod- ern science will sooner or later prove attractive. Do not get entangled too deeply. I would rather give each of you good old Sir Thomas Browne's advice : not to let these matters stretch your pia-mater. Lastly, you will not only be better, but happier men, if you endeavour to do your duty day by day, not from self interest, not from any outside aim however high, but simply because it is right, content to let the reward come when it will. " Knowest thou Yesterday its aim and reason ? Worked thou well To-day, for worthy things ? Then calmly wait To-morrow's hidden season, And fear not thou, what hap soe'er it brings!" Beschaffenheit des Blutes und Knochenmarkes bei ✓ pernicioser Anamie. Von Dr. Osier, Professor an der McGill Universitat in Montreal (CaDada). Ein zweiter Fall von pernicioser Anamie hat mir von Neuem Gelegenheit gegeben das Blut und Knochenmark genau zu unter- suchen und die Angaben von Cohnheim und von mir uber die Be- schaffenheit des letzteren zu bestatigen. Der Patient, ein 54jahriger Englander, zeigte die ausgesprochenen Symptome jener Krankheit und starb 2 Tage, nachdem eine Trans- fusion gemacht worden war. Die Leichenschau ergab nur allgemeine Anamie und starke Fettentartung. Das bei Lebzeiten untersuchte Blut war diinu und wassrig und zeigte keine Vermehrung der weissen Korperchen. Die gewohnlichen rothen Korperchen waren blass, platt und unregelmassig gestaltet. Die bei dieser Krankheit so gewohn- lichen Microcyten waren sehr zahlreich, oft 10—12 in einem Gesichts- feld von Hartnack 9 imm. und 3. Sie waren rund, zeigten aber oft eine Delle. Kernhaltige rothe Korperchen wurden trotz langeren Suchens nicht gefunden, ebenso Avenig grosse farblose, den Markzellen ahnliche Elemente, wie sie Litten als im Blute vorkommend beschreibt (Berl. klin. Woehenschr. 1877. No. 20). Das Mark aller darauf untersuchten Knocben (Brustbein, Rippen, Wirbel, Fibula, Radius) war dunkel violetroth und enthielt mit Aus- nahme desjenigen der Fibula kein Fett. Es fanden sich in ihm die gewohnlichen Markzellen, sowohl die grossen grobkornigen, wie die kleinen lymphoiden, ferner rothe Blutkorperchen, darunter sehr viele kleine, jedoch nicht zahlreicher als im Blute, endlich kernhaltige rothe Korperchen, in jeder Hinsicht den friiher von mir beschriebenen (Cbl. 1877, 258) gleichend. Sie fanden sich sehr zahlreich namentlich im Brustbein, am wenigsten in dem Wirbelmark, waren betrachtlich grosser als die gewohnlichen rothen Zellen und von gleich starker Farbung. Die meisten hatten einen Kern, doch waren solche mit 2, 3, selbst 4 Kernen nicht ungewohnlich. Die Kerne lagen in der Kegel excentrisch, oft freilich halbwegs aus der Zelle herausgetreten. Auch in diesem Falle erschienen sie ungefarbt. — Sop.-Abdr. h. d. Centralbl. f. d. med. Wissenscb. 1877. No. 28. Drnck von H. S. Hermann in Berlin. Ueber die Beschaffenheit des Blutes and Knochenmarkes in der progressiven perniciosen Anamie. V Von Dr. Osier and Dr. Gardner, Professoren an McGill University in Montreal (Canada). Der Fall betraf einen 52jahr. Englander mit alien Zeicben der oben genannten und weit vorgeschrittenen Knmkbeit, ausgenommen Haut- und Netzhautblutungen. Das wahrend des Lebens untersuchte Blut zeigte Folgencies: Die meisten rothen Korperchen erscheinen gross, aber ohne den gewohnlichen kreisformigen Contur; viele sind oval, andere von verscbiedener Gestalt mit unregelmassigen Auslaufern und Fortsatzen. Sie sind blass und platt und viele zeigen aucb, wenn man sie rollen lasst, nicht die biconcave Form. Im jedem Gesichts- feld (HartnaCK's Irani. 9, Oc. 3) sieht man die kleinen runden von Eichhokst (Cbl. 1876, 465) beschriebenen Korperchen, zuweilen bis 6 otler 8. In 40 aufs Gerathewohl unternommenen Messungen waren (mit Hartnack's Iram. 16.) die aussersten Maasse 0,00363 und 0,01181 Mm. Kernhaltige rothe Korperchen wurden auch bei langem Suchen vermisst. Die weissen Korperchen zeigten keine Abnormitat und schieneu auch nicht vermehrt zu seiu. M. Schultze's Zerfalls- kornehen fehlen ganzlich. Die Leichenschau ergab betracbtliehe Verfettung des Herzens, der Nieren und der Leber, die Milz war eher etwas kleiner, als nor- mal und wog nur 170 Grm., die Lymphdriisen nir^jends vergrossert, im Mesenteriura sogar sehr klein. Das Knochenmark (von Sternum, Rippen, Clavieula, Fibula, Wirbel) bat eine dunkle violet-rothe Farbe, ist dick, etwa von der Oonsistenz des Milzparenchyms im Fieber. Es enthalt: 1) farblose Korperchen (Markzellen) verschiedener Gestalt mit kornigem Protoplasma und deutlichem blaschenformigein Kern. Die meisten sind grosser, als die weissen Blutzellen und haben ge- wohnlich nur einen Kern. Ausserdem finden sich zahlreiche kleine runde, den Lymphkorperchen gleichende Elemente. 2) Rothe Blut- korperchen in zwei Arten: a) gewohnliehe biconcave, etwas unregel- massig gestaltete Scheiben und haufig, wie auch wahrend des Lebens beobachtet, mit langen Fortsatzen. Diese bilden den grosseren Theil. b) Kleine ruude, nicht kernhaltige Korperchen, etwa ^4-/4 so gross, als die gewohulichen, ahnlich den im Blute gesehenen. Sie sind sehr zahlreich in der Fibula, wo sie gut Vk der gefarbten Elemente aus- machen. 3) Kernhaltige rothe Korperchen (Neumann's Uebergangs- formen) sind zahlreich im Sternum und der Rippe, in den anderen genannten Knocben sind sie sehr sparsam oder wegen der Blasse der rotben Korperchen hier schwioriger zu sehen. Meistens sind sie grosser, als die gewohnlichen rotheD Korperchen, zeigen aber, wie diese ein ganz gleichmassig gefarbtes Stroma rait einem fein^ranulirten Kern. Sie stellen runde, nicht biconcave Scheiben dar, oft mit un- regelmassigen Umrissen, oder mit einem spitzen Auslaufer. Ihre Far- bung ist meist eben so stark, wie die der gewohnlichen rothen, zu- weilen starker, oder schwacher. Die Kerne sind rund oder elliptisch und nehmen &—-% des Zellkorpers ein, sie sind solid, gekornt und erscheinen in den Zellen gefarbt. Ein Kernkoiperchen konnte nicht wahrgenommen werden. Die Lage des Kerns in den Zellen Avar ver- schieden, bald nach dera Tode erschien er central gelagert. In den am folgenden Tage untersuchten Proben dage^en lagen viel<: Kerne peripherisch und andere waren aus den Zellen ausgetreten und er- schienen nun ganz ungefarbt. In 3 oder 4 Proben Avurden Kerne von Dumbbell-Form gesehen. Zellen mit 2 Kernen waren nicht selten und auch solche mit 3 oder 4 Kernen wurden beobachtet. In 15 Messungen ergaben II einen Durchmesser dieser Zellen von uber 0,01250 Mm. Im Folgenden geben wir die Messungen von 3 Zellen mit ihrem Kern: 1) 0,01409:0,01136; Kern: 0,00954:0,00863 Mm. 2) 0,01136 : 0,01045; Kern: 0,00454:0,00500Mm. 3) 0,01227 : 0,01272; Kern: 0,00682 : 0,00772. Es erhellt hieraus die Unregelmassigkeit der Form dieser Korperchen und die annahernde elliptische Gestalt der Kerne. 4) Blutkorperhaltige Zellen, sehr reichlich im Wirbelmark wo 3—4 in einem Gesichtsfeld erscheinen und 5—6 rothe Korperclten mit deutlich erhaltener Farbe und Gestalt enthalten. Im Sternum und Rippe sind sie viel sparlicher, in der Fibula und Clavicula gar nicht zu sehen. 3) Von Myeloplaxen Avurden 1—2 im Sternum- und Rippenraark gefunden. 6) Fettzellen im Clavicularmark in gerin- ger Zahl, im Sternum-, Wirbel- und Rippenmark gar nicht zu fin- den. 7) CHARCOT'sche octaedrische Krystalle waren iil>erall im Mark 12—30 Stunden nach dem Tode zu finden. Der beschriebene Befund gleicht ziemlich dem von OOHNHEIM*) beschriebeuen. Auch Pepper**) und Scheby-Bdch***) erwabnen Hyperplasie des Marks bei pernicioser Anamie, so dass es wahr- scbeinlich ist, dass gewisse Falle dieser Krankheit zur myelogenen Form von Pseudoleukainie zu rechnen sind. *) Virchow's Arch. LXVIII. 2. **) Amer. Journ. of med. sc. 1875. Octbr ***) Deutschea Arch f. klin. Med. 1876. April. Sep.-Abdr. a. d. Centralbl. f. d. med. Wiasenscb. 1877. No. 15. 'J CASK OF U PROGRESSIVE PERNICIOUS ANyEMIA. CLINICAL REPORT. , -.. BY JOHN BELL, A.M., M.I). PATHOLOGICAL REPORT, V/ITH REMARKS, BY • . '■ WILLIAM OSLER, M.D., ^ Professor of th& Institutes of Medicine, McGill University. J$toutrael 5 PRINTKD BY LOVELL PRINTING AND PUBLISHING CO. 1877. 1 > CASE OF PROGRESSIVE PERNICIOUS ANEMIA. CLIJSSICAL REPORT, BY JOHN BELL, A.M., M.D. PATHOLOGICAL REPORT, WITH REMARKS, BY WILLIAM OSLER, M.D, Professor of the Institutes of Medicine, McGill University. Jttontrael: PRINTED BY LOVELL PRINTING AND PUBLISHING CO. 1877. From the Transactions of the Canada Medical Association, 1877. 1 r CASK OF PROGRESSIVE PERNICIOUS ANAEMIA. CLINICAL REPORT. BY JOHN BELL, A.M., M.D., PATHOLOGICAL REPORT, WITH REMARKS. BY WILLIAM OSLER, M.D. Professor of the Institutes of Medicine, McGill University. J. B.,aged 47, a native of Leicester, England, a rubber weaver by trade, and a resident in this country since 1857, came under my care in 1875, suffering from weakness and loss of appetite, which symptoms, with appropriate treatment and dieting, disap- peared. In May, 1876, they recurred, and persisted more or less throughout the year. In February of present year his condition became such as to require constant medical attention. His history is as follows : He is a man slightly under the medium height, but well built, complexion fair, intelligence good, family history good; one brother suffers from dyspepsia, another is epileptic. lie is married and has six children, all strong and healthy. For the first ten years of residence in this country he farmed, follow- ing at the same time the occupation of a shoemaker. Subsequently he came to Montreal, and for eight months was a conductor on the street Railway, during which period he enjoyed excellent health. For the rest of his life he served as a felt cutter for overshoes in the Canada Rubber factory. His general health had always been good. About three years ago the purchase of a piece of property some distance out of town, and the anxiety consequent upon making the necessary payments, caused considerable mental worry, and he suffered at the time from general debility. About the same timo two of his children had a mild form of typhoid fever. The chief symptoms he complains of are excessive weakness and indisposition to exertion, together with loss of appetite. The skin is blanched ; mucous membranes pale, sclerotics pearly, and he suffers from palpitation and shortness of breath on exertion. On physical examination the organs are apparently healthy; heart sounds natural; liver and spleen not enlarged ; no enlarge- ment of oxternal lymphatics. No increase in the colourless blood 4 CANADA MEDICAL ASSOCIATION. corpuscles, but changes found in tb red corpuscles, which will be _ noticed later on. ' Ordered pill of reduced iron, grs. ii., and phosphorus j^gr. March 14th. Has been depressed in spirits, and meditating suicide. Feels chilly, and has attacks of occasional vomiting, a murmur is audible at tho base. Heart's beat feeble. Pulse, 104. Temperature, 99-5°. > 17th. Vomited bile on getting up. Logs somewhat swollen; d face puffy j complains of great weakness and shortness of breath, ] ringing in ears, and other signs of anaemia. Stopped the pills and j ordered cit. of iron and strychnia. Temperature, 99-7. Pulse, 92. I 22nd. Very little change. Bowels inclined to be constipated. 1 Urine natural looking, no albumen ; slight trace of sugar. Cora- ] plains of indistinctness of vision. Sleeps well. j 27th. Has been in bed since 24th. Hands and feet not so much 1 swollen. Slight hacking cough. Feels too faint to sit up to have j the bed made. Pulse and temperature about the same. 31st. Has had for two days vomiting and slight purging, j which are now checked. Urine natural. Complains of numbness * of left arm and hand. Vision impaired, sees peculiar coloured 1 disks. Dr. Buller examined the eyes to-day and reports as follows: Choroid unusually heavily pigmented, but apparently every- where normal. Optic nerves pale, but not the pallor of atrophy, as there is no conspicuous absence of the smaller vessels which are always observable in the healthy optic papilla. On the surface of the right nerve the upper of the two small arteries which may j generally be seen running transversely outwards towards tho region of the macula lutea, present a peculiar appearance, the i portion traversing the face of the nerve is much enlarged, some- what fusiform, of a dark colour, like a retinal vein, but has not sharply defined walls. Just beyond the edge of the nerve this vessel J is for a short distance almost normal in appearance, but further outwards it is obscured by a thin, superficial, streaky-looking ] extravasation of blood. The macula itself is occupied by an irre- gular dark red patch about half as large as the optic papilla, pro- bably an extravasation of blood. There are a number of minute 1 blood stains in the region of nerve and macula, nearly all of them thin and streaky, and generally close to some retinal vessel of moderate size. Some appear to be in intimate relation j with the retinal veins, others with the arteries; they are all of the ; PERNICIOUS ANAEMIA. 5 same dark venous colour. There is a slight haziness of the retina throughout the region occupied by extravasation, but apparently none towards the equator of the eyes. The arteries are decidedly paler and smaller than they should be in a state of health. The patient speaks of seeing a dark spot about the size of a spectacle lens before the eye when he looks at any object, but thinks vision is not impaired. The left eye was examined by the direct method only, and also showed numerous small retinal haemorrhages similar to those described in the right eye. The region of the macula, however, was not minutely examined, the debility of the patient not per- mitting a more prolonged investigation. April 4th.—Pulse 112, temperature 100.4°. Complains of tight- ness in chest, and pains in the head. Feels sick at stomach when he gets up. Numbness in both hands. Feeling that he could not go on much longer, he asked to have transfusion performed, having been previously well instructed as to tho chances of success, immediate and remote. The operation was accordingly performed on the 6th at 1.10 p.m., Dr. Buller kindly supplying the necessary amount of blood. I proposed transmitting the blood into one of the veins of the foot, but it was impossible to find one prominent enough, so that the median basilic of the right arm was selected. Ten ounces of blood were withdrawn from Dr. Buller, defibrinated by whipping with a wire egg-beater and passing through linen (lawn), the temperature being maintained by means of hot water. A v shaped incision was then made in the vein, and the nozzle of Aveling's transfusion appa- ratus introduced, and six ounces of blood pumped in without the patient exhibiting any uneasiness. The effect of the new blood was apparent in increased fullness of the superficial veins, a pinker color of the lips, and increased moisture of the skin. After re- moval of the nozzle from the vein it was found impossible to check tho haemorrhage by a compress, so that it was necessary to apply ligatures to both ends of the vein. It would have been better had these been placed in position before the vein was opened ; as it was, one or two ounces of blood were lost. The operation lasted about ten minutes. Pulse at the time was 102, temperature 99.1°. Half an hour after he complained of feeling chilly, and the temperature began to rise ; at the end of the hour rigors were well marked, accompanying every eighth or tenth expiration, and tho tempera- ture was 102°, the pulse 120, respirations 34. At the end of second i 6 CANADA MEDICAL ASSOCIATION. hour the rigors had diminished somewhat. Pulse 132, intermittent and feeble; temperature 103.1°. About three hours and a half after the operation the temperature was 104.1°, the highest it reached. Pulse and respirations about the same. He takes brandy and beef tea alternately every fifteen minutes. Passed I iii. of normal urine, containing no albumen. Until midnight the temperature remained about 103° and pulse between 140 and 150; they then gradually fell, and at 8 a.m. temperature 100°, pulse 100, respirations 28. He slept tolerably well through the night, passed I viii of normal urine, and towards morning had a large healthy looking liquid stool, getting out of bed for the purpose. He says he is stronger, and his mind is clcaror than before tho operation. April 7th.—Tho temperature continued to fall, and at 8 o'clock in tho evening was 99°. Urine was passed three times during the day, and he had ono stool in the morning. The pulse is firmer, fuller, ranging from 102 to 112, and does not intermit. Takes nourishment well, only vomited once. April 8th.—Slept at intervals through the night, and took stimulants and nourishment well. Passed urine several times. Complained a little of pain in the right arm, and was restless towards day break. The temperature gradually rose from 99° at 7. p.m. to 101° at 7 a.m., the pulse ranging from 110 to 120. Respirations 25 to 30. From 7 o'clock the temperature and pulse gradually rose, till at 12 the former was 104°, the latter 130, and vory feeble. Takes brandy and beef tea every ten or fifteen minutes, and dozes at intervals. Respirations 140- and shallow. After 12 o'clock he became very restless, and did not caro to take nourishment. The pulse rose to nearly 150, the respirations became more rapid and very shallow, and the temperature fell to 102°. Breathing got more and more difficult, and he died at 1.40 p.m., about forty-eight hours after the transfusion. AUTOPSY, TWENTY-FOUR HOURS AFTER DEATH. Body that of a spare man, 5 feet 5 inches in height; com- plexion fair, hair light, whiskers red. The skin presents a yellowish tinge over the whole body, most marked on the face, neck, and shoulders. Rigor mortis well developed. Slight oedema of lower extremities. Four or five smooth white cicatrices on outer side of right leg. Freckles abundant on forearms. Panni- culus adiposus thin. Brain.—Skull unusually thick; marrow ofdipke i*ed. About PERNICIOUS AN/EMIA. 7 2 oz. of serum escapes on removal of the dura mater. Vessels of the pia mater empty. Pacchionian granulations numerous. Brain substance pale, of good consistence. Nothing abnormal in the ventricles or ganglia at the base. The remarkable pallor of tho tissues is the most noticeable feature. Weight, 3 lbs. 3 oz. Thorax and Abdomen.—The voluntary muscles exposed in the preliminary incision are of a rich dark red color. Intestines and omentum pale and bloodless; position of abdominal viscera normal. In the thorax tho right pleura contains a pint of reddish serum, the left half a pint, in which a few floculi of lymph arc seen. There are pigmentary (?) deposits upon parietal layer over diaphragm and bodies of the vertebrae. Pericardium is normal, a few ecchymoses on visceral layer over left ventricle. Heart, very flaccid, walls of chambers collapsed. A good deal of sub-poricardial fat, especially over right cavities. Venae cavae nearly empty. Right auricle contains 3 iss. of blood, light claret coloured, and one small coagulum, partly decolourized. Right ventricle contains a very small amount of blood ; walls thin ; endocardium stained. Valves healthy. Mus. papill. pale yellow colour. Left auricle empty. Left ventricle contains very little blood ; lining membrane stained. Walls of normal thickness, muscle soft, somewhat paler than normal. Valves healthy. Aorta of normal diameter. Lungs; pigmentation moderate; slight con- gestion (post-mortem) in dependent parts, and also an excess of serosity. Structure healthy. Spleen, slightly enlarged, weighs |x. Numerous adhesions, in- filtrated with serum, bind it to the diaphragm, stomach, and colon. On section pulp very soft, dark red in colour, almost diffluent. Left kidney (5£ inches long). Section shows a pale, coarse organ, somewhat softer than natural. Left supra-renal capsule pale, soft in the centre. Right kidney, moderatoly congested in the corti- cal portion and at bases of pyramids. Cones very pale. Right capsule healthy. Bladder healthy. Vesiculae seminales contain sper- matozoa. Stomach distended with gas; contains about 4 oz. of a brownish viscid fluid. Numerous ecchymoses along the greater curvature, especially at the cardiac end. The veins contain blood. Mucous membrane looks normal. Duodenum and jejunum healthy. Coats of the ileum very thin, translucent, and anaemic. The solitary glands prominent in the upper part; only one patch of Pcyer found in the lower portion. Large bowel normal. 8 CANADA MEDICAL ASSOCIATION. Mesenteric glands appear even smaller than natural. Pancreas healthy. Liver, a few ecchymoses on capsule, a small cicatrix on upper surface of right lobe. Substance pale, in parts much softened. "Weight, 3 lbs. 8 oz. Gall bladder contains normal-looking bile. HISTOLOGICAL EXAMINATION. The blood examined during life was very thin, watery, and of pale claret colour. It presented the following characteristics:— Colourless corpuscles appear perfectly natural in structuro and size, and are not numerically increased. No largo granular ones, such as described by Littcn,1 could bo found. Two forms of coloured corpuscles : (a) ordinary forms, which are paler than natural, flattened out, less biconcave, and are very irregu- lar in outline, some ovoid, others with sinuous borders, others again with pointed processes, (b) Small red corpuscles—micro- cytes,—erroneously described by Eichorst as pathognomonic of this affection. They were numerous, 8 to 10 occurring in the field of No. 9 im. and oc. 3. The diameter ranged from 1-5000" to 1-9000." They equalled, or even exceeded, in colouration the ordi- nary forms; some were crenated, and they frequently presented a pit or cup-like depression on one side. In the repeated examin- ations of the blood, extending over three months, these forms increased but little numerically. Schultzc's granular masses were not noticed. No appreciable difference could be detected in the histological appearance of the blood an hour after the transfusion. The heart presented signs of moderately advanced fatty degen- eration, the striae in many fibres being obscured by molecular fat and droplets of oil. Spleen.—The normal elements, cells of the spleen pulp, and spindle-shaped corpuscles of the trabccula, together with numerous blood corpuscles, were the only structures noticeable in teased preparations. Kidneys.—In both cortical and pyramidal portions the cells of the tubules appear very granular, somewhat swollen, and a large number of oil droplets are seen in and about the tubules. Liver.— The cells contain oil drops in excess, and in many the nuclei are obscured. There is also some fatty infiltration. The marrow of all the bones examined, sternum, ribs vertebrae radius, fibula, was of a violet-red colour, of good consistence, and, 1 Berliner Klinische Wochenschrift, No. 19,1877. PERNICIOUS AN.EMIA. 9 with the exception of that of the fibula, contained no fat. There were found the ordinary large, coarsely granulai*, marrow cells, numerous small lymphoid corpuscles, and red blood corpuscles of both sizes ; and, in addition, very many nucleated red blood cor- puscles, corresponding with those described by various writers as occurring in the marrow in cases of leukaemia, and by Cohnheim1 and myself2 as constituents of this tissue in certain cases of pernicious anaemia. They were most abundant in the marrow of the sternum, fewest in that of the vertebrae. They were considerably larger than the ordinary red blood corpuscles and of about the same intensity of colouration. The majority had only one nucleus, but ceils with two, three, and four were not un- common. The position of the nucleus was usually eccentric, often, indeed, protruding halfway from the corpuscle. The nuclei were colourless. The disease which Addison was the first to recognize aud de- scribe as Idiopathic Anaemia has within the past five years excited an unusual degree of interest, owing, in great part, to the publica- tion in 1872, by Biermer, of Zurich, of a series of observations upon a form of anaemia which he regarded as a new disease, and to which he gave, as marking the chief characters of tho affection, the name " Progressive Pernicious Anaemia." Lebcrt had previously, about tho same time as Addison, under the term " Essential Anae- mia," described similar cases. Though, no doubt, long before Addison wrote, instances of this disease had been from time to time observed, still to him is due the credit of having given the first accurate clinical picture of the affection in his own inimitable way. Judge from the following quotation, which is given purposely, as his name has not received full justice in connection with this affection. He says : " For a long period I had from time to time met with a very remarkable form of anaemia, occurring without any discoverable cause whatever—cases in which there had been no previous loss of blood, no chlorosis, no purpura, no renal, splenic, miasmatic, glandular, strumous or malignant disease. Accordingly, in speaking of this form in clinical lecture, I, perhaps with little propriety, applied to it the term < idiopathic,' to distinguish it from cases in which there existed more or less evidence of some of the usual causes or concomitants of the anae- mic state. Tho disease presented in every instance the same l Virchovrs Archiv. Bd. Ixviii. 2 Centralblatt fiir die Med. Wisscnschaften, Nos. 15 and 2«, 1877. 10 CANADA MEDICAL ASSOCIATION. general characters, pursued a similar coui'se, and, with scarcely a single exception, was followed after a variable period by the same fatal result. It occurs in both sexes generally, but not exclusively, beyond the middle period of life, and, so far as I at present know, chiefly in persons of a large and bulky frame and with a strongly marked tendency to the formation of fat. It makes its approach in so slow and insidious a manner that the patient can hardly fix a date to his earliest feeling of that languor which is to become so extreme. The countenance gets pale, the whites of the eyes pearly, the general frame flabby rather than wasted, the pulse, perhaps large, but remarkably soft and compressible..........there is increasing indisposition to exertion, with an uncomfortable feeling of faintness or breathlessness on attempting it; the heart is readily made to palpitate; the whole surface of the body presents a blanched, smooth, and waxy appearance; the lips, gums and tongue seem bloodless; the flabbiness of the solids increases; the appetite fails; extreme languor and faintness supervene, breath- lessness and palpitation being produced by the most trifling exer- tion or emotion ; some slight oedema is probably perceived about the ankles; the debility becomes extreme. The patient can no longer rise from his bed, the mind occasionally wanders, he falls into a half torpid state, and at length expires." With this classi- cal picture the case hero reported corresponds in every particular, the characteristic feature being the profound anaemia, shown by the pallor of the skin and mucous membranes, and the various functional symptoms of this condition, haemic murmurs, etc. • no emaciation; progressive increase of all these symptoms in spite of medicaments which are effective in the ordinary anaemias, and, lastly, the absence, post-mortem, of any changes to account for the affection, bloodlossness and fatty degeneration of the organs being the only recognizable alterations. Our knowledge of the etiology of the disease cannot be said to have advanced materially since Addison wrote. The very general fatty degeneration of the internal organs, by far the most constant and marked lesion, is to be regarded as a secondary change. The coarse and histological changes in the spleen and lymphatic glands, where, if anywhere, we should naturally ex- pect to find alterations giving some clue to the failure in blood- making function, are not constant, sometimes they have been found slightly enlarged, at others atrophied. Indeed, so far as these organs are concerned, the numerous and careful observations PERNICIOUS AN.EMIA. 11 of the past five years have failed to discover any definite lesion in them which would account for the symptoms, or in any way con- nect derangement of their function with the production of the disease. In one direction, however, there has been some progress, and to this we shall briefly allude. Clinicall}- the cases present certain similarities to those of leukaemia and Hodgkin's disease, or pseudo-leukaemia. Now these latter diseases differ chiefly in this, viz., that in leukaemia the colourless blood corpuscles are in excess; in pseudo-leukaemia they are not. Both present three varieties: 1st the splenic, in which the chief lesion is the great enlargement of the spleen; 2nd, the lymphatic, in which the lymph glands throughout the body are mainly affected ; and, 3rd, the researches of Neumann, Mosler, and others have made us acquainted with a variety known as the myelogenous or medullary, in which the marrow of the bones is the seat of disease. This tissue is now generally regarded as sharing, in the young animal at any rate, with the spleen and lymph glands in the formation of blood corpuscles. In the long bones of the adult it is in a state of atrophy, and its place, in great part, supplied by fat. In many cases of leukaemia and pseudo-leukaemia, it increases, becomes more vascular, its cellular elements multiply, nucleated red blood corpuscles, such as occur in the embryo, are formed, and the whole tissue passes into a condition of hyperplasia, strictly analo- gous to that affecting the spleen and lymphatic glands. This may be, as in a case recently reported by Mosler,1 the primary lesion in leukaemia, and the development of the marrow may produce definite symptoms, such as swelling and tenderness of certain parts of the bones; so that the myelogenous forms of these affec- tions are now well recognized. Clinically the myelogenous form of pseudo-leukaemia, though rarely uncomplicated, presents such a similarity to pernicious anaemia that Jaccoud,2 and Immerman' suggested the identity of the two affections, while Prof. Pepper,4 declared distinctly that pernicious anaemia was " merely the simple medullary form of pseudo-leukaemia." As I have quite recently, in commenting upon another case,5 referred fully to the facts for and against this view, I need not 1 Berliner Klinische Wochenschrift, Nos 50, 51, 52, 1876. 2 Nouv. Diet, de Med. et de Chirurg. Leucocythemie. 3 Ziemssen's Handbuch der Speciellen Pathologie and Therapie, Bd. xiii. Art. Pro. Pernio. Anaemia. 4 American Journal of Medical Sciences, Oct., 1875. 5 Canada Medical and Surgical Journal, March, 1877, 12 CANADA MEDICAL ASSOCIATION. recapitulate them here. In the present state of our knowledge it may, I think, be reasonably affirmed that certain cases of idiopathic anaemia may be placed in the category of myelogen ous affections, and among them the one here reported. To many it may appear far-fetched to seek in the altered condition of the bone marrow an explanation of the extreme anaemia of this disease, but the reports of numerous eases leave no room for doubt that a serious alteration in its structure, and a return in adult life to its embryonic state, may profoundly influence the compo- sition of the blood, producing anaemia and death. It must be borne in mind that the red marrow in the short bones of an adult probably equals in bulk the constituents of the spleen, and struc- turally is very similar to that organ and to the lymphatic glands. In the long bones it is largely replaced by fat, but traces of it still remain. Now, granting that the marrow is a tissue which shares in the blood-making functions, it is quite as reasonable to suppose that, if hyperplasia of the elements of the spleen can lead to serious disturbance in the composition of the blood, pro- ducing the splenic form of leukaemia or pseudo-leukaemia, accord- ing as the colourless corpuscles of the blood are increased or not, so a general increase of the constituents of the marrow may induce similar conditions. For it is to be remembered that, in a general hyperplasia of the marrow, the actual amount of lymphoid tissue in the osseous system equals Or perhaps exceeds that of an enlarged spleen. Why a simple hyperplasia of this tissue should interfere with the elaboration of the blood, altering in the one case the mutual proportion of the corpuscles, and in the other simply reducing the total number, we do not know, but we are just as ignorant why an enlarged' spleen and lymphatic glands should produce in the one case leukaemia and in the other not. OVER-STRAIN OF THE HEART, AS ILLUSTRATED BY A CASE OP HYPERTROPHY, DILATATION AND FATTY DEGEN- ERATION OF THE HEART, CONSEQUENT UPON PROLONGED MUSCULAR EXERTION. A WILLIAM OSLER, M_D_, Professor of the Institutes op Medicine, McGill University, Montreal. (From the Canada Medical and Surgical Journal, March, 1878.) PRINTED AT THE "GAZETTE" PRINTING HOUSE 1878. OVER-STRAIN OF THE HEART, AS illustrated by a case of HYPERTROPHY, DILATATION AND FATTY DEGEN- ERATION OF THE HEART, CONSEQUENT UPON PROLONGED MUSCULAR EXERTION. WILLIAM OSLER, MJD-, Professor of "the Institutes of Medicine, McGill University, Montreal (From the Canada Medical and SurgicalJoumal, 3Iarch, 1878.) $Jtonto at: PRINTED AT THE "GAZETTE" PRINTING noUSE 1878. (From Canada Medical and Surgical Journal, March, 1878 J CASE OF HYPERTROPHY, DILATATION AND FATTY DEGEN- ERATION OF THE HEART, CONSEQUENT UPON PROLONGED MUSCULAR EXERTION. Do fatal and uncomplicated cases of hypertrophy and dilata- tion of the heart ever occur as consequences of severe and prolonged muscular exertion ? The following case is offered as a contribution to this question, upon which there is as yet a considerable diversity of opinion among Pathologists. On Nov. 7th, 1876,1 performed an autopsy on a large, power- fully-built, muscular man, who had died with all the symptoms of chronic valvular disease, and in whom great dilatation and hypertrophy of the heart were found, but without presenting any of the conditions commonly recognized as productive of these states,—no valvular affection, no arterial degeneration, no emphysema or other chronic pulmonary disorder, no renal disease ; there was, in fact, an entire absence of the lesions usually met with in cases of this kind. I am indebted to my colleague Dr. Ross for permission to use 4 the following clinical notes, taken by Dr. James Bell, at that time the ward clerk : J. W., aet. 39, an Englishman, was admitted into the Montreal General Hospital, Nov. 2nd, 1876. He is a large, powerfully- built man, with tremendous chest girth. Ho had been a soldier for 18 years, serving in the different British stations, and latterly has followed the occupation of a blacksmith. Has never had syphilis, or rheumatic fever. Has always been a healthy man, though intemperate. In July last he suffered from shortness of breath and slight haemoptysis, for which, in August, he entered the hospital, and was under treatment nearly two months for " some heart affection," being discharged very much improved. He then worked for three weeks as a day labourer and suffered much from exposure to cold and wet. On October 20th he had a chill, which was followed by swelling of the legs and abdomen, with slight dyspnoea. He gave up work on the 24th, and was treated as an out-door patient for a few days before entering Hospital on November 2nd. When admitted, in addition to the above-mentioned symptoms he complained of great pain over the region of the heart. The legs were oedematous, and the conjunctivae and face of a sub-icteroid hue. On physical exam- ination, the cardiac dulness was found to extend a? high as the upper border of the third rib, and to the right b'.ider of the sternum. A systolic murmur was heard at the left cage of the sternum in the third interspace. Apex beat could hot be dis- tinctly felt. The pulse at the wrist was barely perceptible. There was dulness over the lower lobe of the left lung. Rough snoring rales were heard over the front of the chest and coarse bubblini! rales behind. Liver dulness extended from the 5th interspace to the costal margin. The urine contained nearly 25 p. c. of albumen. The day after admission he expectorated nearly three pints of florid blood and vomited very frequently. In spite of treat- ment (dry cupping, ergot, digitalis, etc.,) his condition became worse. On November 5th the pulse was quite imperceptible at the wrist, the cyanosis became extreme, and the patient died early on the morning of the 5th, with all the symptoms of chronic valvular disease. 5 Post-mortem, 30 hours after death. Face, neck, and skin of thorax intensely livid. Tissues beneath the skin of anterior part of trunk and about the root of the neck emphysematous. Scro- tum much swollen. Legs oedematous. Brain.—Sinuses of dura mater and veins of the pia mater full. Arteries at the base not diseased. Nothing abnormal in the brain substance. Heart weighs 610 grms. (21i oz.) Right chambers distended with dark clots and fluid blood ; the venae cavae are also dilated and full, much blood escaping from them in the removal of the organ. Light auricle is very large, size of a small orange; walls of about the usual thickness. Right ventricle dilated, anterior wall measures \" in thickness ; columnae carneae are not hypertrophied. Tricuspid orifice 5|" in circumference ; valves healthy. Pulmonary valves normal; circumference of orifice 3". Left ventricle contains some fluid blood, and a small partially decolourized clot in the mitral orifice. The chamber is much dilated, measuring 4J" from apex to aortic ring, and bulges considerably towards the right ventricle. Endocardium thick and opaque, especially over the septum. Musculi papillares fibroid at apices ; walls over middle cf anterior part §" in thick- ness ; posterior wall |-" ; ventricular septum, a quarter of an inch below aortic valve, \". Mitral valves slightly thickened at the edges, otherwise healthy. Orifice measures 4\" in circum- ference. Aortic valves competent, segments thin and natural- looking ; orifice at the ring measures 2£" in circumference. Aorta looks—relatively—smaller than natural. It is not athero- matous, either in the arch or in its course. Muscular substance of whole heart, and especially the left ventricle, looks pale, and on examination is found to be in a condition of advanced fatty degeneration; much fatty infiltration also exists Ibetween the individual fibres. Arteries of the body present no signs of degeneration. Lungs, ^xcvi of serum in left pleura, the lung on this side is collapsed and only slightly crepitant above. Two very large spots of apoplexy in the anterior part of upper lobe, and 6 about them the lung tissue is hepatized. Another, also large, occupies the anterior border of the lower lobe. Right lung is crepitant, but contains much blood and serum. At the lower and front part of anterior lobe is a small, consolidated area. Spleen, 250 grms., firm. Kidneys, not enlarged. Capsules detach easily ; surfaces smooth. On section pyramids and Malpighian tufts of the cortex are injected. Stomach and intestines present nothing unusual; the large and small veins are very full. Liver, a little enlarged, of good consistence ; venules of hepatic vein gorged—nutmeg organ. The degree of hypertrophy and dilatation will be seen at a glance in the folloAving table : Heart of J. W. (Peacock.) Normal Heart. (BlZOT.) Normal Heart. Right ventricle, ant. Avail.... 3'" 1.85'" Left " " " ... .87" .53" 0.43" " post. Avail... .5" 4.5" 3.33 2.61 Mitral orifice, circumference 4.25" 3.58 4.29 Aortic u " 2.75" 3.17 2.74 Tricuspid "• " Pulmonary orifice '• - -Weight of Heart - - - - 5.87" 4.50 3.3" 3.3 :-J 21.5 oz. 9.75 oz. 4.81 2.79 The dilatation of the left ventricle is very marked, Avhile the hypertrophy of the Avails is moderate. Judged by Peacock's standard, the mitral orifice is somewhat dilated while the aortic ring is even smaller than natural, though by Bizot's standard it is just normal. It certainly appeared very much out of propor- tion to the huge left ventricle. The tricuspid orifice is very large, and the right chamber considerably dilated, Avhile the opening of the pulmonary artery is about normal. The hypertrophy and dilatation in themselves presented nothing remarkable, and the other lesions Avere those of every- day occurrence in organic heart disease—hydro-thorax, oedema and haemorrhagic infarction of the lungs, venous congestion of 7 the liver, spleen and kidneys ; the fatal result depending on the condition of the lungs. But what could account for the hyper- trophy and dilatation ? This was the difficulty, and so impressed was I at the time with the unusual character of the lesion that a most searching examination of the different organs was made and careful measurements of the heart were taken, but no satisfactory cause could be found for the cardiac affection, so that the notes Avere laid aside and the case labelled ' idiopathic.' A few months after, in Nos. 17 and 18 of the Berliner Klin- ische Wbchenschrift, 1877, there appeared a paper by Dr. Zunker, one of Professor Leyden's Assistants at the Charite", Berlin, on a case of " Dilatation and Fatty Degeneration of the Heart, in consequence of over exertion," which, in its clinical features and anatomical characters is almost the exact counter- part of the one under consideration, except that the dilatation was a little more marked and the hypertrophy not so great. This gave a possible clue to the interpretation of the case, and I immediately made enquiries about the past life of the man, but was not very successful, as his wife had left the city, and from her alone could definite information have been obtained. It was, however, ascertained, that after leaving the army he had worked as a blacksmith, and subsequently as a corporation labourer. He was, as I have said, powerfully built and very muscular, an acquaintance describing him as a " perfect picture of a man." From the facts I have gathered, and the similarity of the case to several which have been recorded, I am inclined to regard the condition of the heart as intimately associated with and dependent upon the over use of a highly developed mus- cular system. Before dealing Avith the question of how the abnormal state Avas brought about, it may be well to make a few preliminary remarks on the influence of prolonged and severe muscular effort on the circulatory system. In the works of one or two of the older writers upon the heart very definite statements are met with bearing on this question: Thus— s Corvisart.* among other causes of heart disease, mentions muscular exertion, and records a fatal case of hypertrophy without valvular disease folloAving violent exertion. Hopef states that '• occupations requiring constantly renewed muscular efforts," produce in time dilatation of the heart. Latham:": was, I believe, the first to recognize fully the impor- tance of over exertion in the causation of heart affections, and under the term " shock of the heart," describes cases of rup- ture of valves, and of hypertrophy, following sudden and severe muscular efforts. The attention of army surgeons Avas early called to the prevalence of heart disease among soldiers, and in the great majority of these without any history of acute rheumatism. McLean§ brought the subject prominently before the authori- ties and the profession, believing the evils to result largely from the constricting influence of the regulation pack and other accoutrements upon the chest. Peacock,|| about the same time, in his lectures on valvular diseases, shoAved how liable the valves Avere to injury from violent muscular efforts. During the American civil Avar the injurious effect of military life upon the heart Avas abundantly proved, and the rich clinical material then afforded enabled several observers^ materially to advance our knowledge in this direction. In 1870 an important monograph by Myers** appeared, * Treatise on the Diseases and Organic Lesions of the Heart, translated byHobb, London, 1813. pp. 28, G3. t A Treatise on Diseases of the Heart, 2nd edition, London, 1855. X Lectures on Diseases of the Heart, London, 1846. § Lecture at Koyal United Service Institution, 1865. — Brit. Medical Journal, 1867. || Valvular Diseases of the Heart, London, 1865. ^ Da Costa: Observations upon Heart Disease in Soldiers. Medical Memoirs of the United States' Sanitary Commission, 1867. Taylor : Remarks on Heart Disease.—Transactions of American Medical Association, vol. 18, 1867. Da Costa : On Irritable Heart.—" Am. Journal Med. Sciences," Jan. 1871. Treadwell: On Over-work and Strain of the Heart.—" Boston Medical and Surgical Journal," 1872. ** Diseases of the Heart among Soldiers, London, 1870. 0 and since that date important articles have been Avritten by Albutt,* Seitz,f Thurn,J Frankel,§ and Levy,|| illustrating in various ways the effects of over-work and strain on the heart. The recent works on the hearty deal either not at all or very cursorily with the subject. The above constitutes the chief literature of the subject, and from an analysis of the papers the following conclusions may be drawn with regard to the effect of ovenvork on the heart. 1. Sudden and violent exertion may cause rupture or lacera- tion of the valves—a very serious lesion, Avhich often proves fatal within a short time. 2. The augmented resistance to the flow of blood during severe and prolonged muscular exertion increases the Avork of the heart, Avhich, in response to the demand made upon it, enlarges. The blood pressure in the aorta, abnormally high even during the diastole, is much increased during the systole of the powerful left ventricle, and the coats of the vessel yield, commonly at the arch, becoming pouched and atheromatous. Incompetency folloAvs,. either from stretching of the aortic orifice or giving Avay of the valves.—(Albutt.) 3. In the functional disorder of the heart described by Da Costa, Myers, and others, as common in young soldiers, and termed by the former, ' irritable heart,' there is hypertrophy of the muscular Avails of the organ, caused by over-work at drill and the constricting effects of the military accoutrements. This may in time be followed by valvular disease. 4. It appears from a number of recorded cases that overwork * Over-work and Strain of the Heart. — St. George's Hospital Reports Vol. 5, 1872. t Zur. Lehre von der ucberanstrengung des Herzens.—Deutsches Archiv. fur Klinische Medicin, 1872. X Ermudung des Herzens und die Entstehung von Herzfehlern. Repub- lished by Seitz, together with the articles of Albutt, Da Costa, and Myers, as a separate volume. § Virchow's Archiv. Bd. 57. || Du Cceur force ou de l'asystole sans lesions valvulaires. These inau- gurale, Nancy, 1875. Resume in Archives Generates, Janvier, 1876. V Ziemssen's Encyclopedia of Practical Medicine. Balfour—Diseases of the Heart, 1875. Hayden—Diseases of the Heart and Aorta, 1875. Reynold's System of Medicine, vol. 4. 1877. 10 ^of the muscles may induce a primary dilatation and hyper- trophy of the heart, which, without valve affection or arterial degeneration may prove fatal, with all the symptoms of chronic cardiac disease. It is this last condition to which I wish specially to direct atten- tion, as I believe the case reported affords an illustration of it. Very few of the writers mentioned above, though dealing specially with the effects of over exertion on the heart, appear to be aware of the possibility of a fatal result as an immediate sequence of primary hypertrophy and dilatation. Peacock* records three cases in which after death no affection of the valves or orifices was found, but simply hypertrophy and dilatation, and explains these conditions by supposing " that from the enlargement of the left ventricle which existed in all the cases the mitral valves had not been properly adjusted during the systole." He offers no explanation as to the cause of the enlargement of the heart, but passes on immediately after to the state of the organ in the Cornish miners, which he refers directly to the severe muscular effort necessary in their work and in climbing long ladders up and doAvn the shafts. Seitzf gives a remarkable series of cases observed in Biermer's Clinic in Zurich, almost all of which presented the following symptoms : " Palpitations, and ill-defined sensations in the cardiac region as if the heart Avere about to stop, shortness of breath, anxiety, feeling of faintness, cyanosis, anasarca, enlargement of the liver, irregularity and intermittent action of the pulse, dila- tation of the heart, apex beat feeble and dislocated downwards and outwards, increase in cardiac dulness. Heart sound* sometimes normal, but not unfrequently murmurs at the apex.'' Post-mortem, the anatomical changes were confined to " Hyper- trophy of the walls and dilatation of the chambers, valves un- affected ; degeneration of a few muscle fibres ; rarely fatty." He regards over work as the most important factor in the pro- duction of these cases. In the case reported by Dr. Zunker from Leyden's Clinic, the * Loc. cit. f Loc. cit. p. 61. 11 connection betAveen the over-exertion and the heart disease is very well brought out. The patient, a journeyman mason, had enjoyed good health up to six Aveeks before his admission. During this time he had been engaged in the unusually severe work of carrying heavy stones up long ladders. He stood this very well for three weeks, when he began to suffer from want of breath and a slight cough. Soon palpitations came on, the short- ness of breath increased, the legs began to swell, and he was forced to take to his bed. He got rapidly worse and was sent to the Charite cyanotic and almost moribund. Hydrothorax of the right side was detected, the chest was tapped, and 128 cc. of clear fluid Ave re drawn off with great relief; but the attacks of dyspnoea recurred, and he died four days after admission with all the symptoms of chronic heart disease. At the autopsy the heart was found enormously dilated, the walls in a condition of fatty degeneration ; no valvular disease, no chronic renal or pulmon- ary affection. In the case of J. W., the evidence of prolonged muscular effort is presumptive rather than direct. The occupations which the man had followed guaranteed a tolerably active exercise of his voluntary muscles, and it has been from among soldiers and smiths that a very large proportion of these heart cases have been described. Moreover, the high development of his muscular system afforded the best possible proof of its constant use. There must have been some agency at work to produce the dilatation and hypertrophy, and considering the above facts, and in the absence of all the recognized causes, I feel more inclined to regard it as due to overwork than to look upon it as spontaneous or idiopathic. But how, it may be asked, is all this brought about ? Severe muscular exertion affects the circulation in two ways : first, by interfering with respiration and the free passage of blood through the lungs; the right heart gets over-loaded, the systemic veins full, and thus an obstacle is offered to the outflow of blood from the arteries ; in consequence of which the left ventricle becomes dilated and must hypertrophy to overcome the increased resist- ance to the arterial flow. According to Peacock, the large 12 hearts of the Cornish miners are produced in this way. In the June number of Von Ziemssen's Archiv, there is an interesting article on " Das Tubinger Herz.," by Dr. Miinzinger, descriptive of a form of heart disease similar in some respects to the one under consideration. It is met with among the A'ine dressers who undergo very severe work in carrying manure in baskets on their backs long distances up the mountains. The exertion re - quired is very great, and the respiration is considerably interfer- ed with by the constricting pressure of shoulder straps. Sooner or later they suffer from dilatation and hypertrophy ; but as this has ahvays been found associated, post-mortem, with emphysema, it is difficult to say in these cases hoAV much is due to this condition and hoAV much to the muscular effort itself. Secondly, the effect of over exertion may act in a much more direct manner. The experiments of Traube upon dogs have shown that during extensive muscular contraction the blood pressure in the arteries is greatly increased, and the same may reasonably be inferred of men. The more laborious the A\rork, and the more violent the contraction of the muscles, so much the greater difficulty has the blood in flowing through the systemic arteries. The arterial pressure is increased and the blood tends to accumulate in the aorta and the left ventricle. If the nutrition be maintained no ill effect will follow from this, for the left ventricle hypertrophies and the balance is restored. That this state does exist is a well attested fact, and Albutt speaking of this early condition of hypertrophy says " that he has found in a few autopsies of such men killed by accident or acute disease, that the ventricles, the left especially, are, like their bicipites, large and red," the heart weighing as much as 16 oz. The lower animals furnish good examples of hypertrophy following severe exercise. Houghton* states that the heart of the celebrated greyhound, ' Master Magrath,' weighed 9.57 oz., just three-lold in excess of the normal proportion of heart- weight to body-weight, and no other cause could be assigned for the great enlargement than the prolonged muscular effort in coursing. * " British Med Journal," 1872.. 13 The hypertrophy is rarely simple, being accompanied as a rule with dilatation, and to this latter the train of ill eft'ects in these cases is chiefly due. In the case before us at some time or other mitral insufficiency was established, either from a dilatation of the orifice, so that the curtains could not meet to close it, or, Avhat is more probable, as Bristowe pointed out, from a degeneration in the muscular papillae and tendinous cords, resulting in a mal-adjustment of the valves. The apices of the papillary muscles were fibroid, in places calcareous, and the cords someAvhat shortened so that they might readily be supposed in the dilated chamber to ki tether the valves too closely and prevent the apposition of the segments." We may reasonably infer that this man had had an hypertrophied heart for years, the balance of power being pre- served so long as the nutrition of the organ was kept up. With the onset of fatty degeneration came the disturbing element; the Avails, no longer able to resist the blood pressure, gradually yielded, the dilatation overcoming the hypertrophy. With this would follow all the ill effects of loss of compensation as in ordin- ary cases, and just such as have been reported in this one ; congestion and oedema of the lungs, dilatation of right chambers, general venous stasis.—all the symptoms in fact of a break- down in that marvellous piece of machinery, the heart. »- MONTREAL GENERAL HOSPITAL. PATHOLOGICAL REPORT For tiik Ykar knmncj May 1st, 1877, WILLIAM OSLER, M.D. Ok McGill University. *' Pathology is the basis of a!l true instruction in practical medicine."—AVilks. VOLUME I. MONTHEAL: DAWSON BROTHERS, PUBLISHERS, 1S7S. 1%.../ —/' ANEURISM OF THE HEPATIC ARTERY. » Hepatic artery. (6, right branch ^J^*^^ «* *** tro-duodenalis, («) cystic arteries, (/) occluded branches of ngrbt trunk. Sc« pajre 24. JAMES BOVELL, M. D. EMERITUS PROFESSOR OF PATHOLOGY IN THE TRINITY MEDICAL SCHOOL, TORONTO' THIS FIRST PATHOLOGICAL REPORT FROM A CANADIAN HOSPITAL IS GRATEFULLY AND AFFECTIONATELY INSCRIBED. PREFACE. Records of exactly one hundred autopsies have been entered in the post-mortem book of the Greneral Hospital for the year ending May 1st, 1877. A few of special interest occurring in private practice have been included. The post-mortems are performed under my supervision by the students attending the Hospital, and the system of inspection followed is that of Virchow, at the Charite, Berlin, fully given in his " Sections-Technik." The notes are taken on the spot from dictation. In the following Report brief summaries are given of the cases of practical and scientific interest. When possible, a synopsis of the clinical features is also given. The cases are grouped under the various organs affected, as this is thought to be a more convenient method than dealing with the individual diseases ; and, as a rule, the organs are dealt with in the order of their pathological importance. To the Medical Staff of the Hospital, by whose order the autopsies are conducted, I am deeply indebted, not only for permission to publish this report, but also for their kind courtesy in all matters relating to these inves- tigations. 1351 St. Catherine Street, Dec. 10th, 1877. CONTENTS. OSSEOUS SYSTEM. =""— PACK Fracture of 1st and 2nd Ribs, near heads .T'............................ 11 Acute Necrosis of Tibia—Pyasmia ffc>............................... 12 Acute Necrosis of Femur—Pya2mia..1............................... 13 Cancer of 2nd and 3rd Vertebrae, and corresponding ribs on right side.V; 14 CIRCULATORY SYSTEM. Heart:— t- Idiopathic (so-called) Hypertrophy and Dilatation. .1i............ 16 Fenestration of Valves of Aortic and Pulmonary Arteries.......... - 20 Arteries:— Atheroma.....................................................j" 20 Aneurism of first part of Thoracic Aorta .".'....................... 20 Sacculated Aneurism of ascending portion of Arch of Aorta...... 21 Sacculated Aneurism of Aorta at termination of the Arch..v.7...... 22 Aneurism of Hepatic Artery—Suppurative Hepatitis.J. ?........... 22 Aneurisms on branches of Pulmonary Arteries on walls of Phthisical Cavities . J............................................... 30 /_, Aneurism of right middle Cerebral Artery,\..................... 30 RESPIRATORY SYSTEM. Trachea:— Ossification of Mucous Membrane . .I........................... 32 Pneumonia of right upper Lobe. Simple Meningitis. '.?.......... 33 Hepatization of left Lung—Diphtheritic Colitis ;................. 34 Pneumonia about a Phthisical Cavity in right Lung.'.-*-............ 34 Chronic Phthisis—Pneumonia of only sound portion of Lungs?"?.. 35 Simple Pneumonia of left Lung ; right-sided Pleurisy.':'.......... 3."> Pneumonia of right Lung, uniform involvement of Pleura?.!...... 35 Remarks on the cases of Pneumonia............................. 36 Gangrene about Phthisical Cavities in left Lung.'. Y............... 37 Fibroid Phthisis .3.1........................................... 38 Chronic Phthisis ; perforation ; pneumothorax .V................. 39 Chronic Phthisis—Cancer of Vertebra and Ribs. .K\ t'.^T.'i........ 40 I'Uuni:— Small fibroid thickenings ..................................... 40 1 nflammation................................................ 40 Effusion enclosed in pockets M.'.-.^.f.^. ..;•.. '.>.?............... 41 o CONTENTS. UASTKO-1NTKSTIXAL SYSTEM. Tongue:— 1"A''a- Epithelioma TT./. :........................................... 4l Pharynx:— Miliary Tuberculosis %?....................................... 42 (Esophagus:— Post-mortem perforation . ."J...........................-........ 4.'' Stomach:— Cancer of Cardiac Orifice "h;.................................... 43 Medullary Cancer—perforation » fl.............................. 4- Small Intestines:— Incarceration of Ileum .?.'..................................... 45 Ulcer of Duodenum . .V........................................ 4f. Typhoid ulceration—perforation. V.............................. 46 '■ u a v£............................. 4G a a a _&;\............................ 47 Typhoid Fever, slight ulceration *'.V............................ 4S u '• one small ulcer ."; Y............................. 4-i Cucum:— Round ulcer—perforation.>.V.................................. 49 Appendix Vermiformis : Concretions in......................'■.....^..,................3ff» T.O Obliteration of Orifice, tube dilated . y.T.^.u-^-.,.'.'. >.V.5. ;%U*fe.Un. 50 Perforation $.$. j^-i.^^l >.'<■>.................................. 51 Peritoneum:— Acute Inflammation........................................I Up 5 1 Tubercular Peritonitis /!....................................... 52 Liver:— ^^-Hypertrophic Cirrhosis.!..................................... 56 Syphiloma . "f................................................. f.o ^y Primary Cancer.'iV?,.......................................... CI Secondary Cancer...........................................h?r~ 6 - t,- Cancer of neck of Gall Bladder !*....•.......................... 64 Suppuration of Portal Vein $"?................................. CI Spleen:— Enlarged...................................................f. 71 In Typhoid Fever..........................................?./> 71 Amyloid degeneration.......................................?J» 71 Miliary Tubercles..........................................2x7. 71 Infarctions.................................................Ir. -« 7 i Fibroid thickening on Capsule...............................\'.% 71 """ Supernumerary Organ.......................................?>.% 71 CONTENTS. ff (.EN1TO-URINARY SYSTEM. Kidney:— t page Inflammation....................'/,-f?.^.-.'.....}. rlk..........TrTji* Morbus Brightii .U>:~;.........................................-v-*> 72 Tuberculous Disease :;*-.!... ....'.".............................• */*. 73 Perinephritic Abscess .v.■:"..................................... 75 Bladder:— Ulceration consequent upon Stone.?."t.......................... 76 L'terus:— Epithelioma of Cervix—pyometra .';.'........................... 77 Ovary:— Dermoid Cyst *t.............................................. 78 CEREBRO-S1TNAL SYSTEM. Tuberculosis: General Tuberculosis—Spinal Meninges affected if............... 7!* Cases of Tubercular Meningitis *i~.'j yl'.'.^............................. s - 2± ,, ^^~ * PATHOLOGICAL REPORT. MONTREAL GENERAL HOSPITAL. Osseous System.—Fractures. Case lxxi.—Fracture of 1st and 2nd ribs near vertebra:, from direct violence ; deep abscess of the neck; obliteration of subclavian artery ; Empyema. . J. L., ;et. 20, was struck on the sternum by the shaft of a fire engine ; almost immediately after a tumour formed in the supra-clavicular region, the arm on that side became paralysed, and on admission was pulseless. Tumour inflamed, was opened, and discharged a milky fluid and blood, subsequently pus. Empyema super- vened, and death. Abscess found to be deep in the neck, immediately above the left pleura, and about as large as a good- sized orange. On putting the fingers into the sac the ends of the fractured ribs can be felt in the posterior wall. The fracture of the 1st rib is straight, just external to the tuberosity; the inner end is imbedded in the wall of the sac, the outer lies one and a half inches from it. The 2nd rib is fractured obliquely, just external to the angle, and is also comminuted. The inner end projects into the sac as a rough, sharp process, and lies at a higher level than the outer end which is external to it. Between the two is a small separated portion enclosed in the sac wall. The lining membrane of the cavity is stained, and in places covered with flakes of fibrin. Immediately below ihe anterior part of the floor of the sac, the apex of the left I 12 PATHOLOGICAL REPORT. lung is firmly attached, and is separated from the abscess by condensed tissue, i of an inch in thickness. At the posterior part of the floor only a thin membrane separates it from the pleural cavity. An orifice, in communication with an external one at the root of the neck, exists at the upper part of the anterior wall. The subclavian artery runs along the inner and upper part of the sac, being lifted somewhat out of its course. It is completely obliterated by a thrombus, which begins an inch from the aorta and extends to the first portion of the axillary. The subclavian vein is also obliterated, though to a less extent. Above the artery, at the top of the sac, is the brachial plexus, the cords of which appear stretched and flattened. Between two and three pints of pus in the. left pleural cavity. Lung compressed. Acute Necrosis—Pycemia. Case lxxxhi. — Necrosis of tibia. Ulcerative endocar- ditis. Pyoemic pneumonia. A. B., set. 12, male. No definite history of an injury ; pains of a rheumatic character about the joints, only slightly more marked at the left ankle ; symptoms of pysemia : death within a week. Acute periosteal abscess found in the lower end of left tibia, with necrosis of the bone, which is denuded and roughened, especially in front. The cancellated part does not appear much affected. Pericardium is beginning to inflame. In the anterior wall of the conus of the right ventricle is a purulent depot the size of a bean, and not far from it a superficial loss of substance, half the size of a three-penny-bit. Traces of atheroma in the sinuses of Valsalva. Scattered throughout both lungs are small, firm, slightly- elevated spots, ranging in size from a pea to a marble. They are most abundant in the upper lobes. On section MONTREAL GENERAL HOSPITAL. 13 some are dark in colour, their firmness alone distinguish- ing them from the lung tissue; others have a greyish red appearance, while others again have softened in the centre, forming small abscesses. A small supernumerary spleen is present. Case xcvi.—Necrosis of femur. Pycemic pneumonia. Abscesses in superficial muscles. Pustular eruption on skin. J. C, vet. 30.—The clinical features of the case are well summarized by Mr. Vineberg,1^ as follows: The disease attacked a strong and apparently healthy man; no history of injury; the symptoms at the outset simulated those of rheumatism ; the pyaemia, set in rapidly, ran its course without rigors or marked fluctuations and remission of temperature, while the presence of a pustular eruption and erysipelatous patches on the skin, with the tuberous elevation beneath the skin—not unlike farcy buds—and the general symptoms, presented a clinical picture very like that of glanders. Left Femur.—Muscles of anterior region of lower third of thigh infiltrated with pus, the posterior ones not so much so, and here and there are distinct abscesses. The periosteum of the lower end of the femur is raised, and contains beneath it much pus, the bone is bare and roughened in front, behind, and on the inner side; on the outer side the periosteum is still adherent. It is covered with a dirty greyish exudation. Scrapings from the bone and roughened surface examined with the microscope show an enormous number of large myelo- plaques. The marrow where the bone is sawn looks healthy; that of the end of the bone itself was not examined. Skin.—Numerous flattened pustules with reddened bases exist over the skin of trunk and upper extremities. Muscles.—In those of the arms and legs many small ' In a paper read before the McGill Medical Society. May s. 1877. 14 PATHOLOGICAL REPORT. tuberous swellings can be felt, which, on section, are found to be abscesses in the substance of the muscles. Long int. saphenous vein occluded by a thrombus. Blood dark and fluid. During life there was a lar^e number of Schultze's granular masses, and the net-work of fibrin fibrils which separated out on the slide under the microscope was unusually dense and coarse. Commencing Pericarditis over right auricle. Lungs. — Numerous firm, slightly-elevated, nodules, ranging in size from a pea to a marble, in all the lobes, but most abundant in the lower. On section, most of them present a white granular surface, interspersed here and there with haemorrhages ; some of the larger ones in the lower lobes have softened at the centre into abscesses. The margins of these pneumonic areas are congested, sometimes haemorrhagic. Cancer. Case lxxxii.—Primary Cancer of bodies of 2nd and 3rd verlebrce and heads of corresponding ribs on right side. Secondary masses in ribs, liver, and brain. Chronic phthisis. Lobar pneumonia. M. C, set. 52: Vertebrae, 2nd and 3rd. Bodies not enlarged, but soft and porous. On stripping off the anterior ligament, a soft, greyish-white juice oozes out. The transverse and articular processes also involved. Two soft cancerous growths spring from the junction of the laminae and body of the 2nd, and encroach upon the calibre of the canal; at the centre of the back part of the body of the 3rd, is another tuberous outgrowth. The cord does not appear much compressed by these masses, and the membranes are unaffected. Ribs, 2nd (right side). For two inches beyond the angle the bone is enlarged, double the size of the"3rd; the arti- cular surfaces are bare. The compact tissue has disap- MONTREAL GENERAL HOSPITAL. 15 peared, and the cancerous growth has elevated and infil- trated the periosteum. On section large cancellae are seen, filled with a reddish-white juice. At the middle of this rib is an irregular swelling, one inch in length,which presents the same appearance as the head. Srd Rib (right). Not nearly so much enlarged, the articular surfaces not affected. Compact tissue gone, but periosteum is free. $th Rib (left). An elongated swelling about the middle, one and a half inches in length, most marked internally. On section external part soft and cuts readily ; the central part is hard and dense. 9th Rib (left). A still larger swelling of same character, two inches in length; not hard in the centre, but not so porous as the heads of the affected ribs. Liver not enlarged ; contains a dozen or more white masses, situated superficially, ranging in size from a wal- nut to a small pea; surfaces of most on a level with liver —the larger are elevated and with depressed centres. On section many haemorrhagic centres are seen in them. Brain. A rounded cancerous mass—1J" by 1\"—occu- pies the superior parietal convolutions of the right side, extending into the longitudinal fissure for a short distance. On section it is greyish-yellow in colour, except at the centre and margins, where there is more blood. Small masses also in the right corpus striatum and left thalamus opticus, and on the pia mater of the lower convolution of the left occipital lobe, and on the pia mater of the right crus cerebri. All of these, on examination, are cancerous in character. Lungs. Left is emphysematous, several very large blebs existing near the root. Throughout both lobes are num- erous, firm, fibroid tubercles, ranging in size from a pin's head to a pea. Lower lobe is solidified, in a state of red hepatization, the air cells being filled up with fibrinous plugs. 16 PATHOLOGICAL REPORT. The right lung contains hardly any air. At the lateral part of the upper lobe is a large dense caseous mass, the ■size of an orange, with a sharp, round contour towards the Jung, and much puckered on the pleural surface. It is very firm, and on section beautifully marbled. At the lower and back part of this lobe the lung presents a very peculiar appearance over an area equal in size to an orange; it is irregular, soft, and spongy; no definite cavity exists, but the tissue at the upper part is soaked with pus, while below there is pus mixed with blood. It looks not unlike the fibrin of blood clot soaked with pus but on examination proves to be a rapidly breaking down lung tissue, infiltrated with cellular elements. The pleura over it is very thick and fibrous. Nearly the whole of the lower lobe is in a condition of grey induration, being firm, airless, and scattered through it are a few caseous anasses. Circulatory System.—Heart. Of five cases of heart disease, one. only presented fea- tures of unusual clinical and pathological interest. It is an instance of hypertrophy with dilatation and advanced fatty degeneration, consequent, I believe, upon prolonged muscular exertion. I am indebted to Dr. Ross, under whose care he was, for permission to use the clinical notes taken by Dr. James Bell, at that time the ward clerk. Case xliv. — Hypertrophy and dilatation of the heart. No valvular or arterial disease. No chronic kidney affection. Hydrothorax. Pulmonary apoplexy. General venous stasis. J. \V., :ct. 39, coachman ; admitted November 2nd, 1876, with dyspnoea, haemoptysis and vomiting. He is a large, powerfully built man, with strongly developed muscles, and in good condition. His family history is good. Was a soldier for 18£ years, serving in India and other British stations. Never had syphilis or rheumatic MONTREAL GENERAL HOSPITAL. 17 fever. Has always been a healthy man, though intem- perate. In July last he suffered from shortness of breath and slight haemoptysis, for which, in August, he entered the hospital, and was under treatment nearly two months for " some heart affection." being discharged very much improved. He then worked for three weeks as a day labourer, and suffered much from exposure to cold and wet. On October 20, he had a chill, which was followed by swelling of the legs and abdomen, with slight dysp- noea. He gave up work on the 24th, and was treated as nn out-door patient for a few days before entering Hos- pital on November 2nd. When admitted, in addition to the above mentioned symptoms, he complained of great pain over the region of the heart. The legs were cedema- tous, and the conjunctivae and face of a sub-icteroid hue. On physical examination, the cardiac dulness is found to extend as high as the upper border of the 3rd rib, and to the right border of the sternum. A systolic murmur was heard at the left edge of the sternum in the 3rd inter- space. Apex beat cannot be distinctly felt. The pulse at the wrist is barely perceptible. There is dulness over the lower lobe of the left lung. Rough snoring rales are heard over the front of the chest, and coarse bubbling rales behind. Liver dulness extends from the 5th inter- space to the costal margin. The urine contains nearly 25 p. c. of albumen. The day after admission, he expec- torated nearly 3 pints of florid blood, and vomited very frequently. In spite of treatment (dry cupping, ergot, digitalis, etc.), his condition became worse. > On Novem- ber 5th, the pulse was quite imperceptible at the wrist,.the cyanosis became extreme, and the patient died early on the morning of the 6th, with all the symptoms of chronic valvular disease. Post mortem, 30 hours after death. Face, neck and skin of thorax intensely livid. Tissues beneath the skin of anterior part of trunk and about the root of the neck 18 PATHOLOGICAL REPORT. emphysematous. Scrotum much swollen. Leg (edema tous. Pericardium contains 3ii of serum; sub-pericardial fat tolerably abundant. Heart weighs 610 grms. (21£ oz.) Right chambers distended with dark clots and fluid blood; the venae cavae are also dilated and full, much blood escaping from them in the removal of the organ Right auricle is very large, size of a small orange; walls of about the usual thickness. Right ventricle dilated, anterior wall measures \" in thickness ; columnae carneae are not hypertrophied. Tricuspid orifice 5f" in circum- ference ; valves healthy. Pulmonary valves normal; circumference of orifice 3". Left ventricle contains some fluid blood, and a small partially decolorized clot in the mitral orifice. The chamber is much dilated, measuring 4|" from apex to aortic ring, and bulges considerably towards the right ventricle. Endocardium thick and opaque, especially over the septum. Musculi papillares fibroid at apices. Walls, over middle of anterior part, $" in thickness; posterior wall |"; ventricular septum, a quarter of an inch below aortic valve, |". Mitral valves slightly thickened at the edges, otherwise healthy. Orifice measures 4|" in circumference. Aortic valves compe- tent, segments thin and natural looking; orifice, at the ring, measures 2f" in circumference. Aorta looks— relatively—smaller than natural. It is not atheromatous, either in the arch or in its course. Muscular substance of whole heart, and especially the left ventricle, looks pale, and on examination is found in a condition of advanced fatty degeneration; a good deal of fatty infil- tration also exists between the individual fibres. Arteries of the body do not present any signs of degeneration. Lungs. ?xcvi of serum in left pleura, and the lung on this side is collapsed and only slightly crepitant above. Two very large spots of apoplexy in the anterior part of upper lobe, and about them the lung tissue is hepatized. Another, also large, occupies the anterior border of the lower lobe. Right lung is crepitant, but contains much MONTREAL GENERAL HOSPITAL. 19 blood and serum. At the lower part of anterior lobe in front is a small, consolidated area. Spleen, 250 grms., firm. Kidneys, not enlarged. Capsules detach easily; surfaces smooth. On section pyramids and Malpighian tufts of the cortex are injected. Stomach and intestines present nothing unusual; the large and small veins are very full. Liver, a little enlarged, of good consistence; venules of hepatic vein gorged—nutmeg organ. Brain. Sinuses of dura mater and veins of the pia mater full. Arteries at the base not diseased. Nothing abnor- mal in the substance. When this case came under observation in the autopsy room, I confess to have been not a little puzzled, and so impressed was I at the time with the unusual character of the lesion that a most searching examination of the different organs was made, and accurate measurements of the heart taken. There were none of the common causes present to account for the hypertrophy of the heart—no valvular disease, no arterial degeneration, no chronic renal or pulmonary disease ; and though aware of the fact that an idiopathic (so-called) hypertrophy of the heart was described, still, I did not know that a fatal issue might follow in such a case with all the symptoms of chronic valvular disease ; nor did a consultation of the various works on the heart guarantee such a supposition. A few months after, in Nos. 17 and 18 of the Berliner Klinische Wochenschrijl, 1877, an article appeared upon a fatal case of dilatation and fatty degeneration of the heart, consequent upon prolonged muscular exertion, which in its symptoms and anatomical characters is almost the exact counterpart of the one here recorded, except that the-dila- tation was a little more marked, and the hypertrophy not so great. On making enquiries it was ascertained that this patient had always been a very powerful, muscular man, and since his discharge from the army had worked 20 P VTHOLOGICAL REPORT. as a blacksmith. Unfdrtunately, his wife, from whom alone definite information could have been obtained, left the city soon after his death, so that the details of his past life are necessarily incomplete. However, in the absence of all the commonly recognized causes of heart disease, it appears reasonable, with the evidence of Albutt, Meyers, DaCosta, Seitz, Thurn, and others before us, to attribute the lesion in this case to overstrain or prolonged muscular exertion. The case, however, is one of such unusual interest that I propose to deal with it more fully in a separate paper. Fenestration of the valves.—In exactly 20 per cent, of the cases were these peculiar little perforations met with in the aortic valves, while in the pulmonary semi-lunar they occurred in only 7 per cent. They are either congenital or result from atrophy, and probably have no pathological significance. Arteries. Atheroma.—In twenty three cases the aorta presented signs of this degeneration, usually slight in amount. In five instances the arch was dilated and the atheromatous condition very marked. Aneurism. y^ Case xxxvi.^-Aneurism of commencement of thoracic aorta, unsuspected during life. Death from general Tuberculosis. A. B., aet. 32, a well-built muscular man. The aorta presents at the arch several calcareous plates and patches of atheroma. A large aneurism, the size of the fist, found just below the termination of the arch. It contains nu- merous fibrinous laminae. The posterior wall of the sac is formed by the 3rd, 4th and 5th dorsal vertebrae, which are bare, and eroded. Left ventricle hypertrophied; valves of the heart normal. The lungs stuffed with recent tubercles, and at MONTREAL GENERAL HOSPITAL. 21 the apices small caseous masses. It is an interesting fact that, so far as could be ascertained, this patient had never- suffered from any symptoms of aneurism. / Case xlix.—Sacculated aneurism of ascending portion of arch of aorta. Rupture into the right pleural sac. J. O, aet. 40, a well-built muscular man. A little to the right of the middle of the sternum is an irregular oval swelling. On opening the thorax the cartilages of the 3rd, 4th, and 5th ribs on the right side, with the corre- sponding portion of the sternum, are found much eroded, the 3rd cartilage having almost entirely disappeared. The sac of the aneurism lies immediately beneath the sternum, which, with the above-named cartilages, forms its anterior wall. In the rest of its extent the wall is made up chiefly of condensed pleural and mediastinal tissues. It springs from the right side of the ascending part of the arch, with which it communicates by a rounded orifice 1|" in dia- meter, the margins of which are thick and project into the sac. The contents consist of fresh coagula and old laminae of fibrin; the entire mass when removed from the sac filled the two hands. The site of rupture was discovered at the right side of the sac, close under the ribs, at which point the blood had burst into the right pleura through an opening \" in diameter. The right pleural cavity is full of coagulated blood, the serum floating uppermost. A large clot, forming a mould of the cavity and grooved by the ribs, was removed entire, and weighed 3| lbs. The lung on this side is compressed and airless; the' visceral layer of the pleura over it rough, and covered with minute patches of lymph. The left ventricle is hypertrophied; muscle of good colour. Aortic valves a little thickened and puc- kered at the edges. Patches of atheroma exist in the intima of the arch. 22 PATHOLOGICAL REPORT. Case lxxxvii.—Sacculated Aneurism of aorta, at termi- nation of the arch ; unsuspected during life. Death from Pneumonia. J. W., aet. 62. Died 18 hours after admission. Heart. Left ventricle contains a dense decolourized clot, walls considerably hypertrophied. Aortic semi-lunar valves thick and atheromatous at bases and about corpora Aiantii. , Aorta.—Whole arch dilated, the intima thickened and rough. At the end of the descending portion there is a sacculated aneurism, the size of a billiard ball, pro- jecting from the antero-lateral part of the vessel toward the right side. The orifice of communication with the sac is 11" by If" in diameter. The intima terminates by a rounded margin at the orifice. The wall of the sac is made up chiefly of the outer coat, and is lined with con- densed laminae of fibrin. Case liii.—Aneurism of Hepatic Artery. Right branch almost obliterated. Multiple abscesses in the Liver. W. H., aet 21. Admitted into Hospital Nov. 8, 1876, under Dr. Ross, died Dec. 7. Symptoms those of abscess of liver. For clinical report by Dr. Ross, see C. M. and S. Journal, July, 1877. Rigor mortis present. Skin of a dirty-brown colour. In the abdomen about 22 oz. of yellow turbid fluid. In the right pleural cavity about 20 oz. of similar fluid. Right lung collapsed. The pleura covered with a thin layer of greenish-yellow lymph. On section, the lung is dark, airless, and sodden. Left Lung. On the visceral layer of the pleura, especially behind, are numerous small ecchymoses. On section, organ contains much blood, is firm, and only slightly crepitant. Heart normal. Kidneys rather pale, cortex swollen, and Malpighian tufts injected. Spleen, weight 445 grms. (14 oz), adherent to the stomach. MONTREAL GENERAL HOSPITAL. 23 Organ soft. On section dark and congested. Intestines normal. No trace of ulceration in the large bowel. Bladder and prostate, normal. Liver, weight 4879J grms. (lOf lbs). The peritoneum around it in many places shows signs of inflammation, the left lobe being intimately adherent to the stomach by a thick layer of firm yellowish-coloured lymph; the right lobe is also cemented to parts in its neighbourhood by lymph of a similar character. A small amount is also observed on the descending colon, but the general peri- toneal surface is not affected, the serous covering of the intestines being clear and glistening. The liver itself retains its normal shape, the upper surface is smooth and not adherent. Towards the right border a yellowish- coloured swelling is evident, which is perceptibly fluc- tuating. Other less distinct yellowish spots* are seen scattered over the organ. To the touch the upper and back part of the right lobe is exceedingly soft and fluctuating. On the under surface many yellowish-white nodules are apparent, some large, others quite small, all distinctly fluctuating. A similar one of large size is . apparent on the under surface of the left lobe. A trans- verse incision through both lobes reveals the fact that we have to deal with a diffuse suppurative hepatitis. An immense quantity of yellowish-white, custard-like pus flowed out. The right lobe is completely honey-combed by a series of small, closely united abscesses, ranging in size from a marble to a walnut. The septa between these are composed of a dark-red tissue. Most of these small abscesses communicate together; some have merged to form larger ones. They all possess distinct lining membranes, which are frequently stained with bile. The left lobe is in a similar condition, and in both the abs- cesses extend throughout the thickness of the organ. Thus, the only portions of liver-substance which are found comparatively free are the lobus quadratus and 24 PATHOLOGICAL REPORT. that portion of the organ lying immediately above and a little to the left of the gall bladder. These parts on section are of a dark colour, lobules distinct, small bile vessels very evident. The gall-bladder is small, contains about three drachms of a clear, somewhat viscid secretion. On pressing it and along its ducts no fluid could be forced out at the papilla biliaria. It was with much difficulty that a probe could be passed along the cystic duct, owing to an unusual number of irregular folds in the mucous membrane, which are evident on slitting up the duct. The common bile duct itself is patent, the mucous membrane of its upper two-thirds stained with bile. There are no clots in the superior mesenteric, gastric, or splenic veins. On slitting up the portal vein itself, a small abscess is found projecting into the calibre of one of its right divisions. The tissue in the neighbourhood of these main divisions is infiltrated with pus. A firm nodule was felt at the portal fissure and mis- taken at first for a bunch of lymph glands. Section of this, however, showed it to be distinctly laminated, and careful dissection of the part revealed the existence of an aneurism just at the bifurcation of the Hepatic Artery, but occupying chiefly the right branch (see frontispiece). The dilatation begins immediately beyond the gastro-duoden- alis (d), and extends for about three inches as a somewhat conical swelling. The left hepatic artery (c) arises from the obtuse end of the aneurism and is unaffected. At the thickest part its circumference measures three inches. For 2| inches it passes to the right and o-ives off two branches (/) which appear occluded, then turns at right angles and passes backwards for 1J inches towards the pos- terior border of the liver, terminating by a conical extrem- ity which is continuous with the main branch of the artery. The arteries of the body had been injected, and the red mass is found in the trunk of the hepatic before MONTREAL GENERAL HOSPITAL. 25- its bifurcation, in the gastro-duodenalis, and the left hepatic branches, all of which are full and tense. The hepatic artery appears to enter the aneurism about J of an inch from the obtuse end, the gastro-duodenalis and left hepatic being given off apparently from the dilatation itself, and on slitting up the hepatic artery it appears at first sight as if these were its only branches, and that its communication with the aneurismal sac had become obli- terated. Careful inspection, however, of the lower and posterior wall reveals a small canal, the calibre of a hypo- dermic needle, which leads directly into the sac. The aneurism being opened by a longitudinal cut on the upper surface, it is seen that the anterior third, comprising the rounded end,, is completely filled with firm decolor- ized laminae of fibrin, concentrically arranged. The middle third of the sac contains semi-coagulated blood and red injection mass, after emptying which there is seen a cavity*about the size of a small walnut. This is in communication with the hepatic artery by the small canal already referred to, which passes for rather more than half an inch through the fibrinous laminae of the anterior end. Two small branches, both containing injection, pass from the cavity, one, the cystic, ( e) going to the gall-bladder, the other, a somewhat larger branch, passing to the central part of the organ. The sac is lined with sheets of fibrin which at the under part are thin- ner than elsewhere, and at this point the blood has infiltrated the proper coats of the aneurism, which, in con- sequence, look reddish black. The terminal portion of the sac lies chiefly in the substance of the right lobe, sur- rounded by suppurating hepatic tissue, which had to be dissected away to expose it; and on section the cavity is found almost completely obliterated by fibrinous laminae, which in the centre are softer, and not so colourless as at the other end of the sac. No direct passage could be traced through this from the central cavity, and the main, 26 PATHOLOGICAL REPORT. branches given off from the aneurism are found empty, and at their commencement plugged with fibrin, which in several extends as a thin sheet along the intima. The condition appears to be one of simple aneurismal dilatation of the vessel, the walls being thin, slightly roughened on the interior, but not markedly atheromatous. The trunk of the hepatic artery itself looks healthy, and there are no evidences of general vascular degeneration. Among the many interesting points in connection with this case, the causation of the multiple abscesses takes the front rank; not only because in this one alone among the recorded cases was the fatal termination due to a suppurative hepatitis, but also on account of the extreme rarity of an opportunity to study the effects of disease of the hepatic artery upon this organ in man. Taking for granted, as from the careful examination we may justly do, that the portal system did not in this in- stance furnish the materies morbi, we have to consider the consequence of total obliteration of the hepatic artery, or of its main branches, and also the effect of small emboli, in the form of particles of fibrin, plugging its terminal twigs. It will be necessary first to refer briefly to a few ana- tomical and pathological points in connection with the blood supply of the liver. This, as in lungs, is two-fold; the portal vein ministering solely to the functions of the gland, the hepatic artery chiefly to its nutrition. The ultimate branches of the portal vein ramify at the peri- phery of the lobules, forming the interlobular vessels, from which numerous capillaries pass into the interior, and finally converge to the centres of the lobules, as the ulti- mate radicals of the hepatic veins. The hepatic artery furnishes blood to the bile ducts, portal and hepatic veins, and the connective tissue of Grlisson's sheath. Its capil- laries empty their blood by small venules into the inter- lobular veins. Hence, remembering this distribution of MONTREAL GENERAL HOSPITAL. 27 the hepatic artery, it is easy to understand that in cases of thrombosis of the portal vein, even where the obstruction is complete, the functions of the organ may be maintained, and both bile and glycogen secreted ; for the capillary plexus of the lobules continues to receive through the interlobular veins the blood which has been emptied into the latter from the venules of the hepatic artery. The nutritive blood serves as a substitute, acts vicariously, for the functional. It has been maintained, and the statement passes current in the text-books, that the converse of this is true, viz : that the portal blood can replace the hepatic, the functional act for the nutritive. This view is based on experiments made upon the lower animals. Schiff states that in the cat the functions of the liver are performed just as well after ligature of the hepatic artery as before ; and Betz found that in the dog, after tying the trunk of the hepatic and all the collateral branches, no important alteration took place either in the structure of the liver or in its secretion. Cohnheim and Litten have shown, howeArer, in a very important paper on " Disturbances in the Circulation of the Liver," (Virchow's Archiv. May, 1876), that in expe- riments on dogs arterial blood still reaches the liver even after ligation of the hepatic, the coronaria ventriculi, and the gastro-duodenalis, owing to the very extensive anas- tomoses and connections of these vessels. In the guinea pig, on the other hand, the supply of arterial blood can be completely shut off, either from the whole organ or from individual lobes. In the former case the operation is always fatal within 24 hours, and even in this time important changes are found to have taken place in the organ. These are all the more marked if, instead of ligating all the arteries, only the one going to the extreme right lobe be tied. The result is an entire necro- sis of the portion of the liver supplied by the ligatured 28 PATHOLOGICAL REPORT. artery, and in every instance the animal died within two days. Cohnheim states that pathological proof of the correct- ness of this view is as yet wanting, but I am inclined to believe that by this case the deficiency is supplied ; for I think the suppuration of the organ best explained on the view, that the shutting off the supply of blood, either by the gradual occlusion of the aneurism by clots, or by the quicker process of emboli conveyed away from the interior of the sac, produced numerous areas of necrosis, which subsequently became, by inflammation and a sequestering suppuration, converted into abscesses. It is impossible to determine, in the absence of any posi- tive evidence, whether the process resulted from emboli or simply by the gradual obliteration of an important blood channel; and in any case there are certain diffi- culties -which, will occur to the minds of many in the view here suggested. There are at least two cases on record of total obliteration of the artery without con- secutive suppuration, one of which was from aneurism. Still, this, if occurring gradually, and not involving the pylori© artery, need not necessarily, as the above-men- tioned experiments prove, deprive the liver of arterial blood. There is no reason to suppose that the obliteration in this case did not occur slowly, for the fibrinous laminae, especially at the anterior end, were firm and tough. Again, on an embolic theory it might be urged that in this instance the emboli, consisting of fibrinous shreds from an aneurismal sac, should have produced simply mechanical effects, infarctions, and not, as in the case of emboli proceeding from necrotic or suppurating foci, abscesses. Mechanical emboli do, however, some- times produce suppuration, and in the liver might do so by causing death of the structures supplied by the ob- structed arteries, viz : the portal vessels, bile ducts, and connective tissue of G-lisson. In the present case, sup- MONTREAL GENERAL HOSPITAL. 29 posing the process to depend on emboli, there would be arterial blood enough sent through collateral branches to furnish material for an active suppuration about the necrotic centres. Altogether, the embolic theory meets the case better than any other. It is to be remembered also, that the disease was not rapidly fatal, but came on slowly, lasted five weeks or more, and it is not unlikely that during this time much of the fibrin was deposited, and the obliteration of the distal end of the aneurism took place. This is rendered still more probable by a con- sideration of the condition of the left hepatic branch, the commencement of which is involved in the aneurism, but which now, owing to the filling of the proximal end of the sac with fibrin, appears to be almost the direct con- tinuation of the main trunk. In fact, for a short distance from the bifurcation, the upper wall of the left branch is made up of condensed fibrin, which is grooved by the blood channel. This explains, too, the occurrence of the abscesses in the territories supplied by the left branch. The almost entire obliteration of the obtuse end of the sac occurred, most probably, after the mischief had been started by the escape of emboli. The appearance of the abscesses adds further support to this view. None of them looked recent or contained shreds of necrotic liver tissue, but all were filled with a creamy pus, and had walls lined by definite pyogenic membranes. There is no clue to the origin of the aneurism itself. The age of the patient, and the absence of arterial degene- ration elsewhere, are almost sufficient to exclude athero- matous degeneration as a cause, and the walls of the sac appear thinned but not evidently diseased. Of other agencies capable of producing aneurism, especially of smaller vessels, embolism is the most important, and, even in the absence of valvular disease, and remembering the unfavorable position of the hepatic artery for emboli, we are inclined to regard it as the most probable cause. 30 PATHOLOGICAL REPORT. It is scarcely possible, considering the situation of this artery, that strain could have had anything to do with its production. Case xlviii.—Aneurismal dilatation of branches of pul- monary artery on the walls of phthisical cavities. Death from hemoptysis. J. L., aet. 44, ill for some time with phthisis, died unex- pectedly of haemorrhage from the lungs. Lungs.—Seven cavities, in size from a walnut to a small orange, found throughout the organs, chiefly in the upper lobes. Five of these contain blood with clots. Caseous masses numerous, and here and there small tubercles. On section of the lower lobes, irregular areas of a darker colour are noticed on the congested surface, which on inspection are seen to be small bronchi filled with clots, the lung tissue about them being deeply stained. On slitting up the branches of the pulmonary artery three aneurismal pouches, the size of peas, are met with in vessels run- ning on the walls of cavities. They appear to be simple diverticula of the vessels, the intima being continued into them. From the side of the cavities they look like little irregular swellings on the wall. The origin of the hae- morrhage was not discovered, though all the branches of the pulmonary artery in the right lung and lower lobe of the left were slit up. The vessels of the upper lobe of the left lung were, by mistake, not examined. No doubt the haemorrhage in this case was due to the rupture of one of these small aneurisms—the cause of the haemorrhage in most of the cases of death from haemop- tysis in chronic Phthisis. (See Ramussen, Edinburgh Medi- cal Journal, 1868, and Powell " Trans. Path. Soc." xxii.) Case ix.—Aneurism at second bifurcation of the right middle cerebral artery. Rupture ; extravasation of blood into MONTREAL GENERAL HOSPITAL. 31 the Sylvian fissure, and laceration of substance of the temporo- sphenoidal lobe. Death in 36 hours. Mrs. R., aet. 40. See report of case by Dr. Bell.—Can. Med. and Surg. Journal, August, 1876. Post mortem, 11 hours after death. Body that of an average sized, poorly nourished woman. Head—Nothing special noticeable about the soft parts or the calvarium. Veins of the pia mater moderately full of blood; sub-arachnoid fluid scanty. In the removal of the brain, clots are met with in the neighbourhood of the middle fossa of the base of the skull on the right side, and they are seen to have proceeded from a large extra- vasation which had taken place in the right Sylvian fissure. The convolutions of the middle lobe in the vicinity are considerably lacerated, the brain tissue broken down and replaced by a dark clot. About a handful of coagu- lated blood was removed, most/of which was in and about the Sylvian fissure. Only a thin layer of blood exists at the base, around the optic commissure and perforated spaces. A delicate coagulum also extended over the con- volutions in the lateral region on the right side. The circle of Willis and middle cerebral artery were removed for subsequent examination. The substance of the brain appears healthy; the ventricles are empty, and nothing abnormal is observed about the ganglia at the base. On carefully washing away the clots from the right middle cerebral artery, the source of the haemorrhage was ascertained to be a small aneurism, situated in the fork of the chief bifurcation of the vessel. This had ruptured,. and the blood had escaped through a large ragged orifice. The remaining vessels of the brain were found healthy, no atheromatous change being detected in their walls. Abdominal organs healthy ; no affection of the kidneys. A beautiful false corpus luteum was found in the left ovary (she had menstruated exactly three weeks before), measuring fully £ of an inch in diameter, and with a pale ! 32 PATHOLOGICAL REPORT. yellow convoluted wall. The central coagulum was of a dark red colour. In the same ovary at the other end was a small corpus luteum about | the size of the large one, with a decolorized coagulum and much more convoluted wall. Uterus somewhat enlarged. Mucous membrane ap- peared congested and tumefied. The situation, size and appearance of the rupture are well shown in the annexed wood-cut. Respiratory System—Trachea. Case lxi.—Ossification of greater portion of mucous mem- brane of trachea. This curious condition was met with in a case of Addi- son's Idiopathic Anaemia.—(See Can. Med. and Surg. Journal, March, 1877.) J. A., aet. 47. Trachea.—Beginning just below the cricoid cartilage, and extending to the bifurcation, the mucous mem- brane is represented by irregular ossific plates, which towards the front of the tube and near the main bronchi form a continuous bony membrane. The free surface is denuded and very rough, numerous pits and projections alternating with each other. Towards the bronchi the ossified membrane is thicker, and firmly united to the subjacent cartilages. MONTREAL GENERAL HOSPITAL. 33 LUNGS.—Pneumonia. Of 14 post mortems in cases of pneumonia the following are of special interest. Case x.—Pneumonia of the upper lobe of the right lung ; extensive meningeal inflammation. H. F., aet. 38. In hospital four days. For clinical report, see Can. Med and Surg. Journal, August, 1876. Lungs.—The upper lobe of the right lung, with the exception of the anterior and lower borders, is in a state of red hepatization. The bronchial tubes of the consoli- dated area are uniformly filled with fibrinous plugs. The other lobes of this, and the whole of the left lung, are engorged, much blood and serum escaping on section. Scattered over the visceral pleura of both lungs, chiefly at the base, are small, white, firm granules, feeling to the touch like small shot, and resembling miliary granu- lations. Some of them are flatter, others are situated upon fibroid bases, and on examination they prove to be fibrous outgrowths of the pleura. Brain.—On removal of the dura mater, the longitudinal fissure is seen filled with yellowish-white lymph, and the Sylvian fissures are in the same condition. A thick layer of lymph exists about the optic nerve, extending over the perforated spaces to the pons, and on either side to the under surface of the temporo-sphenoidal lobes, and posteriorly over the medulla and contiguous portion of the cerebellum. A considerable amount of greenish- yellow lymph exists over the superior convolutions of the frontal lobes, and the same is seen in small quantities upon the parietal convolutions. Upon the left occipital lobe is a thin layer of extravasation. The vessels of the pia mater are moderately full. On section the white sub- stance is glistening and moist. Fornix and septum exceed- ingly soft. Ventricles contain a moderate amount of fluid, 3 34 PATHOLOGICAL REPORT. and their walls are soft. Here and there on the course of the vessels are small extravasations, and the same are noticed along the vessels on the fourth ventricle. No trace of miliary tubercles found about the vessels or parts at the base. Cask xv.—Almost entire hepatization of left lung, with small pneumonic area in right. Extensive diphtheritic Colitis- M. S., aet. 22. In hospital six days. Lungs.—With the exception of the apex, the whole of the left lung is solidified, and in a state of red hepatiza- tion. The visceral pleura is inflamed and covered with a layer of lymph, which in the fissure between the lobes is very thick. In the posterior part of the lower lobe of right lung is a patch of hepatization the size of an orange. Large Intestine.—The mucous membrane of the ciecum is covered over with a thin layer of yellowish, firmly adherent lymph, which can be stripped off, showing a much injected surface beneath. The first foot of the colon presents nothing abnormal, but in the next eighteen inches the mucous membrane is congested and covered with elevated patches of lymph, many of which are isolated, the majority, however, being united and arranged in a linear direction. The patches are elevated, the isolated ones of the same shape and size as rupia crusts; on section they are seen to extend through the whole thickness of the mucous membrane. These patches occur throughout the descending colon and sigmoid flexure ; in the latter region there is an irregular one, 4" in length. Case lxii.—Diabetes, phthisical cavity in right lung sur- rounded by hepatized tissue. J. W., aet. 26. Clinical history, Can. Med. and Surg. Journal, August, 1877. Lungs.—Posterior part of upper lobe of right lung is occupied by an irregular cavity, elongated in form, hold- MONTREAL GENERAL HOSPITAL. 35 ing about an ounce. The walls are made up of a dirty brown, pasty material, caseous in character. There are no fibroid or other changes about the cavity, but it is sur- rounded by lung tissue in the second stage of pneumonia. The whole of the lower lobe of this lung is solidified, and the lower lobe on the other side is in the same condition. Case lxih.—Chronic phthisis. Almost entire destruction of both lungs. Healthy portion involved in a pneumonia. J. F., aet. 35. In hospital for a long time, caught cold, and died of inflammation of the only sound portion of his lungs. Lungs.—Right lung, with the exception of anterior half of lower lobe, is a mass of cavities and caseous nodules. The unaffected part is in a condition of red hepatization, a few firm nodules being seen in it. The pleura over it is covered with a thick layer of recent lymph. Left lung almost entirely destroyed by cavities. Case lxiv.—Simple pneumonia of left lung, right-sided pleurisy. A. G., aet. 22, ill 6 days. Lungs.—Three and a half pints of serous fluid in right pleural* sac. The pleura of lower and middle lobes is covered with thick lymph. Both of these lobes collapsed and airless. Anterior two thirds of upper lobe of left lung in condition of red hepatization; the pleura over it not involved in the inflammation; rest of the organ in a state of acute oedema. Case Jji.—Pneiimonia of right lung, uniform involvement of pleura covering it. H. L., aet. 36. Lungs.—Right uniformly hepatized. The visceral layer of pleura extensively inflamed and covered with a dense layer of yellowish-white lymph, in places, fully \" vol 36 PATHOLOGICAL REPORT. thickness. Left lung much engorged and cedematous. Right lung weighs 3 lbs,. 6| ounces; left, 1 lb. 13 oz. Remarks.—Throughout the past winter pneumonia prevailed to an unusual extent, and was very fatal, espe- cially to elderly and debilitated persons. Ten fatal cases occurred in the G-eneral Hospital, some of which, as above recorded, presented very interesting pathological features. Foremost among these is the case complicated with simple meningitis, a rare, and, from a clinical stand-point, puz- zling complication, the pneumonic symptoms being masked by the cerebral phenomena, and rendered liable, to be over-looked. It is interesting to note that the pneu- monia was of the upper lobe, a situation which, when affected, appears more liable to be accompanied with brain symptoms, delirium, &c. The complication of diphtheritic or croupous colitis in pneumonia is not referred to in any of the text books on Pathology or Practice of Medicine which I have consulted. Dr. Bristowe^ was the first, so far as I can learn, to call attention to this condition, which he found in two out of 30 cases of secondary pneumonia, and in four of 16 cases of the primary disease. The distinct false membrane on the mucous surface of the caecum in the above case corresponds with his description of the early stage of the affection, and represents a condition in the large bowel known by the name of pellicular or diphtheritic colitis, which occurs sometimes as an idiopathic affection, but more frequently is secondary to some other disease. I find no mention in any of the works at my disposal of the large rupia-like masses of exudation scattered singly and in rows upon the mucous membrane. Several of the autopsies suggested a practical point of much importance, viz., the propriety of bleeding in cer- * Transactions of the Pathological Society of London. Vol. via. p. 66. MONTREAL GENERAL HOSPITAL. 37 tain cases. Thus, for example : A young man, aged 20, full-blooded, died of pneumonia on the 5th day. At the autopsy, right heart and venous system gorged. Left lung uniformly solid, in a condition of red hepatization, its tissue dry, containing but little blood ; right lung in a condition of acute oedema, the surface on section bathed with bloody serum. Death most probably resulted from the vain effort of the right heart to send a certain volume of blood through an area of pulmonary capillaries reduced one-half by disease; in consequence the blood pressure was nearly doubled in the normal capillaries, trans- udation of serum under the increased lateral pressure occurred and a suffocative oedema terminated the case. The reduction of the volume of blood by a copious venesection would have restored the natural equilibrium between the circulating fluid and the pulmonary capil- laries ; just as nature gradually adjusts it in the case of a consumptive, with more than one-half of these capillaries destroyed. Gangrene. Case xii.—Phthisical cavities in left lung; gangrene of pulmonary tissue about one of them. H. L, aet. 38. Lungs.—Occupying the back part of the left lung at the middle third of the upper lobe is an area of gangrene, the size of a large orange. It is situated immediately beneath the pleura, and was perforated by the finger in the removal of the organ. On section it is found to con- sist of dark, exceedingly foetid, decomposing lung tissue, which, after pouring a stream of water upon it, adheres to the vessels and bronchi as irregular shreds. The lung in the immediate neighbourhood is consolidated, and seve- ral small cavities and caseous nodules are present in the other lobes. Bronchial tubes contain an offensive mucus, and the membrane is very dark-coloured. 38 PATHOLOGICAL REPORT. Phthisis. Of twelve cases, three only are worthy of notice. Case xxxviii.—Fibroid contraction and induration of entire right lung, cavity at apex. Displacement of heart; hypertrophy with dilatation of right chambers. For clinical history see Can. Med. and Surg. Journal, Feb. 1877. Lungs.—Right, universally adherent, and removed with difficulty; organ firm, solid, and to the touch gives no indication of crepitation. On section no trace of the lobes remains. A large cavity occupies almost the entire apex, situated chiefly in the antero-lateral region, the posterior wall being composed of irregular fibroid masses through which two or three large bronchi open directly into the cavity. The upper and antero-lateral walls are made up of a layer of fibrous tissue 1-2'" in thickness, the outer part white, the inner portion darkly pigmented. Two irregular prolongations from this cavity extend down- wards and forwards towards the anterior margin of the lung, and another narrow one extends for two inches along the posterior part of the organ, immediately beneath the pleura, which is here thin. The lining membrane of these cavities is dark red in colour, and traversed by numerous bands, the remnants of bronchi and blood- vessels. The base of the organ is firmly united to the diaphragm, and the portion which is received into the angle between this membrane and the ribs is, for the extent of 1|", transformed into a mass of white fibroid tissue, devoid of any trace of lung substance. Between the upper margin of this fibroid area and the cavity at the apex—a distance of 3"—the lung presents a marbled appearance, is dense, firm, and with the exception of one small spot close to the root, airless; a few small dilated bronchi are evident below, while immediately beneath the pleura are one or two inconsiderable cavities filled MONTREAL GENERAL HOSPITAL. 39 with a bloody and purulent matter. The anterior border. of the organ is in the same condition, and on section numerous small cavities (some of which are dilated bronchi) with bloody contents are seen. The organ is not excessively pigmented. The main bronchus and its branches of the 2nd and 3rd degree are somewhat dilated. Bronchial glands firm, not enlarged, moderately pig- mented. Left lung adherent at the apex only. On section a large irregular cavity with thick dense walls occupies the upper and anterior part of the apex, the lining membrane of which is haemorrhagic. The remainder of the organ is extensively emphysematous, especially at the anterior border, but presents no other degenerative signs. Heart.—The cavities of the right side much dilated and full of blood, walls of right ventricle appear somewhat thickened. Tricuspid orifice dilated, admitting four fingers nearly to the second joint. Segments of the valves i little thickened at the edges. Musculi papillares look elongated and the apices are fibroid. Case lxxxi.—Chronic phthisis.—Perforation of the lung —Pneumothorax. Dermoid cyst of right ovary. .1. S., aet. 21.—On opening the abdomen the liver is seen to be displaced downwards, the upper border corre- sponding to the lower margin of the ribs. On penetrating the right pleural sac a considerable amount of air rushed out. 18 ounces of a clear, serous fluid in this cavity. Lungs.—The left upper lobe is riddled with cavities ; the lower lobe is slightly crepitant, and contains numerous caseous and tubercular nodules. Upper and middle lobes of right lung almost airless, except at free border ; lower lobe collapsed. No adhesions except at extreme apex The visceral layer of the pleura of lower lobe is covered with patches of lymph. At the upper and poster- ior part of this lobe, about an inch from the root of the 40 PATHOLOGICAL REPORT. lung, and the same distance from the upper lobe, there is a small oval perforation, 21'" by 1£"', through which air bubbles on pressure. For a couple of lines about the orifice the pleura is pale ; beyond this the membrane is injected and covered with recent lymph. The perforation does not lead into a definite cavity, but into a rapidly softening portion of lung, infiltrated with pus, and in parts quite diffluent. Case lxxxii.—Chronic Phthisis. Cancer of the vertebral and ribs. Reported under Osseous System. Pleura. Small fibroid thickenings on visceral layer.—In three in- stances localized fibrous outgrowths of the pleura have been noticed, much resembling miliary tubercles in size and general appearance. The first case in which they occurred was that of pneumonia complicated with menin- gitis, and the note with reference to them in the post mortem book is as follows : " Scattered over the surface of pleura of both lungs, chiefly of lower lobes, are small, white, firm granules, feeling to the touch like small shot, and resembling miliary granulations. Some of them, however, are flatter, not granular, and they may be simple fibroid thickenings of the pleura." Such they proved on examination to be. They occurred in a case of cancer of the liver, though not so abundantly, on the pleura cover- ing the left lung; and a third time on the pleura of the upper lobe of the left lung in a case of pneumonia. They are found chiefly on the interlobular tissue, sometimes as shot-like elevations on small opacities of the membrane. These are of interest on account of the resemblance they present to miliary tubercles ; so much so that an experienced pathologist seeing them in the first case, raised a question as to the nature, whether simple or tuberculous, of the meningitis accompanying it. Inflammation.—Of fifteen cases in which the membrane was affected, thirteen were simple in character, and i MONTREAL GENERAL HOSPITAL. 41 accompanied with a variable quantity of exudation; the other two were cases of empyema. In the following cases the effusion was enclosed in pockets, and though, for convenience, the chest was tapped, post mortem, the whole of the fluid could not be drawn off. Case lxvii.—Pleurisy: Fatty and fibroid Heart. A.B., aet. 63. Right Pleura.—By tapping, about seven pints of clear citron-coloured fluid were withdrawn. On removing the sternum a definite pocket is found from which the fluid had been removed. The upper wall of the cavity is formed of a layer of tenacious lymph. Another smaller pocket exists in the upper and back part of the pleural cavity. Case lxxxviii.—Suppuration of portal vein. Empyema. A. B., aet. 40. Left Pleura.—About 54 oz. of pus in this cavity. Ante- riorly it is contained in two pockets, one the size of a large orange immediately at the apex, the other corresponding in position with the third and fourth ribs, just external to the cartilages. This latter pocket communicates by a small round orifice with the general cavity, which occu- pies the lower and whole of the back part of this side. The pus was withdrawn from the latter without affecting in any way the contents of the cavity at the apex and not entirely emptying the other one. G-astro-Intestinal System. Tongue.—Epithelioma. Case xlv.—Epithelioma of right side of Tongue, extend- ing from base to near the apex. Removal of organ with gal- vanic ecraseur. Suppuration beneath cervical fascia. Pycemia- J. L., set. 36. 42 PATHOLOGICAL REPORT. The tissues of the neck behind the deep fascia, princi- pally on the right side and in front, are uniformly infil- trated with pus, which extends also to the anterior mediastinum. There is no definite collection of pus. Lungs.—Left, healthy looking. Middle and part of the upper lobe of right are firm to the touch, non-crepitant, and the surface section is bathed with a sero-sanguineous fluid. A small purulent focus exists at external part of middle lobe, not an accumulation of pus, but an area 1" by |", irregularly infiltrated. Case xlii.—Epithelioma of Tongue. Secondary nodules in liver. A. B., aet. 72.—Tongue almost entirely eaten away by the cancer, the base only remaining. The tissues in the neighbourhood are involved and the internal surface of the lower jaw on both sides is much eroded. Epiglottis and larynx not affected. The liver contains three masses of secondary cancer, the largest the size of a horse chestnut. situated superficially and presenting the usual characters of these growths. The lungs present caseous masses at the apices. Heart somewhat atrophied. Spleen very small, weighing scarce- ly two ounces. Pharynx.—Miliary Tuberculosis. Case lxxx.—Chronic Phthisis. Miliary tubercles in lungs and pharynx. A. O., aet. 22. Lungs : upper lobes riddled with commu- nicating, cavities, one of which, the size of a small egg, is filled with a clear, somewhat viscid, jelly-like material. Numerous tubercles and caseous nodules in the lower lobes. Pharynx. — Scattered over the posterior and lateral walls are numerous, small, firm, granulations, which on examination prove to be miliary tubercles. They are con- MONTREAL GENERAL HOSPITAL. 43 r/ned to the pharynx. There is no ulceration and the 'aiynx is not involved. With the exception of two suspi- cious spots in the cortex of the right kidney, the other organs are unaffected. In another case of chronic phthisis the same condition of the pharynx was observed, and without ulceration. These cases are of interest as showing the existence of extensive miliary tuberculosis in the pharynx without ulceration, and without involvement of the larynx. The condition is by no means common in phthisis. Attention has recently been directed to this subject in an able article by Frankel.* OESOPHAGUS. Post-mortem digestion.—In CASE lxix, a man dead of Typhus fever, an oval perforation of the oesophagus at the posterior wall, just above the diaphragm, was found. It extended 1|" in length by V' in breadth; the edges thin, dark in colour, not at all congested. A small amount of fluid was in the tissues of the posterior mediastinum. The stomach contained semi-digested food, and its mucous membrane was softened. Stomach.—Cancer. Case xxiv.—Cancer of the cardiac orifice, involving the asophagus. Secondary masses in other parts of the organ. M., H., aet. 52. Stomach.—The cardiac orifice is blocked by irregular cancerous projections from the mucosa, so that the tip of the forefinger is with difficulty introduced. The growth appears as an annular ring, extending for about an inch above and below the orifice. The walls are here much thickened, and the distinction between the oats lost; the surface of the cancer is much ulcerated. For a distance of an inch or more the mucous membrane * Uebcr die Miliartuberculose des Pharynx. " Berliner Klin. Wochen- Bchrift,'' Nos. 4G and 47, 1876. (Sec Can. Med. and Surg. Journal, Feb. 1877). 44 PATHOLOGICAL REPORT. of the lesser curvature appears healthy, but between this and the pylorus is a long, flat, cancerous mass, not ulcer- ated. A string of projecting nodules extends along the greater curvature, and on the posterior wall is a thick, flat mass beginning to ulcerate on the surface. The growth corresponds in histological characters with medullary cancer. No secondary masses in any other organ. Case lxii.—Medullary Cancer, involving the pyloric zone of the stomach. Perforation, peritonitis. F. M., aet. 33, had had for some time indefinite gastric symptoms, accompanied with occasional attacks of vomit- ing. There was no tumour to be felt externally. He left the hospital, to return_a short time after in a condition of collapse. Abdomen.—Intestines of a bright red colour and covered here and there with flakes of lymph. The omentum is pushed up and lies beneath the costal cartilages. On separating the transverse colon from the stomach, a round perforation about the size of a sixpence is seen in the latter, through which the contents escape. Stomach.—On opening the organ a large, irregular, can- cerous mass, about 2J" in width, extends around the pyloric zone, but does not involve the orifice. In the centre of this, corresponding to the lower and anterior part of the greater curvature, is a round perforation, the margins of which are thin and of a dark colour. The cancer is moderately firm, much raised, the surface ulcer- ated, especially at the lesser curvature. Though it con- tains a considerable proportion of fibrous elements, yet the general character of the growth corresponds rather with the medullary form of cancer. MONTREAL GENERAL HOSPITAL. 45 Small Intestine.—Incarceration. Case xcii.—Passage of two feet of the ileum through a loop attached to the sigmoid flexure. M. H., aet. 50, taken ill suddenly with vomiting and symptoms of obstruction, which continued 48 hours, when 6he died unexpectedly in a condition of coma. On opening abdomen, a small amount of bloody fluid is found in peritoneal cavity. The intestines are slate- coloured, relaxed, smooth, and present no sign of inflam- mation. On tracing them towards the caecum it is found that the lower two feet of the ileum have passed through a loop attached to the sigmoid flexure and have become strangulated, being very dark, in places almost black, as if necrosis of the part was beginning. Careful examina- tion of the constricting band shows that it is connected by both ends with the sigmoid flexure, and is composed of fatty and fibrous tissue, in structure looking very like the glandulae epiploicae near it. At its upper part, and near the attachment, it is broad, but the part farthest from the large bowel is exceedingly thin. The intestine passes through on the side of the ring next the sigmoid flexure, the lower end of the ileum being uppermost, and nipped about 1\" from the ileo-caecal valve. The mesentery passes through on the right side, and at and about the constric- tion is very dark. The diameter of the ring is about an inch. It is remarkable that though the strangulated por- tion of the bowel was dark and congested, yet there were no signs of inflammation, nor any lymph upon the peri- toneum. Nothing abnormal in other organs. Ulceration—Simple. Case xci.—Round ulcer of duodenum. M.G-., aet. 12, dead of bronchitis and pulmonary collapse. About 1£" from the pylorus, on the posterior wall 46 PATHOLOGICAL REPORT. of the duodenum, is a distinct ulcer the size of a three- penny bit, with slightly raised edges, lying between two valvulae conniventes. Nothing else abnormal in the intestines. In two instances—one a case of grey degeneration of the cordf the other a case of cancer of the uterus—there were simple round ulcers in the ileum. Typhoid Ulceration and Perforation. Of seven autopsies in typhoid fever the following are of interest:— Case Ii.—Perforation of typhoid ulcer during conva'ea- cence, owing to an indiscretion in diet. A. P., aet. 18, a convalescent for nearly two weeks, during which time the temperature had been normal. A day or two before his intended discharge he ate several mutton chops, and within 24 hours was in a state of col- lapse from perforation. Abdomen.—Coils of small intestine of a rose-red colour ; several pints of a dirty fluid, mixed with faecal matter, in the peritoneal cavity. A few flakes of lymph on some parts of the ileum, but the congestion is confined to the coils near the abdominal walls. On carefully examining the intestines a small perforation is seen, situated about eight inches above the valve, and through it faecal matter exudes. On slitting up the ileum the perforation is found at the bottom of an ulcer about the size of a copper. It is button-hole in shape, 4'" in length, 2"' in breadth, and looks like a small transverse rent in the muscular coat. There is no inflammation about the ulcer, but it and the other:-. in the bowel appear to have been healing. Case xxviii.—Perforation of a deep ulcer at end of second week. A. B., oat. 40, had been ill with typhoid fever two weeks; symptoms of peritonitis 18 hours before death. MONTREAL GENERAL HOSPITAL. 47 Abdomen.—Intestines of a vivid red colour, and the general peritoneum inflamed. On carefully working down the coils from the duodenum, no lymph or adhesions are met with until the ileum is reached; on tracing it towards the pelvis, the coils are found matted together and cover- ed with thick greyish-yellow lymph. About a foot from the valve a perforation is seen, fluid faeces of a yellowish colour flowing out, so revealing it. Intestine.—On slitting up the jejunum and ileum the mucous membrane is found pale, and in the lower two feet of the latter there are six or eight round, deep ulcers, the largest, about the size of a shilling, presenting an ir- regular perforation. The mucous membrane about the ulcers is not injected, nor are their edges raised. Case xciii.— Typhoid Fever. Perforation. Peritonitis.— J. E., aet. 29. In hospital 9 days. Peritoneum.—Coils of intestine present a vivid red ap- pearance, being covered here and there wTith flakes of lymph, and stained with faecal matter. Nearly two pints of a dirty semi-feculent fluid in the cavity. About twelve inches from the valve a perforation is seen. Intestine.—As the lower part of the ileum is approached there are several ulcers, most abundant in the foot of gut above the valve. Most of these are small and round, not elongated, and have yellowish-stained sloughs adhering to them which, with few exceptions, are only beginning to separate. About a foot from the valve is an ulcer, the size of a shilling, which has perforated. Near the valve are six or eight round, punched-out ulcers, the bases of which are formed by the muscular coats of the intestine. No ulceration in the caecum or colon. The following also present features of interest, as show- ing what a slight amount of intestinal disturbance may accompany fatal cases : 48 PATHOLOGICAL REPORT. Case xxxiii.—Four round ulcers in the ileum. Peyers patches not generally involved. Slight hypostatic pneumonia. A. B., aet. 24, a small, feebly developed man. In hos- pital 8 days. Intestines. — Several intensely black patches, quite superficial, on peritoneal surface. Mucous membrane of jejunum covered with a flaky, yellowish matter, very closely adherent, and washed off with difficulty. In the ileum, five inches from the valve, there is a somewhat elliptical ulcer, placed rather transversely to the axis of the gut, and about the size of a penny. The base is made up of the circular fibres, and the edges are neither elevated nor congested. Two other smaller ones are situated close to it, and five inches higher up is a fourth, also small, and having a punched-out appearance. The patches above this are not elevated, but have a peculiar mahogany-brown colour, and on close inspection the individual follicles are seen to be a little swollen. The solitary glands are scarcely visible. No ulceration in the large bowel. Mesen- teric glands moderately swollen. Case xxxiv.—Slight swelling of Peyefs glands, only one small spot of ulceration. J. O. aet. 40, a stout man, of intemperate habits. In liospital five days. Temperature moderate, and general symptoms not bad ; he had no delirium, but was exces- sively timid and nervous, so much so that the House Sur- geon expressed the belief that he was frightened to death. Intestines.—Peyer's patches slightly swollen, their bases congested and the follicles in each very distinct. The solitary glands in the neighbourhood of the valve are en- larged. In only one small patch, about a foot from the end of the ileum, is there any trace of ulceration, and on this it is not at all advanced. No affection of the large intestine. Mesenteric glands a little swollen. Spleen weighs 15 oz., and is very soft. MONTREAL GENERAL HOSPITAL. 49 Heart.—Right and left segments of aortic semi-lunar valves have merged together, presenting one sinus behind, with an indistinct separation near the attachment to the aorta. Segment a little thickened, but valve appears com- petent. CiECUM. Case xxxii.—Round ulcer of ccecum, perforation, general peritonitis. M. G-., aet. 19, a well-built young man. In hospital 4 days and a half, with symptoms at first like obstruction of the-bowels, subsequently those of peritonitis. Three weeks before he had an attack of what was supposed to be strangulation, from which he recovered. Abdomen.—General peritoneal surface much inflamed, and of a deep-red colour. On separating the coils of small intestine patches of lymph are met with, uniting them together. A pint of fluid in the cavity. The intestines are swollen and distended, the walls soft and tumefied. The inflammation is much more extensive toward the pelvis and in the neighbourhood of the ileo-caecal valve. Evidences of a bygone peritonitis are seen in the form of slight opacities and puckerings on the serous surfaces, both visceral and parietal. Small Intestine.—Mucous membrane tumefied; other- wise unaltered. Ctecum.—The inflammation about it is most intense, and the lymph most abundant. On carefully separating it a round patch, 2|" in diameter, is seen on the abdominal parietes, of a greyish-red colour, and somewhat depressed. Corresponding to the centre of this is a round perforation of the caecal wall, 1|" in diameter, the coats of the intes- tines about it being much inflamed. On slitting up the gut a single ulcer, which has perforated, is seen on the upper and outer wall; its edges are thin, and the mucous 4 50 PATHOLOGICAL report. membrane about much inflamed. Nothing else noticeable in the large intestine. Remarks.—Perforation of the circum is rather an un- usual accident, much more so than perforation of its ap- pendix. In this case the trouble probably originated in an attack of the typhlitis ster cor alls of Rokitansky, in- duced by the lodgment of hard masses of faeces. There were evidences about the perforation, between the caecum and iliac fascia, of inflammation (perityphlitis) of an older date than the general peritonitis; and there can be no doubt that it was in the first illness that the perforation happened, its evil effects being limited by a local inflam- mation, which subsequently, owing to some not ascer- tained cause, spread to the general peritoneum. There was a very marked contrast between the area of inflamma- tion immediately about the perforation and that towards the head of the caecum ; the former was darker, more greyish in colour, and the contiguous surfaces were not so easily separated. It is important to note, with refer- ence to the diagnosis, that the symptoms appeared to point to obstruction of the bowels; doubtless, a more thorough inspection would have satisfactorily decided the question. Appendix Vermiformis. In three cases there were found in it firm concretions of faecal matter, oval in form, and about the size of date stones. In Case xxviii., mentioned above, its calibre was obliter- ated for the first half inch of its length, patent for an inch "beyond the obliteration. In another case of typhoid fever, it was also partially closed. It was ulcerated in a case of phthisis, chiefly at the caecal end, which was almost entirely closed by the swelling of the membrane, in consequence of which the tube was dilated with the retained secretions, being nearly the thickness of the Ihumb. MONTREAL GENERAL HOSPITAL. 51 The following is the only instance of perforation noticed :— Case lxxxviii.—Abscesses in the mesentery. Suppura- tion of portal vein. Empyema. Perforation of appendix, general peritonitis. J. L., aet. 42. Had had typhoid fever three months previously. Abdomen.—General peritonitis ; 80 oz. of turbid fluid removed; intestines covered over with thick yellow lymph, most abundant on the coils of the ileum and on the pelvic organs. The appendix lies directly over the promontory of the sacrum, and is about the length and size of the index finger. It is much swollen, and the walls soft. On care- fully removing it the fluid contents escape from an oval perforation on the under side, which is adherent to the tissues over the sacrum by thick lymph. On slitting up the caecum, which is healthy, a probe cannot be passed into the appendix, nor can its orifice be seen. From the side of the latter the probe enters a small sulcus which passes for two or three lines beneath the mucous mem- brane of the caecum. About 1J" from the caecum is a round perforation, £" in diameter, the margins thin and dark-coloured. There is no foreign body or concretion. Peritoneum. Acute Inflammation.—In eleven cases of acute peritonitis, the following were the causes:—Three, perforation of typhoid ulcers; one, perforation of cancer of stomach ; one, perforation of caecum; one, perforation of appendix vermiformis; one, rupture of an abscess in broad ligament; two followed the operation of ovariotomy ; one, cancer of the liver; and one followed delivery in a woman with Bright's disease. 52 pathological report. Tubercular Peritonitis. y/ Case vii.—Acute tubercular inflammation of the periton eum. Small caseous mass in left lung.—Right-sided pleurisy. General hyperplasia of the bone marrow. J. McT., aet. 35.—Had been a soldier for twelve years, latterly a sailor; admitted in September, 1875, complain- ing of weakness, loss of appetite, and frequent attacks of vomiting. No albumen in urine. Blood normal. Systolic murmur at apex. No enlargement of abdominal organs. Tenderness on deep pressure along right costal border and ensiform cartilage. The vomiting became more marked, and he had occasional attacks of diarrhoea. The symptoms pointed, though vaguely, to disease of the stomach, either round ulcer or cancer. The vomiting was with difficulty controlled, and patient became very weak and anaemic, the skin slightly icteric. Towards January he got so feeble that he was unable to move from bed, and the vomiting was so persistent as to necessitate feeding per rectum. Through January and February the vomiting diminished, but the patient wasted slowly, and the case was regarded as malignant disease, involving per- haps the peritoneum. In the beginning of May the peri- tonitis became acute and general, and he died on the 25 th, profoundly exhausted. For some weeks before death haemorrhages occurred in various parts of the skin. Peritoneum, contains 56 oz. of a turbid, slightly bloody fluid, in which are flocculi of lymph. Here and there the coils of intestines are matted together by easily separable adhesions. The transverse colon and stomach are in this way glued together, the former covers also the anterior border of the liver. The entire peritoneum, ex- cept the portion over the stomach, is of a dark red colour, infiltrated, sodden, and readily stripped off from the sub- jacent tissues. Localized patches of lymph occur here and there upon it. The whole membrane presents a great MONTREAL GENERAL HOSPITAL. 53 number of small white areas, flat, not projecting above the surface, and ranging in size from a hemp seed to a split pea. As a rule they are isolated, but occasionally groups are seen. They exist in about equal numbers over the intestines, mesentery, and parietal peritoneum. Be- neath the latter are from eight to ten larger white patches, which, on section, have a caseous appearance, are firm to the touch, not encapsuled, and extend to the depth of about \". On examination of these small and large white masses, they are found to be almost entirely subperitoneal and composed of aggregations of corpuscles of a lymphoid character, a little smaller than the colourless blood corpus- cles, and with one, rarely two, nuclei. In sections through those on the intestinal wall, the corpuscles are seen to infiltrate to some extent the muscular coats. The mesen- teric glands are but little enlarged. Heart ; ecchymoses on pericardium, walls flabby, muscle pale, very little blood in the chambers. Pleura; 35 oz. of turbid fluid in right sac. Arisceral and parietal layers congested, and covered with flakes of lymph. A few ounces of fluid in left sac. Lungs.—Right, crepitant, except at extreme base. Lower lobe collapsed. Organ contains a good deal of serous fluid. Left, upper lobe crepitant, lower collapsed and cedematous. At anterior border of upper lobe is a firm block of condensed tissue, somewhat triangular shaped, which on section is made up of a small cavity, looking not unlike a dilated tube, and one or two caseous knots, the lung for a short distance about being solidified, and of a greyish colour. No miliary tubercles in either lung. Spleen, weighs 5 oz., unaltered. Liver, 21bs. 2h oz., anaemic, and yellowish in colour. Kidneys, normal in size, but very firm in texture. In the cortex of the right are several small purulent depots, about which the substance is much congested. 54 PATHOLOGICAL REPORT. Stomach.—Mucous membrane of normal thickness, but soft and readily torn No trace of cicatrices or tumour. It contains about a pint of fluid. Small Intestines contain yellowish liquid faeces; walk are thick, owinsr to an infiltrated, swollen condition of all the coats. Mucous membrane is dark in colour. Peyer's- glands not enlarged. Large Intestine contains large masses of yellowish solid faeces. Brain presents nothing abnormal. Medulla of bones.—That of the long bones has a uniform greyish-red colour, nowhere having the yellowish fatty aspect of normal marrow. In the cancellated portions and short bones it has a lighter red colour. On examina- tion there were, (1), red-blood corpuscles, presenting con- siderable differences in size, some hardly the jtoW' in dia- meter, and many curiously irregular in form. (2) Ordinary marrow cells, and lymphoid corpuscles, which together with the blood corpuscles constitute the chief mass of the tissue. (3) Nucleated red-blood corpuscles—the embryo- nal or transitional forms of Neumann, of which in each specimen examined four or five examples were met. They are larger than the ordinary coloured forms and have usually a single nucleus. The colouration of these corpuscles is nearly, if not quite, as marked as in the ordinary forms. (4) Cells containing red-blood corpuscles, of which a few examples occurred. There are no myeloplaques. Clinically, as well as pathologically, this case presents many points of interest. The prolonged gastric irritation, which was the prominent symptom during the first five months of his illness, receives no suitable explanation in the condition found post-mortem. Are we to suppose the peritoneal trouble to have begun with the onset of the symptoms in September, or were these latter due to some constitutional dyscrasia, upon which the affection of the MONTREAL GENERAL HOSPITAL. 5S peritonenm was grafted, dating only three weeks before death, when symptoms of acute inflammation of the mem- brane developed ? Certain cases of tubercular peritonitis are notoriously obscure, the symptoms pointing rather to disease of some viscus covered by the peritoneum, as the bladder or intestines, than to an affection of the membrane itself: and in this case the gastric trouble may have been, caused by the chronic irritation induced during the grad- ual eruption of the tubercles. The condition, however.. at the time of death was rather one of acute peritonitis,. as evidenced by the injection and tumefaction of the coats of the intestines, and there was nowhere that matting of the coils together by firm adhesions and tubercular matter which is seen in many cases of chronic tubercular periton- itis ; but it is a question whether the recent inflammation may not have been super-added on a membrane already studded with tubercles, though with the exception of the large masses on the parietal peritoneum, they did not look very old. The anaemia and wasting, together with the gastric irritation, presented a clinical picture, not unlike certain of those constitutional affections dependent upon some profound alteration in the constitution of the blood, such as pernicious anaemia ; and the finding post-mortem of a condition of hyperplasia of the bone marrow, I at first regarded as lending support to this view, seeking in it the explanation of the deterioration of the blood ; for there can be no doubt that alteration in the medulla of the bones may seriously influence the composition of this fluid. Moreover, the peritoneal affection was not what I had been accustomed to see in tubercular conditions of this mem- brane, for, with the exception of the large masses on the parietal layer, the tubercles were not firm and nodular in character, as is usual with these growths on serous membranes, but had rather the appearance of localized lymphoid infiltrations. Since the occurrence of this case. 56 PATHOLOGICAL REPORT. however, two other instances of hyperplasia of the bone- marrow in chronic wasting diseases have come under ■ my notice, so that I am now less ready to refer this one to the category of myelogenous affections, but would regard it rather as a case of tubercular peritonitis, latent in its course, and towards the end accompanied by an acute inflammation of the membrane, the consequence probably of a fresh outbreak of tubercles. The absence of the tubercles in the other organs is a condition which not unfrequently obtains in this affection. Liver.—Hypertrophic Cirrhosis. ' y^ Case i.—Cirrhosis of Liver, with enlargement.—Jaundice. ^ No Ascites.—Delirium Tremens (?).—Erysipelas of the head. J. H., aet. 34, intemperate habits, admitted to the Hos- pital April 30th, 1876, with jaundice, diarrhoea, and deli- rium. He had been seen by Dr. Roddick a few days before, when he complained of pain in the region of the liver, and great enlargement of the organ was then detected. Nothing definite could be obtained as to the duration of the jaundice, for he was incoherent, and had no friends. Shortly after admission he was attacked with erysipelas of the face and scalp, to which he succumbed rapidly on the 4th of May. At the autopsy the body was found to be well nour- ished and of fair muscular development. Skin moder- ately jaundiced. Several purpuric spots noticed. Brain.—Healthy. Abdomen.—No fluid in peritoneal cavity. Liver projects considerably below the margin of the ribs. Thorax—No fluid in pleural cavities. A few extrava- sations on the visceral leaves. Heart.—Slight thickening of the mitral segments and some atheroma at the bases of the aortic semi-lunar. Other- wise healthv- MONTREAL GENERAL HOSPITAL. 57 Lungs. — Crepitant, except lower lobe of left lung, which is collapsed. Spleen.—Weighs 19 oz„ (538.46 grammes). Capsule a little thickened and puckered. Pulp soft. Kidneys.—Right, 9-| oz.; left, 8 oz., of a greenish-yellow hue. Collecting tubules of the pyramids full of urates and bile pigment. Stomach, — Contains 5 vi of semi-coagulated blood. Mucous membrane dark-coloured, swollen in places and congested. Intestines, dark, and contain a small quantity of altered blood. Large veins not particularly full, but the mucous membrane is reddened. Liver weighs 6lbs. 11 jV oz., (3053 grms), and is uniformly enlarged. No adhesions, or fibroid thickenings in capsule. Surface of organ of a dark olive-green colour, and studded with small granulations, half the size of a pea and larger. These little projections have a.greenish-yellow appear- ance, while the intervening tissue is white. On the under surface of the left lobe the largest nodules are seen. The organ is very firm, and cuts with resistance, the surface of section presents a deep, greenish-yellow colour, while the ]obules are separated by strands of white connective tissue. The portal vein is large, appearing even dilated. The gall-bladder is elongated, filled with inspissated bile, which towards the orifice of the cystic duct has col- lected into three consistent but easily broken balls, which completely close the orifice. The mucous membrane of the ductus communis choledochus is somewhat swollen, but :he bile ducts do not appear to be dilated. Microscopic appearances.—Sections under a low power present islets of liver substance surrounded by a connec- tive tissue rich in nuclei, which in most of the speci- mens examined almost equals in amount the liver substance. The limit between these two elements is rarely well defined, but there is a gradual blending of the one 58 PATHOLOGICAL REPORT. with the other. In certain lobules the invasion is uniform and intercellular, groups of two or three cells being separated by a nucleated growth ; but in most the invasion is peripheral, and lobules in all stages of destruction may be seen with the liver cells in the central parts still in close contact with each other. The connective tissue differs in no respect from that seen in ordinary cirrhosis, save that the nuclei are perhaps more abundant in proportion to the fibroid tissue. Only in the central parts of wide areas is there an indistinctly fibrillated appearance, and here the nuclei are scattered,' while in the neighbourhood of the lobules themselves the tissue is more embryonic in character, and the nuclei pre- dominate, in some spots being crowded together with little or no intervening material. The method of invasion can be traced in all its stages, the new growth creeping in, as it were, from the periphery between the cells, sometimes separating them in rows, but frequently surrounding individual cells or groups of two or three. This appear- ance will, of course, vary with the direction of the section ; if at right angles to the central vein of the lobules the appearance is of fibrous bands passing in from the peri- phery, while if parallel to the central vein.cells, or groups of them, are separated by an intervening tissue, rich in small nuclei. Such is the condition of the external zone of most of the lobules. There is no definite limit between the two constituents, such as is commonly seen in the atro- phic form of the disease, where strands of fibrous tissue encircle and constrict lobules, and the boundary between the two is often, as in specimens before me, clearly defined. This was rarely to be found in the case under consider- ation. The liver cells do not present any remarkable alterations In lobules not much involved in the sclerosis, they appear quite natural, but in the affected areas they are stuffed with yellow pigment grains or oil drops, frequently a MONTREAL GENERAL HOSPITAL. 59- combination of the two. The fatty infiltration is not extensive and is very unequally distributed, being marked in some lobules and absent in others. In the periphery of the acini, cells in all stages of atrophy may be seen, some appearing flattened, but the majority look simply diminished in size. Where the central part of a lobule, containing 40 to 50 cells, alone remains, the whole process can be distinctly traced. In the outermost part little groups of yellow granules are seen in the fibroid tissue, in the next zone small cells filled with these granules occur, separated by numerous nuclei, while in the central part are 10-15 cells, the outlines of which are still dis- tinct, the nuclei well marked, and the bile pigment not so excessive in amount. In various sections numerous fine specimens of bilirubin crystals occurred, scattered among the cells. Here and there in the extra-lobular tissue biliary canali- culi are seen, made up of rows of cuboidal cells, enclosing a very narrow tube. They do not appear to be specially numerous, certainly not more so than in sections of a well-marked specimen of atrophic cirrhosis obtained a short time since from the body of an old toper. The recognition of a distinct variety of cirrhosis of the liver accompanied with enlargement, has only been made within the past few years, owing in a great part to the labours of certain French Pathologists. When the speci- men came under observation it appeared to be such an anomaly that the standard authors were ransacked for information, but in vain; the only references to an increase in volume of the organ in cirrhosis related to the initial stage of the disease and as a consequence of fatty infiltra- tion. Happily, just at the time, a number of the Revue des Sciences Medicales came to hand, with a condensation of M. Hanot's Thesis on Hypertrophic Cirrhosis, in which he seeks to establish this as a special variety of the disease, characterized clinically by enlargement of the 60 PATHOLOGICAL REPORT. organ, prolonged jaundice, and the absence of ascites, and pathologically by the fact that the affection originates' about the bile ducts, and leads to an increase, not a dim- inution, in the size of the organ. Cornil and Ranvier* describe the histological condition, and support this view of the origin of the disease. In a recent number of the British and Foreign Medico-Chirurgical Review^ there is an excellent resumS of the papers on the subject, and the writer agres in the main with Hanot. The chief histological differences between this and the common form of cirrhosis appear to be that the growth surounds single lobules rather than groups of them, and tends more to invade the acini, and that greater numbers of the so-called biliary canaliculi are found in the extra- lobular connective tissue. As will be seen in the above description, the first of these characters is well marked in our specimen, but the second is not so decided. The clinical history of the disease in this instance, so far as known, corresponds with that of the cases recorded by Hanot. The liver exceeds in weight any of the speci- mens mentioned in the authorities referred to. Syphiloma. Case Y.—Syphilitic ulceration of left frontal bone. Large node on left tibia. Gummata in Liver. T. M., aet. 24, admitted May 4th, with syphilitic disease of frontal bones, and died of erysipelas of the head on the 16th. Liver weighs nearly 5lbs., and is elongated in the trans- verse direction. Left lobe much flattened, measuring 8" from anterior to posterior border, the right lobe at the gall- bladder measuring only 6". Capsule much thickened, especially about the longitudinal ligament. Five pucker- * "Manuel d' Histologic Pathologique," p. 922. t July, 1877. MONTREAL GENERAL HOSPITAL. 61 ed cicatrices are seen on surface of the right lobe, and some small extravasations exist beneath the capsule. On section of the organ from right to left three gummata are seen in the substance, each about the size of a large wal- nut, two corresponding to cicatrices in right lobe. Each presents a firm, white, central area, which cuts with re- sistance, and a capsule of fibrous tissue, which towards the liver substance is not well defined, but blends insen- sibly with it, and at this part is more translucent. Four others presenting similar characters are seen; two, the smallest, in the left lobe. Microscopically the central portions show an indistinctly fibrous appearance, at the periphery the fibres are more marked, while the zone in the immediate neighborhood of the liver substance shows a small-celled growth involving the lobules. The other organs presented nothing abnormal. Cancer. Case-LV.—Primary Cancer of the Liver. Ascites. Javn- dice—Secondary mass in tail of Pancreas, small secondary nodules in Kidneys. A. B., aet, 65, in hospital for several months. Body much emaciated. Abdomen distended. Skin moderately jaundiced. From the peritoneal cavity 250 oz. of bile-stained serum were removed. Intestines slate coloured, and here and there small flakes of lymph are seen upon them. The descending colon passes down to about an inch and a half below the crest of the ilium, then turns and passes up upon the kidney nearly to the spleen, at which point it is firmly united to the omental tissue; turning again it passes obliquely to the lumbar vertebrae, descending in front of them and the sacrum to the anus. In the whole of its course it is closely attached. The ileum two inches from the valve is united by a firm band to the psoas muscle. Liver.—Weight 4J lbs.; closely adherent to the dia- 62 PATHOLOGICAL REPORT. phragm behind and at the right border, and also below to the tissue in the neighbourhood of the right kidney. Though somewhat smaller than natural the shape of the organ is maintained. The upper surface is exceedingly irregular, owing to the presence of numerous cancerous masses, a very large one much depressed in the centre being seen a little to the right of the longitudinal fissure, occupying an area fully three inches in diameter. Above the gall bladder there is another puckered spot, and nu- merous nodules exist in the liver substance about it. The whole of the surface to the right of the longitudinal fissure is involved in the disease, and the capsule here is thick- ened, opaque and fibroid. The posterior border is not so much affected, only here and there presenting isolated nodules. Where the longitudinal ligament is attached to the diaphragm there is an extensive, somewhat flattened, cancerous mass. The under surface of the right lobe is comparatively free, nodules being seen only at the anterior border. The lobus Spigelii presents a single deep puck- ering". Manv elevated tuberous nodules exist in the under surface of the left lobe. All of these masses are raised above the surrounding liver substance, and the majority of them present cup-like depressions. A longi- tudinal section from right to left, through both lobes, shows the greater part of the liver substance to be the jseat of disease. The large white mass noticed in the right lobe extends fully two inches into the organ, and innum- erable small nodules are arranged about it. Quite three- fourths of the liver substance exposed on the section is occupied by the cancerous growth. The lower and posterior parts do not contain so many nodules. The hepatic tissue is very dark, and stained with bile ; the central veins of the lobules are injected, and apparently dilated; a good deal of blood escapes from the larger veins. The gall-bladder contains a small quantity of dark bile. MONTREAL GENERAL HOSPITAL. 63 A cancerous girdle surrounds the middle of the organ, and the fundus is also affected. Nothing abnormal in the heart and lungs. Kidneys.—Two small cancerous nodules the size of peas in the cortex of the left organ, and two others some- what smaller in the right. Spleen, small, and looks healthy. Pancreas.—The tail is firmly united to the tissue in the hilus of the spleen, forming a firm, hard mass, about the size of a walnut, which on examination is found to be cancerous. Stomach.—About 20 small, punched-out ulcers, with haemorrhagic bases are seen on the mucous membrane of the fundus. The intestines are dark in colour, the veins full, and the coats sodden. The abdominal lymphatic glands are not enlarged. The left external femoral artery contains a firm thrombus. The general character of the growth and the absence of any considerable mass of cancer elsewhere render it more than probable that the disease in the liver was primary- The presence of one large tumour, around which numerous smaller nodules are aggregated, is almost characteristic of primary cancer, the situation of which, however, is more commonly towards the under surface of the organ, and not, as in this case, just to the right of the longitudinal ligament. Though the weight of the organ was increased, its volume was decidedly diminished, an unusual circumstance in cancer, and one apt to lead, as I believe it did in the present case, to some confusion with cirrhosis. Secondary Cancer.—Oi three cases one followed cancer of the tongue, another cancer of the vertebrae and ribs, and in the third the primary lesion was in the gall bladder. The latter, a very remarkable case, is given in 04 PATHOLOGICAL REPORT. detail by Dr. Bell, in Canada Med. ty Surg. Journal for April, 1877. The pathological condition was as follows : Case LXXXIV.— Cancer of neck of the gall-bladder and, lymphatic glands in the portal fissure. Compression of the hepatic ducts. Secondary masses in liver. Enormous disten- sion of gall-bladder and hcemorrhage into it.—Gall stones. Body that of a well-made, but spare woman. Sirin intensely jaundiced ; conjunctiva* yellow. Rigor mortis absent. Abdomen.—On opening this cavity a few ounces of slightly turbid and sanguineous fluid were removed. The liver is seen to be somewhat enlarged, and extends fully 3| inches below the margin of the ribs. Projecting from the under surface of the right lobe is an enormously dis- tended gall-bladder, which reaches within two inches of the^pubis. The upper surface is free, but to the left side it is attached by loose and somewhat fresh adhesions to the pushed up omentum and stomach. The apex, which is rounded, presents an irregular surface as if it had been attached, and on the side of the broad ligament, at a point a little to the right of the uterus, is a round space, covered on the -surface with decolorized fibrin, haemorrhagic below, which looks as if the gall-bladder had here been adherent. Behind it is firmly attached to the trans- verse colon.* Traces of peritonitis in fhe form of thin flakes of lymph exist over the coils of intestines. An extravasation of blood has taken place into the tissues about, or rather upon, the peritoneum in the pelvic cavity, especially between the uterus and rectum. The corpuscles have subsided, leaving a pale yellow, fibrinous layer above, which is firm, and quite adherent to the surrounding- parts. Liver looks a little larger than normal, and is of a dark- greenish colour. Scattered over the surface are a dozen or more cancerous masses, white in colour, ranging in size MONTREAL GENERAL HOSPITAL. 65 from a cherry to a walnut, the larger of them with depressed centres. The anterior portion of the right lobe is separated from the rest of the organ by a shallow groove, the position of which on the body was just below the costal border. The left lobe is flattened, and its anterior margin notched. On section the liver substance is deeply bile-stained ; the lobules are not very distinct. There are but few cancerous nodules in the interior. On opening the distended gall-bladder it is found occupied by a large coagulum, the upper part of which, owing to the sinking of the blood corpuscles, is decolorized. Hardly any serum is present except that contained in the meshes of the clot. Nine or ten gall stones, about the size of marbles, and with numerous facets are found. At the neck a small irregular mass of cancer projects into the cavity, and com- pletely blocks up the cystic duct. The walls of the bladder are thin, not cancerous, and at the posterior part, just where the transverse colon is attached, there is a portion infiltrated with blood. On close inspection it is seen that ulceration and destruction of the wall has here taken place There can be no doubt that by this process a vessel has been opened, and the haemorrhage caused. The glands in the hilus of the liver are enlarged and cancerous, and compress the hepatic ducts. The portal vein does not appear to be interfered with. Heart and Lungs, quite healthy; a few ounces of fluid in left pleura. Slight atheroma in aorta and aortic segment of mitral. Spleen not enlarged, and of a deep brownish-red colour. Case lxxxviii.—Extensive abscesses in the mesentery, following typhoid fever. Suppuration of the portal vein and its branches in the Liver. Empyema. Perforation of the appendix vermiformis ; Peritonitis : Miliary Tubercles in lungs. Amyloid degeneration of spleen, liver, and mucous membrane of small intestines. 5 66 pathological report. A. B., aet, 37. History of an attack of typhoid fever three months before, from which he had not entirely recovered, remaining febrile and very weak. Empyema supervened, and finally an attack of acute peritonitis. There was no jaundice, nor, so far as I can learn, did the symptoms point specially to any trouble in the liver. Peritoneum, extensively inflamed and contains 80 ounces of turbid fluid. The inflammation is most intense about, and has evidently spread from, the appendix vermiformis, the caecal end of which is obliterated, while the under surface presents an oval perforation. Pericardium and Heart healthy. Left pleura contains 54 ounces of pus. Left lung compressed and, with the ex- ception of tho apex, airless. Numerous miliary tubercles scattered through it. Right lung crepitant; one or two caseous nodules at the apex; miliary granulations abun- dant. Spleen weighs 330 grms., firm, Malpighian corpuscles enlarged, translucent, and re-act with iodine. Kidneys firm, pale, slight re-action with iodine in the right. Ureters and bladder healthy. Stomach contains about a pint of greenish fluid ; the mucous membrane is thin and soft. The duodenum is firmly adherent in its first part to the gall bladder, the tissues in the neighbourhood being closely matted together. On pressing the common bile duct a yellowish secretion first flows out, and is followed by pure pus. About an inch and a half from the pylorus, towards the upper surface of the first portion of the duodenum, pus is seen to exude from a round orifice the size of a pea. On passing a probe into this it is found to communicate directly with the enlarged and suppurating portal vein, to be shortly described. Mucous membrane of jejunum and ileum reacts on the application of iodine. Nothing abnormal in the large bowel. The mesentery is enlarged, thickened, and the whole structure fluctuates like a sac of pus. Towards the root, and at some spots near the bowel, the fluctuationis limited, as if the individual glands were involved. On MONTREAL GENERAL HOSPITAL. 67 section of the membrane, pus is found to spread uniformly between the folds, and, after thoroughly washing with water, it appears as if riddled by communicating cavities. In some spots the pus is limited within the capsules of lymphatic glands. On tracing the mesenteric veins from the intestinal border many are found to lead directly into these suppurating areas, others are shut off by thrombi. At the distal border, where the mesentery is cut away, close to the superior mesenteric artery, there is an irre- gular opening, from which pus flows, while a probe in it passes in several directions. Whether or not this repre- sents the superior mesenteric vein it is difficult to say; the situation corresponds with it. Liver, enlarged, firm to the touch, but at the same time yielding and elastic. On section the substance cuts with resistance, looks glistening, and on the application of iodine ■ the intermediate zone of each lobule becomes a mahogany- brown colour, the central and interlobular areas remain- ing unaffected. On the surface of the organ, especially on the posterior and right borders are several small, irregular swellings, Avhichon section are found to contain pus. The abscesses are tolerably numerous in these regions, and range in size from a pin's head to marbles. Many are in communication with each other, or are separated by nar- row portions of liver substance. On closer dissection it is found that these abscesses stand in direct connection with, and indeed, are only suppurating portal veins. This having been ascertained,a thorough inspection of this vessel was undertaken. Outside the liver the vein is represented by an elongated abscess with thick, irregular walls, made up anteriorly of condensed connective tissue, posteriorly to a large extent by the head of the pancreas, the lobules of which have been laid bare in the suppuration. Immediately where the vessels enter the liver its calibre is relatively diminished. The splenic vein ends abruptly on the wall of the suppurating vessel, being 68 PATHOLOGICAL REPORT. closed by a thrombus, while the portion behind is much dilated. Unfortunately, in removing the liver, duodenum, stomach and pancreas together, the mesentery was cut oft' just below the latter, and no trace could be found of the superior mesenteric vein and the manner of its com- munication with the portal. On passing a director along the branches of the portal vein and slitting them up they are found full of pus, sometimes cream-coloured, at others tinged with bile. The branch passing out to the right lobe of the organ, at about an inch from the hilus, widens into two large sinuses, one going to the right border, the other towards the posterior. Into these open numerous branches from which large quantities of yellowish creamy pus can be squeezed. Near the upper surface of the right lobe is a cavity of the size of a walnut, in communication with a vein, and from its upper end one or two branches are given off. The posterior border of the organ appears on section riddled with such cavities, which are found in every instance to be merely dilated branches of the vein. In the anterior portion of the organ over the gall bladder there is less disease than in other parts. The extreme left border is also unaffected, and the branch going to it does not contain pus. The lining wall of the suppurating vessels passes over abruptly into the liver substance, is firm, and of a peculiar yellowish-white colour. There is no zone of hyperaemia about the inflamed vessels, the hepatic tissue beyond the opaque white margin looks natural. In branches in which the suppuration is not far advanced, the remains of the intima, like a soft, stringy mass, can be seen, as if the process was confined rather to the adventitiaand Glisson's sheath. On almost any section of the organ peculiar yellowish-white areas occur, very often of an irregular foliaceous appearance. Occasionally groups of them appear isolated, but on making a section through them they are always found to be in connection with suppurating vessels, the smaller ones being surrceni 1 MONTREAL GENERAL HOSPITAL. 69 ed by one or two necrotic liver lobules of a glistening, opaque-white colour. The first and second division of the vein passing to the hinder and right borders are considerably dilated, and on the lower wall the branches of the artery and duct are seen as elevated cords. The former at its commencement -appears nearly double the usual size, and on the walls of all the larger suppurating veins its branches could be seen. The common bile duct is pervious and a probe can readily be passed into the hepatic ducts, which appear quite free from disease and contain bile. The cystic duct is also patent, At the junction of the cystic and hepatic ducts the sub-mucous tissue is greyish-white in colour, and the same condition extends along the former to the gall- bladder. This organ is large, somewhat distended, and contains about 3 oz. of laudable pus, not tinged with bile. The mucous membrane is transformed into a thick greyish- white structure, which is here and there congested. At the upper and back part of the opening of the cystic duct there is an irregular wide sinus leading towards the portal fissure, and along it a probe can be passed for 1-|", termin- ating close to the dilated and suppurating branches of the vein. A direct communication with the latter could not be made out, but water poured into the sinus oozed out in the vein. All the parts about the head of the pancreas are closely adherent together, and there are several separate lymphatic glands in a condition of suppuration. Lying along the left side of the lower 2" of the abdom- inal aorta, and extending another 2|" at the left of the left internal iliac and ending on the wall of the rectum, is a narrow shut sac, full of pus, the walls thick, dark in colour, and lined by a definite pyogenic membrane. There is no communication with the rectum, the walls of which at the point of attachment appear healthy, nor is there any open- ing at the upper end. 70 PATHOLOGICAL REPORT. The right vena azygos is remarkably large and distended with blood, almost equalling in size the inf. vena cava. The left is also large. Suppuration of the portal vein—pylephlebitis—is among the rare affections of the liver. Frerichs (1861), collected twenty-five cases, of which only three or four followed, as in this instance, suppuration in the mesentery ; the others resulted from injury, ulcerative processes in intestine and stomach, abscess of spleen, &c In the Pathological Society of London two or three cases have been presented up to the present time. The remarkable combination of lesions met with in this case, and the absence of a proper clinical history, render it somewhat difficult to decide upon the starting point of the process,—the first link in the series. The typhoid fever may be regarded as the primary affection to which the suppuration in the mesentery and chain of retro- peritoneal glands wTas secondary ; the pylephlebitis resulting probably from an extension of the inflamma- tion in the mesenteric veins to the vena portae and its branches. Another source of infection, however, was present, viz: the inflammation in the appendix vermifor- mis, which formed the starting-point of the disease in three or four of the recorded cases; but I see no reason in this instance to regard the ulceration and perforation of the appendix as anything more than an accidental occur- rence, arising from obliteration of the orifice—probably the result of a typhoid ulcer—and retention of secretion. The fatal issue was due to the extension of the inflam- mation in the neighbourhood of the appendix to the general peritoneum. It is impossible to say, not having a clinical record, whether the empyema was a sequela of the typhoid fever, or of pyaemic origin resulting from the pylephlebitis, though it is remarkable to find how rarely pyaemic abscesses occur in this disease, being noted in only 5 out of the 25 cases collected by Frerichs. The MONTREAL GENERAL HOSPITAL. 71 tuberculosis of the lungs was probably secondary to the empyema. A point of interest is the way in which the collateral circulation was established, though, unfortu- nately, owing to the length of time spent over the other conditions, no careful dissection could be made. The right vena azygos was greatly distended, and the left was also much larger than normal. The only distended veins observed in the abdomen were those about the hilus of the spleen, and the vasa brevia of the stomach. Spleen. Size.—The extremes occurred in a case of cirrhosis, in which the organ weighed 31^ oz., and in a case of cancer of the tongue in an old woman, greatly emaciated, in which it weighed only 2\ oz. In seven fatal cases of Typhoid fever the extremes were 7 oz. and 19 oz.; both in cases of perforation, the former at the end of the 2nd week, the latter after nearly two weeks convalescence. Albuminoid degeneration occurred under the following- conditions :—cancer of vertebrae ; syphilitic ulceration of frontal bone, with gummata in liver ; tubercular nephritis; pylephlebitis. In none was the enlargement very great. Miliary tubercles were met with in three instances, one a case of general tuberculosis, the others chronic phthisis. Fresh infarctions were found in a case of aortic valve disease, and in a case of Bright's disease during preg- nancy. In the latter no affection of the heart could be determined. The capsule in nine cases was thickened and fibroid, either in localized spots or over the whole surface. In one instance it was of almost cartilaginous character, and in another the localized thickenings were calcareous. Small supernumerary spleens were met with in three cases. 72 PATHOLOGICAL REPORT. Genito-Urinary System. Kidneys. Inflammation.—In two cases of death after lithotomy in old nien these organs were extensively inflamed, though not in a condition of suppurative nephritis ; one of them, case xciv (see below, under Bladder), the affection was limited to the apices of the pyramids, which were much involved and covered with a grey, diphtheritic-looking membrane. Morbus Brighlii. Of five cases two (xxix and xlvii), occurred in connection with pregnancy, death having taken place in the latter three weeks after delivery, in the former at the seventh month. They presented well- marked examples of the large mottled kidney, the org&ns weighing in both 10 and 11 oz. each. Case lx was of special interest, but, unfortunately, the notes got mislaid and were not entered in the post-mortem book. It was an instance of chronic Bright's disease, with small contracted kidney, occurring in a girl aged 20, who had a well-ascertained history of an attack of scarlatina six or seven years before. The kidneys were reduced to about one-half the normal size, capsules firmly adherent, surfaces granular, substance very firm, cortices much diminished and the arteries very prominent. The heart was considerably hypertrophied, the left ventricle parti- cularly so ; no valve disease. Tuberculous disease.—Miliary tubercles were met with in three cases of chronic phthisis, in three of general tuberculosis, and also accompanying the three following cases of chronic tuberculous nephritis. Case xxi.—Tuberculous disease of right kidney, pelvis, ureter and bladder. Tubercles in left kidney and lungs. Perforation of tuberculous ulcer in bladder. Peritonitis. John M., aet. 41. MONTREAL GENERAL HOSPITAL. 73 Right kidney weighs 13 oz. On section a large caseous mass occupies the situation of the infundibula and pyra- mids, while the cortical portion is riddled with softening tubercles, hardly a trace of healthy-looking tissue remain- ing. The pelvis is somewhat dilated, and contains a few drachms of pus; the walls are thickened and caseous. Ureter as thick as the ring-finger, the mucous membrane swollen, and infiltrated with tuberculous matter, which is here and there softening. Left kidney weighs 6 oz. About a dozen tubercles, the size of peas, occur in substance of the organ. Pelvis and ureter healthy. Bladder united to the rectum by recent lymph. On opening it the mucous surface is rough, irregular, and contains numerous caseous masses, many of which have ulcerated. At the posterior wall is a large dark ulcer, in the centre of which are two small oval perforations. The outer surface of the organ is covered with fine miliary L'Tanulations. The prostate is occupied by two large tuberculous cavi- ties. The lungs contain small cavities and caseous masses at the apices, and numerous miliary tubercles throughout the lobes. Case liv.—Old scrofulous disease of right kidney, which :v converted into cysts. Recent affection of the left. J. T., rct. 32. For clinical report by Dr. Ross, see Can. Med, <$- Surg. Journal, Aug. 1877. Right kidney, small, presents a lobulated appearance, and to the touch is semi-fluctuating. On section the whole organ is seen to be converted into a number of cysts con- taining a serous fluid in which white flocculi float. There are about a dozen of them, averaging the size of a walnut, find communicating together? The lining membrane of some of them is smooth, of others rough from the presence 74 PATHOLOGICAL REPORT. of tuberculous matter. * A small remnant of the cortex of the organ is left. Left kidney, very large, more than three times the size- of the right. On section, the pelvis is found dilated, and the walls thick, and covered with a greyish exudation The calyces are also dilated, and their walls in a similar condition. The pyramids and cortex are swollen and injected, and throughout both are numerous suppurating foci, and small caseous masses, the latter being very abun- dant, and closely aggregated together at the upper end of the organ. On stripping off the capsule, the surface is found studded with large and small tubercles, the smaller ones coming away with the capsule, the larger adhering to the cortex. These masses are firm, usually solid throughout, but occasionally softened in the centre. Bladder.—Mucous membrane roughened and ulcerated, fully three-fourths being destroyed, and in places the ulcer- ation has extended to the muscular walls. The ureters are not affected. Lungs contain a few masses of caseous tubercles. Case lxxix.—Old disease of the right kidney, which is converted into five or six cysts, filled with aputty-like material. Extensive tuberculous disease of the organ. Miliary tuber- cles in lungs. Albuminoid spleen. A. G., a middle-aged woman, short, stout and well- nourished. No history. Right kidney, weighs rather less than 2 oz., (60 grms), and is converted into five or six cysts filled with material not unlike fluid plaster-of-Paris. A central cyst contains a clear gelatinous fluid, while the contents of those of the lower end of the organ are more consistent and caseous in character. There is no trace of kidney substance to be seen. The pelvis and ureter on this side are much con- tracted, but still pervious. Left kidney weighs 12^ oz., (350 grms.) ; and is much MONTREAL GENERAL HOSPITAL. 75- enlarged. On section the lower third of the organ is occupied by four large cysts containing caseous matter, which lie more in the pyramidal portion, separated from the capsule by a layer of cortex £ of an inch in thickness. The remainder of the organ is comparatively healthy, though scattered through it are numerous tubercles,. ranging in size from miliary granulations to peas. The vessels are full, especially in the pyramids. The pelvis and calyces are slightly dilated, but not thickened, and only a few tubercles exist on the mucous membrane. The ureter is of full size, and the inner coat presents here and there a caseous patch. Bladder small and contracted ; mucosa rough and exten- sively ulcerated, the muscular coat being bare over the greater portion of the surface. Lungs crepitant throughout. A tiny cavity, the size of a pea, in the right apex. A few miliary granulations in both. Spleen; Malpighian corpuscles enlarged and translucent^ reacting with Iodine. Peri-nephritic Abscess. Case xxv.—Suppuration about right kidney. Pycemic abscesses in elbows, ankles, and anterior mediastinum. Peritonitis. Pleurisy. S. L., aet 11, sent to hospital supposed to be suffering from rheumatism, but the joint affections proved to be pyaemic in character. On removing the intestines a large, fluctuating swelling is observed in the region of the right kidney, behind the peritoneum, and extending downwards in the direction of the psoas muscle. On cutting into it a pint of laudable pus escaped. The abscess is situated behind and below the kidney, the lower end of which is directly bathed by the pus. The Psoas muscle is infiltrated, and its fibres shreddy and degenerated. The pus has burrowed beneath 76 PATHOLOGICAL REPORT. the pelvic peritoneum and is in immediate contact with the walls of the bladder and vagina, neither of which are, however, perforated. There is no disease of the bones of the spine or pelvis. On slitting up the common and internal iliac veins, the latter is found obstructed by a thrombus, which is closely adherent to its walls and ex- tends for a short distance as a rough projection into the common iliac. Right kidney is flattened; on section it is soft and the cortex presents a mottled appearance. Ureter and bladder normal. On removing the sternum an abscess is found in the anterior mediastinum, close to the bone, and extending for an inch along the cartilages of the 5th and 6th ribs on the left side. Pericardium, is rough, both layers being covered with small papilliform processes. No flakes of lymph ; J oz. of turbid fluid. The left pleura close to the vertebral column is intensely inflamed, covered with lymph, and the tissues in the neighbourhood ecchymotic. Lungs crepitant; one pyaemic block in the anterior border of the left lower lobe. Bladder. The following case is of interest as showing the effect of prolonged irritation of a calculus on the organ. Case xciv.—Stone in the Bladder. Prostatic tumours around the urethral orifice. Ulceration on mucous membrane. Pyelitis ; ulceration of apices of renal pyramids. A. B., aet. 80, had suffered from stone for years. It was crushed in several sittings and a large proportion brought away, but he sank before the whole could be removed. Bladder contains an ounce of turbid fluid, and 3ii of crushed stone. The mucous membrane is dark in colour, MONTREAL GENERAL HOSPITAL. 77 here and there eroded Dut not deeply. The muscular walls are hypertrophied, and strong bands cross each other on the inner surface. Around the urethral orifice are several outgrowths from the prostate ; the largest is behind, springing from the base of the gland, and projecting like an enlarged middle lobe. The anterior one is irregular, not so prominent and is divided by small fissures. On the right between these two portions is a pedunculated tumour, a little larger than a pea, freely movable, and which fits directly over the orifice of the urethra, being displaced by the passage of the catheter. The prostate itself is not much enlarged ; the ducts are dilated and contain numerous reddish-brown calculi, the largest about the size of a buck-shot. The ureters are moderately dilated, the right more than the left, the mucous membrane is swollen and inflamed. The pelvis of the right kidney is dilated, and the lining membrane covered with a dirty greyish exudation. The same condition extends into the calyces and the apices of many of the pyramids are eroded. The same thing, though in a less degree, exists in the other organ. Uterus.—Cancer. Case xli.—Epithelioma of cervix; obstruction of the canal; dilatation of the uterine cavity. Pyromelra. A. J., aet. 80. Uterus.—On removal of the abdominal viscera, an oval tumour is seen to occupy the pelvic cavity, extending to the brim, and situated in the position of the uterus, between the bladder and rectum. It is soft, fluctuating, and on examination proved to be the greatly distended body of the uterus. On attempting to make out its exact position, the finger was accidentally thrust into the lower part of the tumour, (the walls in this situation being very thin) and a large quantity of pus escaped. On removal of the pelvic viscera it is found that a cancerous mass involves the 78 PATHOLOGICAL REPORT. cervix uteri, and upper part of the vagina, occupying the whole circumference of the former and the upper third of the latter, not extending to either rectum or bladder. No trace of the canal of the cervix remains, an irregular por- tion, somewhat pedunculated, corresponds to the position of the os externum. The disease is confined almost entirely to the cervix, extending only to a slight extent around the lower zone of the body, causing a thickening of the wall in this situation. The cavity of the organ is dilated into a sac, the size of a cocoa-nut, which contains nearly a pint of pus. The walls are thin, scarcely 3'" in diameter; the inner surface smooth and of a dark-grey colour. The round ligaments and Fallopian tubes are inserted at the junction of the lower and middle thirds of the dilated body. The latter are not enlarged ; one could be traced and opened as far as the wall of the uterus, where it was lost. There is no dilatation of the internal orifices. The cancer is soft and white in colour in the vagina and lower part of cervix, firmer above where it gradually merges with the uterine wall. In histological characters it correspends with the so-called epithelioma of this region. No secondary masses of cancer. Ovary. Case lxxxi.—Dermoid or Piliferous cyst of right ovary. Chronic Phthisis. Pneumo-thorax. J. C, set. 21. Right ovary is occupied by a mass the size of an orange, which to the touch is yielding, as if filled with putty-like material. On incising it the capsule is found to be thin and membranous, easily peeled off, exposing a fatty- looking mass, around which are numerous brown and black hairs. At one point a dense whisk passes round the en- tire circumference of the tumour. The hairs are readily MONTREAL GENERAL HOSPITAL. 79 detached and average eight or ten inches in length, being pointed at both ends. They are nearly all superficial, forming a thin layer, immediately within the capsule, and on top of the fatty sebaceous matter, which constitutes a layer J " in thickness, white in colour, and containing a few hairs. This rests upon the central body of the tumour, which forms a firm mass, about the size of a walnut, closely attached to the broad ligament, at the usual site of the ovary. The surface is rough, irregular and pitted, and from it numerous hairs arise and pass out through the sebaceous matter. The layer has the structure of skin, and contains numerous hair follicles and sebaceous glands. On section of the central mass a small cavity, the size of a marble, is found, full of clear, viscid fluid. Beneath this, corresponding to the attached border of the tumour, the parts are very dense and hard, and on careful dissection an irregular piece of bone was found, shaped somewhat like the flange of a screw, having a handle-like process, and an expanded, concave body, which is beset on both surfaces with sharp dentate projections. In colour and hardness it resembles enamel. Cerebro-spinal System. Tuberculosis. Case xyiii.—Small cavity and caseous masses in lung. General tuberculosis. Meninges of brain unaffected; cen- tral softening. Spinal meninges extensively involved. 0. B., act. 20, sailor. Symptoms chiefly spinal, and attributed to a fall which he had sustained three weeks before his death. Autopsy 36 hours after death. Brain, extremely soft, and with difficulty removed. Sub- arachnoid fluid in excess. Large veins of pia mater moderately full. Convolutions pale and flattened. Arach- 80 PATHOLOGICAL report. noid and pia mater are clear and natural looking, both at base and cortex. The former where it stretches from the cerebellum to the cord is cloudy, but there is no lymph or inflammatory effusion. Middle cerebral arteries and pia mater of Sylvian fissures carefully examined for tubercles, but none were found, even on microscopical examination. On section of the hemispheres the brain substance is soft, moist, and glistening; puncta vasculosa indistinct. Lateral ventricles much dilated, and contain ^iiss of fluid. The dila- tation affects especially the posterior horns, which extend far back towards the cerebellum. The walls are excessively soft, and, for the most part, converted into a reddish-white creamy substance, consisting of degenerating brain matter, blood corpuscles, and Gluge's cells. A gentle stream of water washes the layer off, leaving the parts beneath rough and irregular, and to the touch very friable. Sep- tum lucidum soft, and on removal separated from the fornix. Velum interpositum and choroid plexuses pale ; no lymph or tubercles. Walls of third ventricle soft, but intact, commissures uninjured. Corpora striata and thai- ami optici soft and moist; grey substance reddened. The most careful examination failed to detect any tuber- cles either in the meninges or brain substance. Spinal cord. On removal, the arachnoid stretching from the cerebellum is noticed to be opaque and granular. Laid upon the table the cord presents at the lower part slight irregularities and bulgings. The dura mater is thick and opaque; the arachnoid lining its inner surface is scattered over with numerous miliary tubercles, like grains of sand, very abundant in the dorsal and lumbar regions, less so in the cervical. As far as the lower part of the cervical enlargement the visceral arachnoid is clear and transparent, and the pia mater can be distinctly seen / through it. From this point to the termination of the cord the arachnoid is opaque, and the sub-arachnoidal space filled with turbid lymph, the membrane over the centre MONTREAL GENERAL HOSPITAL. 81 of the lumbar enlargement being much distended. On exposing the pia mater a thin layer of yellowish-white lymph covers it in the dorsal and lumbar regions, becom- ing more abundant at the cauda equina, the filaments of which are surrounded by thick lymph as far as the termination of the sacral canal. On the lumbar enlarge- ment is an isolated white mass, looking like an enlarged tubercle, attached to the pia mater, but on section the contents are soft, and like the lymph over the general surface. The vessels of the pia mater on the posterior part of the cord are full, on the anterior empty. Scattered over the membrane, chiefly along the course of, and about the vessels, are numerous miliary granulations, most abundant below the cervical enlargement, only a few being noticed above this point.. The cord appears very tightly embraced by the pia mater, so much so that the surface looks wrinkled, and on puncturing it at the cervical enlarge- ment, the white substance bulges out as a soft rounded mass. Section of the cord shows it to be very soft, but not otherwise altered. Lungs.—Small caseous masses in both apices, and in the left an old cavity, the size of a walnut, with firm dark walls. Rest of organs crepitant, but stuffed with small miliary tubercles, isolated, angular, and translucent. Spleen.—Innumerable firm miliary granulations through- out the tissue. Kidneys.—A few tubercles in the cortex of the right organ. Liver contains scattered tubercles. Case xliii,—Meningeal affection slight. Ventricles dis- tended, walls soft. Very few miliary tubercles in the organs. E. H., a delicately built girl, ict. 19 ; symptoms chiefly cerebral. Brain. Parts about the optic nerves matted together, 6 82 PATHOLOGICAL REPORT. and the arachnoid opaque. No lymph at the base or in the Sylvian fissures. Careful inspection fails to discover any tubercles on the pia mater ; but on stripping off the membrane on the Sylvian fissures, and washing it in water, numerous miliary granulations can be seen, chiefly as fusiform thickenings of the small arterioles passing into the convolutions. Veins on the cortex moderately full, convolutions a little flattened. On sec- tion of the hemisphere, the white substance is of average consistence, but moist. The lateral ventricles are large, and contain a slightly turbid fluid. The ependyma is granular ; over the ganglia, soft. Fornix and septum very soft, and could not be lifted up. Spinal cord. Veins full. Arachnoid in cervical portion opaque. On the visceral layer of arachnoid in the lower three-fourths of the cord there are numerous small carti- laginous plates, thin, flexible, irregular in outline, and presenting the usual glistening appearance of these bodies. No tubercles on pia mater. Lungs. Lower lobe of right, heavy, airless, and contains much blood and serum. A few tubercles through the substance of both organs. Bronchial glands enlarged; one presents several caseous masses, the others, small, firm miliary granulations. No tubercles in the other organs. Case lxxv.—Meningeal affection very extensive on the cortex, slight at the base. Ventricles large, walls not soft. Large caseous mass in left lung. Miliary tubercles in lungs and on peritonaeum. J. S., set. 2|, male child, much emaciated. Cervical glands much enlarged; one over ramus of right jaw fluctuates. Brain. On surface the veins of pia mater look full, and there is a good deal of fluid beneath the arachnoid. A thick layer of yellowish-white lymph exists along the longitudinal fissure, especially on the right side, and on MONTREAL GENERAL HOSPITAL. 83 separating the hemispheres the same is seen in the region of the occipito-parietal fissures. On the inner surface of the left hemisphere, near the fissure of Rolando, is a thick, tuberculous patch, which extends into the brain substances for a quarter of an inch, and the pia mater about it is studded with small tubercles. Over the left frontal convolutions above there are eight or ten tubercles, the size of No. 8 shot. On the right parietal lobe, just above the Sylvian fissure, there is a thick layer of lymph. The base is comparatively free, the arachnoid clear, and no lymph is seen. In the right Sylvian fissure the parts are matted together, and tubercles may be seen about the smaller arteries. On section of the hemis- pheres, the brain substance is found to be glistening and moist, not hyperaemic. The ventricles are moderately enlarged, and contain a clear serum; ependyma clear; walls not softened, and the fornix and septum are tolera- bly consistent, being lifted without tearing. Lungs. The left has a peculiar soft puffy feel. At the lower part of the upper lobe is an oval caseous mass, the size of a large cherry, firmly encapsuled and dry. The rest of this organ and the right lung are stuffed with miliary tubercles, all of which are small, isolated, and translucent; no cheesy masses in the latter. Bronchial glands enlarged ; two caseous. A few tubercles on both layers of the pleura. Peritonaeum. On the visceral layer, especially over the shrunken small intestines, are numerous small dark tubercles, from size of No. 8 shot to peas. On the parie- tal layer they also abound, and on the left side form a flattened irregular mass, with very dark edges. The glands at the root of the mesentery are enormously enlarged and caseous, forming a bunch as large as the closed fist of the child. No tubercles in the other organs. 84 PATHOLOGICAL REPORT. Case lxxvi. — Slight meningeal inflammation. One caseous mass and a few tubercles in Lungs. Old morbus- coxce. A. B., aet. 5 J, an ill-nourished, emaciated child. Brain. Pia mater injected, and of a deeper red colour than usual. No tubercles or lymph about cortex or sides,. but the arachnoid over the sulci is cloudy and granular. At the base the arachnoid is quite clear, but the pia mater is somewhat more adherent than usual and matted about the chiasma. No lymph. On the Sylvian fissures small tubercles occur on the arterioles, and in the right there are a few flakes of lymph. On the small arteries over the pons and medulla are numerous translucent granula- tions. At the upper border of the cerebellum, near its attachment to the cerebrum, there is a layer of thick lymph. On section of the hemispheres the brain sub- stance is moist; puncta vasculosa distinct. The ventricles are slightly dilated, and contain a clear fluid. Walls not so firm as natural. Fornix and septum tear easily. Velum interpositum and choroid plexuses cloudy, and a few tubercles are seen about the arteries. Lungs. At extreme apex of right is a small caseous spot, the size of a pea, and in the tissue for an inch about it are two or three dozen miliary tubercles. In the left lung, which is crepitant throughout, there are also a few miliary granulations at the apex. Bronchial glands are large, one or two of them caseous. Head oi right femur is rough and ulcerated, no cartilage remaining. General Diseases. Pernicious Anccmia. Case lxi.—Profound Anccmia without discoverable lesion. Fatty degeneration of organs. Hyperplasia of bone-marrow. G. A., aet. 52, an Englishman.—For clinical report by MONTREAL GENERAL HOSPITAL. 85 Dr. Gardner, see C. M. $r S. Journal, March, 1877. A description of the blood and bone-marrow, by Dr. Gardner and myself, occurs in the Centralblatt f. die medicinischen Wissenschaften, No. 15, 1877 : Berlin. Autopsy,—Thirty-two hours after death. Body that of a well-built man of fair muscular devel- opment. Hair grey. No emaciation ; panniculus adiposus well developed, especially over abdomen. Skin of extraordinary pallor, with slight lemon tint, the shoul- ders marked with patches of deeper yellow hue. A few old psoriasis spots seen in the region of the elbows and knees. No petechiae. Lineae albicantiae in the skin of groins, and upper and outer aspect of thighs, and on the outer edge of anterior folds of axillae. Fingers slightly clubbed, and the nails of both hands markedly incurvated. Rigor mortis moderately well marked. Post mortem stains scarcely perceptible, No enlargement of the super- ficial lymphatic glands. No cadaveric odour. Brain.—Not examined. On making the preliminary incision a layer ## deep yellow fat, fully an inch in thickness, is cut through over the abdomen. Muscles of the thorax of a remarkably healthy red colour. In the abdominal cavity the position of the viscera normal. Omentum moderately fatty. In the thorax a considerable amount of fat over the peri- cardium. The left pleural sac contains twelve ounces of bloody, yellowish-tinged, serum. A few strong adhesions posteriorly. In the right pleural sac ten to twelve ounces of fluid of the same character. Adhesions more numerous at apex and sides. Pericardium,—Contains six drachms of a yellowish, bloody serum. No ecchymoses on either leaf. Heart,—Large, excessively flabby. Sub-pericardial fat abundant about the base and in the anterior ventricular groove. Patch of attrition over upper part of right ventricle in front, and another behind, near the inferior vena cava. On opening the heart in situ an ounce of 86 PATHOLOGICAL REPORT. blood, with one small coagulum, in the cavities of the right side, and ten drachms in those of the left. Organ flaccid, and walls collapsed when on the table. Right auricle normal. Right ventricle somewhat dilated, the endocardium stained by imbibition. Tricuspid valves a little thickened and gelatinous at the edges; orifice ot normal size. Pulmonary semi-lunar valves healthy, one segment fenestrated. Cavity of left ventricle large, walls of normal thickness. Mitral A'alves quite healthy, a little stained, orifice of proper size. Aortic semi-lunar valves a little opaque; slight atheroma at their base, and on the aorta opposite their free borders. Sinuses of Valsalva very distinct. Nothing abnormal in the left auricle. Muscle substance of the organ exceedingly pale, having a yellowish, faded-leaf appearance, especially marked in the walls of the left ventricle. Aorta.—Both arch and trunk of full size. Beyond the left sub-clavian there is a flattened patch of atheroma, about the size of a half-penny. Lungs.—Deeply pigmented ; crepitant throughout ; lower lobes cedematous and dark in colour posteriorly, The mucous membrane of the Trachea at the bifurcation, and extending irregularly nearly to the larynx, is repre- sented by a number of bony plates, lying immediately upon the cartilages, which are themselves very dense and partially ossified. s Spleen.—Weight, six ounces ; soft and flabby, Capsule a little opapue. On section, pulp soft, of a light brownish- red colour. Trabeculae distinct. Malpighian corpuscles not evident. Very little blood in the organ ; none could be obtained from the splenic vein. Left Kidney.—Length, 5". Unusual amount of super- ficial fat. Capsule loosely attached and on removal leaves a very anaemic-looking organ. No atrophy of the cortex, which is pale and bloodless. Pyramids, except at the bases, also pale. Right Kidney, 4J" long, dark red in colour, uniformly congested, forming a striking contrast MONTREAL GENERAL HOSPITAL. 87 to the other. Capsule easily detached; stellate veins prominent. On section, both cortex and medulla contain much blood. Supra-Renal Capsules.—The right is soft in centre, and somewhat larger than tho left, but nothing unusual about either. Bladder.—Distended with pale urine. Mucous mem- brane healthy looking. Prostate gland of full size. Tonsils and glands at root of tongue not enlarged. Several ecchymoses beneath the mucous membrane of the anterior wall of the pharynx. (Esophagus presents nothing unusual; a few small ex- travasations are noticed near the cardia. Mucous membrane of stomach pale, and at the cardiac end thin ; at the pylorus it is thicker. Duodenum healthy; common bile duct is pervious. Jejunum contains a quantity of dirty yellow mucus. Mucous membrane is pale. In the ileum, Peyer's patches are scarcely perceptible ; the solitary glands towards the ileo-caecal valve are alone distinct. In the large bowel the mucous membrane is anaemic. No ulceration. Scybalae in transverse and descending colon. Liver.—Rather small, of a light yellow colour, especially in the left lobe. Capsule smooth. On section a small quantity of liquid blood is seen in some of the hepatic veins. In places there is a very slight injection of the intra-lobular veins, which relieves the otherwise uni- formly pale surface. Gall-bladder.—Full of dark tarry bile. Pancreas.—Looks healthy. Abdominal blood-vessels almost empty. No blood in inferior vena cava or aorta. Intima of both healthy- looking. Thoracic Duct pervious throughout. Mesenteric and retro-peritoneal lymphatic glands small, the former unusually so, requiring considerable searching to obtain any. The amount of blood in the body appeared remark- 88 PATHOLOGICAL REPORT. ably diminished, and it was only by pressing along the limbs that sufficient could be obtained to fill a small homoeopathic phial. Piece of the sternum, the upper half of right fibula, the inner third of left clavicle, half a rib, and one of the last dorsal vertebrae were removed for the examination of the marrow. Blood was collected from the heart, and junction of the left jugular vein with the sub-clavian. A striking feature in the autopsy is the extreme anaemia of the organs, their almost entire bloodlessness and consequent pallor, the right kidney excepted. HISTOLOGICAL EXAMINATION. The blood examined during life, and after death, pre- sented the following appearances. (Hartnack, No. 9 im. andOc. 3.) About one-half of the red-blood corpuscles run together to form rouleaux. The majority of them appear of large size but do not present the characteristic round contours of these bodies; many are ovoid, others lozenge-shaped, or of various forms, with irregular projections and pro- cesses. Isolated corpuscles look of the natural pale yellow colour, but the alternating light and dark centre with the change of focus is not so distinct as usual. On touching the top cover and causing them to roll over, many do not present the bi-concave appearance, but look thin and flattened out. A limited number are crenated. In each field certain small round red corpuscles are seen, sometimes as many as six or eight. They are spheres, not biconcave, of a pale yellow colour, occasionally crenated or irregular in form. The measurements of some of the coloured elements are given below (Hartnack No. 16 im.), from which an accurate idea is obtained [of the remarkable discrepancies' in size. About forty measurements were made of corpus- MONTREAL GENERAL HOSPITAL. 89 cles taken at random in two or three specimens obtained a few days before .death. Of these one was 1-1833" by 1-2619", being somewhat elongated. Five ranged from 1-2750" to 1-2115", these being the extremes. In twenty- two the range was from 1-3000" to 1-4200". In this group the ordinary-looking red disks occurred. In five the diameter varied from between 1-5000'' and 1-9000." In five the diameter was less than the 1-6000", the lowest being 1-6874." Prolonged examination failed to discover a single nucleated red corpuscle. The colourless corpuscles did not appear relatively increased. One or two were seen in each field of the No. 9 and 3. The measurements in five corpuscles ranged from 1-2500" to 1-1800". They were quite natural look- ing, and displayed a remarkable degree of vitality. In a slide mounted and surrounded with paraffine at 1 P.M., the amoeboid movements were very active, the temperature of the room being about 60°.* At 7 P.M. the slide was carried in the hand a distance of a quarter of a mile to the house of a friend (temperature 14.2° F.), and the irregu- lar changes in outline were still observed, and continued until 8:40, when the observation was discontinued. There was an entire absence of Schultze's granular masses. Prolonged examination of different specimens after death, made for this special object, resulted in the detection of two nucleated red blood corpuscles. Heart.—The fibres are in a condition of extreme fatty degeneration, the striae being obscured by the number of densely crowded droplets and fine molecular fat; only * It may l>e here mentioned that the statement of Ranvier, Traite d'Histologie (p. 240), that the amoeboid movements of white blood corpuscles ilo not go on at ordinary temperatures is incorrect. In University College Laboratory, London, I found on one occasion that the amoeboid movement ,continued in the colourless corpuscles twenty-four hours after removal from the body. The blood was sealed in a capillary tube, and remained at the ordinary temperature in the month of June. 90 PATHOLOGICAL REPORT. here and there a fibre occurs in which the striae are faintly seen, In teased preparations numerous short bits occur, together with oil-drops and granules of fatty matter. In places there appears to be a good deal of interfibrillar connective tissue with fat cells. Muscles of the Trunk.—The fibres of the thoracic muscles—which were observed to be of such a natural appearance—present no trace of fatty degeneration. Spleen.—The ordinary corpuscles of the pulp, together with elongated, sometimes branched, cells of the retiform tissue are the chief elements seen in teased specimens. Tho red corpuscles have lost their colouring matter. A few cells containing red blood corpuscles are seen, but no nucleated red cells. Kidney.—Teased preparations show the epithelium of the tubules, both in the cortex and pyramids, covered with fatty matter in the form of minute drops and fine granules ; nowhere, not even in the large collecting tubes are the cells distinct. The Malpighian corpuscles also contain many granules and small oil-drops, and the same exist abundantly in the field. Liver.—Cells are stuffed with oil-drops ; none noticed without them, while in many the protoplasm and nucleus are entirely obscured. Free fat exists infiltrated between the cells, and in the field. In a few bile pigment is seen. Mesenteric Glands.—Teased portions present a large number of perfectly normal-looking lymph corpuscles, among which the connective tissue elements occur in the usual proportion. Many of the small vessels and capil- laries have their walls uniformly studded with fat grains, and may be traced as dark branching lines. In others, the deposition in not so extensive. Nothing abnormal observed in the axilliary lymphatic glands. Medulla of Bones.—The marrow of all the bones examined—sternum, ribs, clavicle, vertebra, fibula—is of MONTREAL GENERAL HOSPITAL. 91 a dark violet-red colour, thick, about the consistence and colour of the spleen pulp in fever. In the clavicle it is more diffluent, of a lighter red colour, and to the naked eye looks a little fatty—an appearance not noticeable in the other bones, not even in the shaft of the fibula. On microscopical examination, the following elements were found :— (1) Colourless corpuscles—marrow cells—of various size, with granular protoplasm, and bold vesicular nuclei. The greater number of these are larger than white blood corpuscles, and have usually a single nucleus, sometimes two. Others are smaller, more approaching the blood corpuscles in form, while in all the specimens examined, small round cells, like ordinary lymph corpuscles, are also found. The above represent the common colourless elements found in marrow, and they form the majority of the corpuscles in the field. In eight of the larger cells the extremes of measurement were 1-1571" by 1-1833" and 1-2200" by 1-2895". (2) Coloured blood corpuscles, of which two varieties are seen ; (a) ordinary biconcave disks, somewhat irregular in shape, and often, as noticed in the blood during life, provided with long processes. They are abundant, forming the large proportion of coloured elements. In the fibula, sternum, and ribs the colouring matter is retained, while in the vertebra and clavicle it has disappeared from most of the corpuscles, aad they are recognizable only as outlines, (b) Small round red corpuscles, non-nucleated, from one-quarter to one-half the size of ordinary corpus- cles, and similar in appearance to the small forms seen in the blood. They occur most numerously in the marrow of the fibula, where they form fully one-fourth of the coloured corpuscles. In the sternum and ribs they are not so abundant, though occurring in each field. As described in the blood itself, they do not appear to be biconcave disks, but spheres. The colouration is quite 92 PATHOLOGICAL REPORT. as intense as in form a, and a few were observed to be crenated. (3) Nucleated red corpuscles, the " transitional" forms of Neumann, which are numerous in the sternum and ribs, less so in the fibula, while in the clavicle and vertebra they occur scantily, or, owing to the general decolorization of the red corpuscles in these bones, are seen with diffi- culty. As shown by the measurements given below they are as a rule larger than ordinary blood corpuscles, but present, like them, a perfectly homogeneous coloured stroma, in which a finely granular nucleus is imbedded. They are spheres, not biconcave, as a rule round, though frequently irregular in outline, or with one end pointed and prolonged. The intensity of the colouration in most equalled that of the ordinary red corpuscles, in some instances being deeper, in others not so marked. The nuclei are either round or elliptical, and occupy from one-quarter to one-half of the body of the cell (see mea- surements). They are solid, granular, and inside the corpuscles look coloured, though not so deeply as the sur- rounding substance. The presence of nucleolus could not be determined. The position in the cells is variable; in specimens examined within a short time after the post- mortem they appeared to be chiefly centric, but in prepar- ations taken the next day very many of them had become quite peripheral, while others had protruded almost through the corpuscle, when it could be clearly seen that the nucleus was colourless. In several instances the nuclei are seen to be entirely outside the cells, though remaining attached to them. In this condition the^y look not unlike the small lymphoid marrow cells, and it is only the large size of the corpuscles to which they adhere, and the fact that in the same field others may be seen half-way out, that enables a correct opinion to be formed. In three or four instances dumb-bell-shaped nuclei were noticed. Cells with two nuclei were not uncommon, MONTREAL GENERAL HOSPITAL. 93' and instances with three and four were observed. As remarked above, the nucleated red forms are numerous in the sternum and ribs, six to eight being seen at once in the field of the No. 9 im. and 3, while in the fibula not more than three or four were noticed in any single field. In fifteen measurements of these forms, eleven were above the 1-2000"; five being 1-1428". The following mea- surements are of three corpuscles with their contained nuclei:— (1) 1-1774" by 1-2200"; nucleus 1-2019" by 1-2896". (2) 1-2200" by 1-2391"; nucleus 1-5500" by 1-5000". (3) 1-2037" by 1-1964"; nucleus 1-3666" by 1-3235. A good idea of the irregularity in outline of these corpuscles and the slightly elliptical character of the nuclei may be gathered from the above. (4) Cells containing red blood corpuscles. These are very abundant in the marrow of the vertebra, three or four occurring in the field at once, and containing from five to six red corpuscles, the colour and outlines of which in most cases are preserved. In the sternum and ribs they are not nearly so numerous ; in the fibula and clavicle they were not observed. (5) Myeloplaques, of which one or two only were met with in the marrow of the sternum and rib. Neither in the shaft nor epiphysis of the fibula could these forms be determined. (6) Fat cells, which are present in marrow of the clavicle in small numbers, absent in the sternum, vertebra, and rib. In marrow from the fibula an oil drop is occa- sionally met with in the field, but here also they are almost entirely absent. (7) The octahedra crystals, first described by Charcots and which always occur in the marrow from twelve to* thirty-six hours after death. 94 PATHOLOGICAL REPORT. CASE xcvii.—Profound anccmia, without discoverable lesion. Fatty degeneration of organs. Hyperplasia of bone- marrow. J. B., aet. 47, an Englishman. For clinical report, by Dr. Bell, see " Transactions of Canada Medical Associa- tion," vol. 1, 1877. A description of the blood and bone- marrow in this case also occurs in the Centralblatt f. d. med. Wissenschaften, No. 25, 1877. Body that of a spare man, 5 feet 5 inches in height; complexion fair, hair light, whiskers red. The skin pre- sents a yellowish tinge over the whole body, most marked on the face, neck, and shoulders. Rigor mortis well developed. Slight oedema of lower extremities. Four or five smooth white cicatrices on the right side of the leg. Freckles abundant on forearms. Panniculus adiposus thin. Brain.—Skull unusually thick ; marrow of diploe red. About 2 oz. of serum escaped on removal of the dura mater. Vessels of the pia mater empty. Pacchionian granulations numerous. Brain substance pale, of good consistence. Nothing abnormal in the ventricles or gan- glia at the base. The remarkable pallor of the tissues is the most noticeable feature Weight, 3 lbs. 3 oz. Thorax and Abdomen.—The voluntary muscles exposed in the preliminary incision are of rich dark-red colour. Intestines and omentum pale and bloodless ; position of abdominal viscera normal. In the thorax the right pleura contains a pint of reddish serum, the left half a pint, in which a few flocculi of lymph are seen. There are pig- mentary ( ?) deposits upon parietal layer over diaphragm and bodies of the vertebrae. Pericardium is normal, a few ecchymoses on visceral layer over left ventricle. Heart, very flaccid, walls of chambers collapsed. A good deal of sub-pericardial fat, especially over the right MONTREAL GENERAL HOSPITAL. 95 cavities. Venae cavae nearly empty. Right auricle con- tains 3 iss. of blood, light claret-coloured, and one small coagulum, partly decolorized. Right ventricle contains a small amount of blood ; walls thin ; endocardium stain- ed. Valves healthy. Musculi papillares pale yellow colour. Left auricle empty. Left ventricles contain very little blood ; lining membrane stained. Walls of normal thickness, muscle soft, somewhat paler than normal. Valves healthy. Aorta of normal diameter. Lungs ; pigmentation moderate; slight congestion (post- mortem) in dependent parts, and also an excess of serosity. Structure healthy. Spleen, slightly enlarged, weighs 3 x. Numerous ad- hesions, infiltrated with serum, bind it to the diaphragm, stomach, and colon. On section, pulp very soft, almost diffluent, dark red in colour. Left kidney, 5h inches long. Section shows a pale, coarse organ, somewhat softer than natural. Left supra-renal capsule pale, soft in the centre. Right kidney, moderately congested in the cortical por- tion and at bases of pyramids. Cones very pale. Right capsule healthy. Bladder healthy. Vesiculas seminales contain spermatozoa. Stomach distended with gas ; con- tains about 4 oz. of a brownish viscid fluid. Numerous ecchymoses along the greater curvature, especially at the cardiac end. The veins contain blood. Mucous mem- brane looks normal. Duodenum and jejunum healthy. Coats of the ileum very thin, translucent, and anaemic. The solitary glands are prominent in the upper part; only one patch of Peyer found in the lower portion. Large bowel normal. Mesenteric glands appear even smaller than natural. Pancreas healthy. Liver, a few ecchymoses on capsule, a small cicatrix on upper surface of right lobe. Substance pale, in parts much softened. Weight 3 lbs. 8 oz. Gall bladder con- tains normal-looking bile. 96 PATHOLOGICAL REPORT. HISTOLOGICAL EXAMINATION. The blood examined during life wTas very thin, watery, and of pale claret colour. It presented the following characteristics :—Colourless corpuscles appear perfectly natural in structure and size, and are not numerically increased. No large granular ones, such as described by Litten^ could be found. Two forms of coloured corpus- cles : (a) ordinary forms, which are paler than natural, flattened out, less biconcave, and very irregular in out- line, some ovoid, others with sinuous borders, others again with pointed processes, (b) Small red corpuscles—micro- cytes,—erroneously described by Eichorst as pathogno- monic of this affection. They were numerous, 8 to 10 occurring in the field of No. 9 im. and oc. 3. The diameter ranged from 1-5000" to 1-9000." They equalled, or even exceeded, in colouration the ordinary forms ; some were crenated, and they frequently presented a pit or cup- like depression on one side. In the repeated examinations of the blood, extending over three months, these forms increased but little numerically. Schultze's granular masses were not noticed. No appre- ciable difference could be detected in the histological appearance of the blood an hour after the transfusion. The heart presented signs of moderately advanced fatty degeneration, the striae in many fibres being obscured by molecular fat and droplets of oil. Spleen.—The normal elements, cells of the spleen pulp, and spindle-shaped corpuscles of the trabecula, together with numerous blood corpuscles, were the only structures noticeable in teased preparations. Kidneys.—In both cortical and pyramidal portions the cells of the tubules appear very granular, somewhat swollen, and a large number of oil droplets are seen in and about the tubules. * Berliner Klinische Wochenschrift, NO. 19, 1878. MONTREAL GENERAL HOSPITAL. 97 Liver.—Cells contain oil drops in excess, and in many the nuclei are obscured. There is also some fatty infiltra- tion. The marrow of all the bones examined, sternum, ribs. vertebrae, radius, fibula, was of a violet-red colour, of good consistence, and with the exception of that of the fibula, contained no fat. There were found the ordinary large, coarsely granular, marrow cells, numerous small lymphoid corpuscles of both sizes ; and, in addition, very many nucleated red blood corpuscles, corresponding with those described by various writers as occurring in the marrow in cases of leukaemia, and by Cohnheim^ and myself f as constituents of this tissue in cerain cases of pernicious anaemia. There were not many in the marrow of the sternum, fewer still in that of the vertebrae. They were considerably larger than the ordinary red blood corpuscles and of about the same intensity of colouration. The majority had only one nucleus, but cells with two, three, and four were not uncommon. The position of the nucleus was usually eccentric, often, indeed, protruding half way from the corpuscle. The nuclei were colourless. * Virchow Archiv., Ixviii. 1876. f Centralblatt f. d. Med. Wissen, No. 15, ] 877. 7 ON THE T^-O PATHOLOGY OF THE SO-CALLED PIG-TYPHOID. - BY WILLIAM OSLER, M.D., Professor of Physiology and Pathology in McGill University, and the Veterinary College, Montreal. Refrint from the Veterinary Journal, June, 1878. %o\xhttu: BAILLIERE, TINDALL AND COX, KING WILLIAM STREET, STRAND. MDCCCLXXVIII. ON THE PATHOLOGY OF THE SO-CALLED PIG-TYPHOID. BY WILLIAM OSLER, M.D., Professor of Physiology and Pathology in McGill University, and the Veterinary College, Montreal. Reprint from the Veterinary Journal, June, 1878. % 0 it h 0 it : BAILLIERE, TINDALL AND COX, KING WILLIAM STREET, STRAND. MDcccLxxvirr. • Hazel], Watson, and Viney, Prir.turs, London and Aylesbury ON THE PATHOLOGY OF THE SO-CALLED PIG-TYPHOID.* The most diverse opinions prevail as to the true nature of this disease; upon these I shall not comment at length. Many of the Continental pathologists class it with Anthrax, and in some of our English text-books it is treated under the same heading. The researches of Budd, in 1865, led him to the conclusion that it was a Typhoid Fever; those of Murchison, that it belonged rather to the dysenteric affections. The interest excited in the disease by these early investigators died away, to be awakened ten years after by a series of papers from the pen of Professor Axe, in which he substantiated and extended the views of Dr. Budd, stating that, etiologically, clinically, and pathologically, the disease was an exact counter- part of human Typhoid. Dr. Klein has more recently inves- tigated the disease with special reference to this point, and has arrived at an opposite conclusion—holding that the so-called Pig-Typhoid has no analogy with the disease bearing this name in man. Having, in the course of my reading, become acquainted with this unsettled state of the matter, I gladly, at Principal McEachran's suggestion, investigated a local epizooty which had broken out near Quebec, in a drove of 300 hogs ; hoping * An abstract of this paper was read before tlie Pathological Society oi New York, January 23rd, 1878. I 4 On the Pathology of the so-called Pig- Typhoid. that, by a scries of independent observations, the truth of one or the other of these views might be confirmed. Etiology. The highly contagious and infectious nature of this malady has been known for years—being first established, I believe, by Dr. Sutton, of Illinois. The following experiments, though limited in number, are, I think, worthy of record, as they con- firm and extend those of Professor Axe and Dr. Klein. Experiment I. September 1st.—A sow pig, ten weeks old, was inoculated with lymph and blood obtained by squeezing a portion of ecchymosed skin from a diseased animal, and collecting the exudation on ivory points. No change noticed until the 6th, when the animal did not appear so lively. Temp. 104!°. 7th.—Place of inoculation has dried up, A diffuse sub- cutaneous redness exists over skin of belly, and certain of the hair follicles are swollen, papular, and surrounded by irregular but circumscribed zones of hyperaemia. These are best seen in the groins, where the general redness is not so marked. Temp. 105° 9th.—Blush on abdomen not so vivid. Spots about hair follicles persist. Animal feeds well. Temp. io6i°. nth.—A few reddened papules on skin of abdomen. Hyper- emia has faded. Temp. io6g°. 13th.—No change. Temp. 106° 14th.—Skin looks harsh, and the hairs appear rougher than natural. Temp. io6f°. 16th.—Eyes watery. Animal looks ill, but feeds well, and has no diarrhoea. Temp. io6i°. 17th.—Back somewhat drawn up. Dirty secretion about the eyelids. Skin of abdomen is of a dusky-red hue, and the papules about the hair follicles are again very distinct. A few ecchymoses about the back of ears. Temp. 105>°. 18th.—Skin of whole body of a deep dusky-red colour, On the Pathology of the so-called Pig- Typhoid. 5 brightest on the abdomen. It disappears on pressure, return- ing very slowly. Over the sternum and in the axillae there are definite ecchymoses. Inguinal glands are swollen. Animal does not feed so well. No diarrhoea. Mucous membrane of rectum reddened. Temp., morning and evening, 1020. 19th.—Much the same. Temp, morning 1040, evening 1050. 20th.—Skin harsh. Eyes lustreless. Not so red. Ecchy- moses have not extended. Temp., morning and evening, 105° 21st—Animal feeds better; redness much diminished. Temp., morning 1040, evening 1030. 22nd.—Inguinal glands still swollen. Temp. 104!°. 23rd.—Ecchymoses fading on belly, but still distinct behind the ears. No diarrhoea. Temp. 1040. 25th.—Animal has lost flesh, but is not much emaciated. Temp. 1030. 26th.—Temp. 106° The extravasations are scarcely visible. 27th.—Temp. 104!°. Swellings of the_inguinal glands not^ so marked. 28th.—Temp. 1040. Animal decidedly better. Feeds well, 29th.—Temp. 103?° 30th.—Temp. 103;.;0. Is brighter; skin not so harsh, but on belly numerous dirty scales can be scraped off. From this time the animal improved in every way, and ap- peared convalescent. On October 10th I inoculated it again with blood from Case V. (fed with diseased intestine). During the succeeding week I was so occupied that the animals were not visited. I then found this one febrile, temp. 1060, ecchy- moses in ears, and suffering from diarrhoea. It became moderately emaciated; the fever kept up, though it was never high ; and extravasations occurred about the thighs. It died on October 25th. Post-mortem.—A few patches in caecum and about valve, and half a dozen in the colon ; some of the latter are excavated with puckered infiltrated edges. Lungs unaffected. Experiment II. September 1st.—A ten-weeks-old sow pig was inoculated by scratching and rubbing in material obtained from an intestinal 6 On the Pathology of the so-called Pig- Typhoid. plaque of a diseased animal. Pulse immediately after the operation ioo. Temp. 1060, with two thermometers. Nothing unusual noticed at the daily visits, until the evening of the 6th, when the animal appeared less lively, and lay beneath the straw. A swelling has been gradually forming at the site of inoculation, and an inguinal gland in the neighbourhood is enlarged. 7th.—A faint, just perceptible redness exists on skin of belly and inner surfaces of front legs; in the latter situation are a few hyperaemic papules about the hair follicles. Temp. 1050. 9th.—Redness gone. No constitutional disturbance. Temp. 1051°. nth.—No change. Temp. 1050. 13th.—Hyperaemia gone. One or two papules in groins and inner surfaces of legs. Temp. 1060. 14th.—Swelling at site of inoculation persists. Inguinal lymphatic glands enlarged on right side. Temp. 1070. 16th.—No change. Temp. io6°i 17th.—Does not look so ill as the other animal inoculated at the same time. No cutaneous affection; no diarrhoea ; feeds well. Temp. I05f°. 18th.—Temp. I02§°; evening 103° 19th.—Morning temp. 101 J°; evening 1040. Condition the same. Has become thin, but not so much so as the other animal. 20th.—Temp., morning 1030, evening 1040. 21st.—Temp., morning 1040, evening 1034°. 22nd.—Morning temp. 1020. Does not look ill. 23 rd.—Temp. 103I0. 24th.—Temp. 1030. 25 th.—Temp. 104° 26th.—Temp. 105. Anus slightly prolapsed, but mucous membrane not injected. No diarrhoea. 27th.—Temp. 104° 28th.—Temp. 1040. 29th.—Temp. 103-J0 30th.—Temp. 103I0. From this time I considered the animal convalescent, though On the Pathology of the so-called Pig-Typhoid. 7 the symptoms were so slight that I had doubts whether it had been affected at all. On October 10th, I inoculated it subcutaneously with blood taken from the inferior cava of animal the subject of Experi- ment V., and killed on that day. During the following week, I was so much occupied that I neglected to visit the pig-pen, and was considerably astonished on the 18th, when the keeper sent word that the animal was dead. He stated that it had become much worse since the inoculation. I found the animal with the cutaneous lesions well marked, and the intestinal disease well developed. Post-mortem.—Extravasations on thighs, buttocks, and ears. Recent peritonitis, pericarditis, and pleurisy. Lower half of left lung pneumonic. Bronchial glands much swollen. Stomach: at fundus there are from ten to fifteen small yellowish patches, the largest the size of a sixpence ; all confined to the mucosa. Entire mucous membrane of caecum infiltrated. In colon numerous button-like masses, many of which extend through the entire thickness of the bowel. No signs of softening or ulceration in any of the patches. Mesenteric glands swollen, but not haemorrhagic. Experiment III. September 10th.—Caseous matter from bronchial tubes of a fatal case, in lohich titere was no intestinal lesion, rubbed up with saline solution (f per cent.) ; of this m. xv. injected subcu- taneously in the left flank. 13th.—Temp., morning 1030, evening 103 5°. 14th.—No change noticed. Temp., morning and evening, 1040. 15th.—Temp., morning 104!°, evening 104J0, 16th.—Site of injection is a little swollen. Temp., morning 104?0, evening 1043°. 17th.—Several distinct rose-coloured spots in right axilla, chiefly about hair follicles. Site of injection more swollen and hard. Temp., morning 1060, evening 105 jj°. 8 On the Pathology of the so-called Pig- Typhoid. t8th.—Other spots of hyperaemia on abdomen. They are about three lines in diameter, slightly elevated, and disappear on pressure. No general rash. Temp., morning 105 , evening 105 r. 19th.—Animal continues to feed well, but the skin and hair look rough. Temp., morning 109!°, evening 107!°. 20th.—No trace of any skin eruption ; the small erythematous spots have faded. Temp., morning 105 j°, evening 1080. 21st.—Site of injection remains hard. Temp., morning 1070, evening 1060. 22nd.—Eyes do not look so bright. Temp., morning 107!°, evening 1070. 23rd.—No diarrhoea. No rash. Temp., morning 1070, evening 1074°. 24th.—Not so well. Eyelids glued together with secretion. Temp., morning 1090, evening 1080. 25th.—Has diarrhoea. A muco-purulent discharge runs from the nose. A very faint rash exists over abdomen. Temp. morning 1070, evening 107!°. 26th.—Diarrhoea profuse. Extremities cold, and the nose blue. Rash scarcely perceptible. Temp., morning 1073-0, even- ing io8|°. 27th.—Very weak, and considerably emaciated. Position when standing and general appearance very characteristic; back arched, and the hinder extremities seem almost unable to support the weight of the body. The gait is tottering. Diarrhoea very severe, and the keeper noticed a little blood in the discharges. Several large purpuric blotches on the hind- legs. No cough. Temp., morning io6|°, evening 1060. 28th.—Extremities cold and nose blue. Emaciation has increased. Extravasations have extended, and are seen on the front-legs as well. Site of injection still hard. Inguinal glands a little enlarged. Temp., morning 1050, evening 1030. 29th.—No change. Diarrhoea continues. Temp., morning 103I0, evening 1060. 30th.—No extension of the extravasation. Dr. Buller exa- mined the eyes, and reports the retinae healthy. Temp., morning Io6|°, evening 10630. On the Pathology of the so-called Pig- Typhoid. 9 October 1st.—Very weak ; can hardly stand. Diarrhoea very profuse. Temp. 1040. 2nd.—Appears completely exhausted. Nose quite blue, and extremities very dark. Temp. 1020. Died in the night. Post-mortem.—Kidneys look natural. In greater curvature of the stomach there is a diphtheritic-looking area about \\ in. in diameter, and near it some small patches of greyish-yellow infiltration. In the caecum are several superficial plaques about the valve, one of which overlaps a patch of Peyer. In the colon are twelve to fourteen isolated areas, involving only the mucosa, and showing no signs of separation. Mesenteric glands swollen ; some of them haemorrhagic. Experiment IV. September 10th.—Mesenteric glands from diseased animal rubbed up with saline solution; m. xv. injected subcutaneously into right flank. 14th.—No change noticed. Temp. 103!°. 16th.—Temp. 1050. 17th.—A few rose-coloured spots noticed over sternum and epigastrium. No swelling at site of injection. Temp. 1070. 18th.—Nothing special noticeable except the hyperaemic spots on abdomen. Temp. 1043°. 19th.—Maculae not so evident. Skin of ears congested. Temp., morning 1093°, evening io64°. 20th.—No skin eruption visible. No swelling at site of injection. Temp., morning 106-I-0, evening 1060. 21st.—Animal feeds well. Temp., morning and evening, 1060. 22nd.—Temp. 1073-°- 23rd.—No rash, but skin feels rougher than normal. Temp. 1080. 24th.—Is wasting, but continues to feed well. Temp. 1070. 25th.—Appears weaker, and has, for the first time, slight diarrhoea. Temp. 107-0. 26th.—Diarrhoea worse. Eyes look weak and the eyelids are covered with secretion. Extremities cold. Nose blue. Temp. 107. io On the Pathology of the so-called Pig-Typhoid. 27th.—A faint rash perceptible on abdomen, and four or five papules, dark in colour and haemorrhagic, are seen just below the ensiform cartilage. Extravasations are also seen on the skin of the hind-legs. Diarrhoea continues. Temp., morning 1054°, evening 1070. 28th.—Condition the same. Temp., morning and evening, 1060. 29th.—Very weak. Ecchymoses have not extended. Ears purplish. Temp. 1060. 30th.—Emaciation more marked, and general appearance very characteristic. Temp. 105 40. October 1st.—Very weak. Diarrhoea excessive. Skin rough and harsh. Temp. 1040. 2nd.—Respirations a little laboured, but no evidence of Pneumonia. Temp. 1040. 3rd.—Very feeble. Can scarcely stand up. Extravasations appear to have extended on the legs, and a few are visible on abdomen. Temp. 1010. 4th.—In a moribund condition. Died in the night. Post-mortem.—Nothing abnormal noticed in heart, lungs, liver, spleen, and kidneys. In mucous membrane of caecum and first two feet of colon, there are numerous ecchymoses. In the rectum they are submucous and more uniform, infiltrating even the muscular coat. About the ileo-caecal valve are confluent plaques, which extend through all the coats and thicken the wall. In the colon the patches are small and button-like. Mesenteric glands swollen, and present extravasations in cortical parts. Experiment V. September loth. — Portions of two intestines, containing numerous plaques, were minced finely and fed to a sow pig ten weeks old. The feeding was done with as little violence as possible, and I do not think the mucous membrane was abraded in the act. 13th.—Temp. 1030. 14th.—Appears quite well. Temp. I04§°. 15th.—Temp., morning 1043° evening 1040. On the Pathology of the so-called Pig- Typhoid. 11 16th.—No change. Temp., morning 1040, evening 1043°. 17th.—No rash. Temp. 105!°. 18th.—Temp., morning 1063°, evening io6f°. 19th.—Has not fed so well, and begins to look ill. No trace of an eruption. Temp., morning 1080, evening 106° 20th.—Faeces consistent, but a little bloody mucus noticed on the one which followed the introduction of the thermometer. Temp., morning 105-f, evening 1060. 21 st.—Skin dry and harsh. Temp., morning 1095°, evening 1081. 22nd.—No rash. No diarrhoea. Temp., morning [i02§°, evening 104^°. 23rd.—Temp., morning 1060, evening 10640. 24th.—Diarrhoea for the first time. Temp., morning 107,0 evening 1074° 25th.—Diarrhoea continues, but is slight. No rash. Temp., morning 1070, evening 107!°. 26th.—Is emaciated and weakened. The diarrhoea has been profuse. Temp. 1080. 27th.—Diarrhoea is better; stools soft but consistent. No ecchymoses. Temp., morning no°, evening io8|°. 28th.—Condition much the same. Is not nearly so weak as the other pigs. Temp., morning 1074°, evening 107". 29th.—Eyes are watery. Temp. 1070. 30th.—Diarrhoea is worse. Temp. 1054°. October 1st.—Emaciation more marked. No rash. Ex- tremities and nose slightly cyanotic. Temp. 106° 2nd.—Feeds tolerably well, and looks much better than the animals inoculated on the same day. 3rd.—Gait staggering, and general appearance characteristic. Temp. 1040. The animal remained in this condition, getting neither better nor worse, until the 10th, when it was bled to death. The extremities and ears were purplish, but not distinctly ecchymotic. Post-mortem.—Heart, lungs, spleen, liver, and kidneys, present no apparent changes. In ccscum are a dozen or more circular patches, slightly depressed below the level of the mucous mem- brane. The surface is uniform, and they do not look as if 12 On the Pathology of the so-called Pig- Typhoid. sloughs had separated from them. For an inch about the valve the mucosa is infiltrated with this greyish-yellow material. On the caecal lip of the valve are eight or ten miliary elevations with translucent centres, looking like small lymph follicles. In the first foot of the colon are six irregular depressed plaques, which appear to be healing: in some there is a distinct line of demarcation between the patch and the mucosa ; in others this is not marked, but the mucous membrane is apparently encroaching on the plaques. In the rest of the colon the patches are numerous, and in many of them a central slough is separating' There is no congestion of the mucous membrane. That the contagion exists in the serum of the skin had been shown by Professor Axe, and verified by Dr. Klein, who had also induced the disease by inoculation with material from the intestines. He had not succeeded in producing the disease with the juice of lymphatic glands, as has been successfully done in Experiment IV. of our cases. In his experiment of feeding an animal with the diseased intestines, infection followed; but he explains it by supposing that the morbid matter gained entrance to the blood through scratches in the mouth. In Experiment V, above given, infection also followed: and I think there is sufficient ground for believing that the disease was induced by the absorption of the materies viorbi from the intestinal tract, for the experiment was very carefully performed, with the express view of avoiding possible abrasion of the mucous membrane of the mouth. Lastly, the successful experiment with the caseousi matter from the bronchial tubes demonstrates, for the first time, that the contagion is also contained in the lungs, and shows us one fruitful source of contamination, not only in the expired breath, but also in the mucus so frequently coughed up. In this connexion I would refer to some admirable papers by Professor Claypole, of Antioch College, Ohio, published in the Western Farmer, Ohio; in which the infectious and contagious nature of the malady is abundantly proved. These are of special value, insomuch as an opinion prevails among many in the Western States that the disease is not communicable. On the Pathology of the so-called Pig- Typhoid. 13 Symptoms. These have already been so fully described by other writers, that I shall refer to one or two points only. In the first place, the temperature range is exceedingly irregular. The relation between the morning and evening temperature is not at all constant, and very generally there was a morning exacerbation and evening fall. In comparing the charts of the five cases, there is an entire absence of the typical curves of human Typhoid. Secondly, the cutaneous eruption in this epizootic was not so marked as in some which have been recorded. The ecchymoses were present in all the cases, with but one exception. These, however, though forming by far the most striking cuta- neous lesions, are not regarded by Professor Axe as constituting the typical and characteristic eruption, which he states to con- sist in "small round raised spots of a faintly red colour." Such were certainly present in four of the five animals experimented upon, but I could not find them in a large number examined at Quebec in all stages of the disease ; and I should like additional experience before concurring in the opinion that they constitute the specific eruption of this Fever. And, thirdly, diarrhoea cannot be regarded as a constant symptom, for in more than half the cases examined the intes- tines contained consistent, sometimes hard, faeces. Pathology. The following is a summary of the pathological changes found in the nineteen cases which I have examined. Skin.—In the majority of the animals definite changes were found in this structure. In the first place, the hairs had a rougher look and harsher feel than normally. The epidermis was fre- quently loosened in the form of fine scales. In four of the animals experimented upon, hyperaemia of the skin existed as a diffuse erythematous redness, which was in two instances general, in the others localized on the belly. During the second week there was, on four of these animals, an eruption of rose- coloured spots upon the abdomen and inner surfaces of the extremities. Some of these spots were flattened, slightly raised, 14 On the Pathology of the so-called Pig-Typhoid. circular, about two to three lines in diameter, and disappeared on pressure; others were more pointed and papular in character, surrounding hair follicles, and situated upon hyperaemic bases. Not more than half a dozen of these were noticed on each animal, and it was only by careful inspection that they could be discovered. In two instances scabs were formed, from beneath which pus exuded. The extravasations of blood into the skin, which form so remarkable a feature of the disease, were present to a greater or less degree in eighteen of the cases. Judging from the reports of other epizootics, I am inclined to think that the cutaneous affection was slighter than usual. The extravasations most com- monly occurred about the abdomen and flanks, the inner surface of the legs, about the hocks, and the ears. They varied from small punctiform and petechial haemorrhages up to extensive areas of infiltration, giving to the skin a uniformly deep-red or purplish-red colour, upon which the impression of the finger made no difference whatever. In several instances the whole skin was covered with irregular blotches, and on cutting in these areas it was seen that the haemorrhages lay chiefly in the corium, though often in the subcutaneous tissue. The ears were perhaps most frequently involved in this process, presenting a deep purple colour. In none of the cases was the skin much swollen, nor in any of the forty or more diseased animals which I saw were there any of the local patches of gangrene or necrosis described by some authors. Pharynx.—In one case there was extensive diphtheria of the nasal passages, pharynx, and larynx ; and in another case there were ulcers on the mucous membrane of the cheeks and lips. Stomach.—In nearly every instance this organ contained food. As a rule, the mucosa was pale; and in three cases plaques or patches similar to those found in the intestines were met with. Intestines.—In fifteen out of the nineteen cases the intestines were affected ; in three they were apparently healthy ; while in one the mucous membrane was ecchymotic. In two only of the nineteen cases did the small intestines present evidence of dis- ease, consisting in a slight degree of diphtheritic-like exudation on the mucous membrane,—once in the ileum and once in the On the Pathology of the so-called Pig- Typhoid. 15 duodenum. The mucous membrane was occasionally congested in places. Peyer's glands looked healthy. The large intestine is the seat of the peculiar anatomical lesions of the disease, and these we shall briefly proceed to describe. The mucous membrane is sometimes congested ; but this was found to be a most variable character, for frequently, even when extensively affected, the mucosa itself was pale, though the large vessels in the submucous tissue were usually full. Extravasations occurred in five or six instances; in Cases 5 and 17 they were remarkably abundant. In the former the colon presented a dark colour, from the presence of extravasa- tion in the submucous coat, while the whole thickness and extent of the rectum was infiltrated with blood. In Case 17 the same condition of the rectum was found. The specific intestinal affection consists in an infiltration of the mucous membrane, either in localized spots or extensive areas, and the production thereby of larger or smaller patches of necrosis, which may assume very varied forms, and in time separate, leaving definite ulcers. I will group together the different appearances which the lesions presented :— 1. A brownish-yellow infiltrate, very like diphtheritic mem- brane, involving only the superficial layers of the mucosa, but frequently very extensive. This form was met with in five or six of the cases, chiefly along the ridges of the caecum and colon On section, it extends for a couple of lines into the mucosa, and cannot be separated without removing portions of that mem- brane. 2. Small greyish elevated spots, ranging in size from a pin's head to a split pea, seated directly upon, and involving the mucosa to a variable depth ; frequently the edges of the pro- jecting spots overlap the mucous membrane. Others, older perhaps, are seen in process of separation, as small central sloughs, divided by narrow grooves from the mucosa, which may even be elevated about them. 3. Patches ranging in size from that of a threepenny-bit to a penny or larger, circular, flattened, intimately adherent to the mucosa, yellowish-grey in colour, sometimes dark in the centre, and usually presenting a concentric 'arrangement, resembling a iC On the Pathology of the so-called Pig-Typhoid. flattened-out rupia crust, or the cross section of a calculus, Sometimes these plaques are ovoid, and frequently two or three have coalesced. The concentric arrangement is their most peculiar feature, and is best marked in the larger ones, where a central spot can often be seen from which the process appears to have extended in zones. Some of the smaller ones differ from these, the surface being uniform and more prominent. On section, the patches show a yellowish-white colour throughout, and involve the coats of the bowel to a variable depth; some being confined to the upper part of the mucosa, others extending through its whole thickness; while others, again, involve the submucosa and muscular coats. They are firm and tenacious, not friable, resisting the scraping of a knife better than the mucous membrane itself. 4. Uniform involvement of large areas of the intestine con- verting the mucous surface into a yellowish irregular structure, like wash-leather, and in some instances extending through all the coats to the peritoneum, rendering the wall thick and inflexible. 5. In two cases most peculiar masses were met with in the colon, looking like warty excrescences, springing from the mucosa ; they are oval, and lie transversely to the axis of the gut, encircling about three-fourths of the tube, and projecting from J in. to 1 in. into the lumen. In the transverse direction they present a rounded concavity, while in the long axis of the bowel they are convex ; the surface is dark or yellow-brown, and sometimes shows concentric lines. On section a firm greyish- yellow structure is disclosed, very dense, and involving all the coats to the peritoneum, which is puckered and retracted over the site of the attachment. One of these measured nearly 1 \ in. in thickness, and materially narrowed the calibre of the intestine. Now all these lesions, though apparently different, are simply modifications of one and the same process. Between the first four, patches intermediate in character were met with, and in a larger experience I have no doubt connecting forms between three and five could be found. Two facts are very remarkable about the condition of the intestinal lesions :—1. The absence of ulceration in most of the On the Pathology "of the so-called Pig- Typhoid. 17 cases ; and—2. The very slight hyperaemia or injection of the mucous membrane about the plaques. Not more than four or five distinct ulcers—i.e., breaches or loss of substance in the mucosa—were met with altogether. In the few instances when the crusts, as they have appropriately been called, have separated, the bases and edges of the ulcers are formed by greyish infiltrated tissue. Nothing exactly corresponding to these appearances is met with in human pathology; the condi- tion which most nearly resembles it occurs in the severer forms of Dysentery ; and a short time ago, in a case of Pneumonia, I met with isolated rupia-like masses, infiltrated and projecting from the membrane of the colon, which somewhat resembled certain of these plaques. Occasionally the solitary glands of Peyer, in the large bowel, were found swollen and distinct. In several instances numerous small elevated bodies, ranging in size from a pin's head to a split pea, were seen, usually with a small central depression and orifice. These closely resembled solitary glands, and, indeed, without microscopic examination, could not, I think, be distin- guished from them. However, as will be subsequently stated, they have nothing to do with the glands of Peyer. Histological Examination. — Fresh portions from a small intestinal plaque teazed up in saline solution, show a finely granular stroma and numerous small cells, irregular in outline solid, looking like fine nuclei, and about one-third the diameter of white blood-corpuscles. In thicker and older masses little can be seen but a granular debris, in which here and there the shrunken remains of corpuscles are noted. A study of sections of small areas the size of pin's heads, where the affection is beginning, shows that the process is confined to the mucosa. In the earliest stage at which I have been able to trace it, the crypts of Lieberkiihn are filled with loosened epithelium, among which small corpuscles somewhat frequently occur. How the latter originate—whether from the epithelium or from the nuclei of the walls of the follicles—I cannot say, but in the next stage they form the predominant elements in the section. The affected area appears infiltrated with small round lymphoid corpuscles, closely aggregated, which destroy all traces of the normal con- 18 On the Pathology of the so-called Pig- Typhoid. stituents of the mucous membrane. The muscularis mucosa is also infiltrated, and its elements separated. The submucosa at the same time contains numerous leucocytes. In larger areas, the size of buttons, it can be seen that the densely-packed corpuscles have undergone a change ; their out- lines are less distinct, or altogether lost, and the section presents a homogeneous granular appearance. In thin sections, towards the surface, a laminated condition can be seen, depending, ap- parently, on thin translucent bars traversing the matrix, very like those met with in croupous and diphtheritic membrane. Comparing the appearance with specimens in human pathology, it most resembles the firm caseous material of the central part of a syphiloma. All the greyish-yellow plaques present great uniformity in this respect. Fine hairs and particles of food are not uncommonly attached to the surface. The deeper parts of the masses present appearances which vary with the depth to which the disease has extended. When of any size, the sub- mucosa is usually involved, and the mass is then densely adherent to the muscular coat, the inner fibres of which are infiltrated with the small corpuscles above referred to. In many instances the entire thickness of the gut is attacked, and converted into a firm, dry, non-vascular structure, on the peritoneal surface of which alone is there any cellular activity. Bacteria and micrococci were occasionally met with, but not in situations or numbers to be of great pathological importance.* None were seen blocking blood or lymph vessels. Several masses were noticed in Lieberkuhn's crypts; most abundant in one in which a hair was found, the root of which was surrounded by groups. The peculiar structures like solitary glands, noticed in some cases, demand a passing word. They have nothing to do with these bodies, but are involutions of the crypts of Lieberkiihn, forming saccular cavities, communicating with the exterior by a narrow orifice which is usually plugged. In sections the contents of the sac very frequently fall out. They are similar, apparently, to what Cornil described as mucous cysts in a case of dysentery; but Kelsch, quoted by Birch-Hirschfeld,* first gave the correct * " Lehrbuch der pathologischen Anatomie," 1877. On the Pathology of the so-called Pig- Typhoid. 19 interpretation of the appearances. Klein gives an excellent account of them in his paper. Lymphatic System.—In ten of the cases, the mesenteric and retro-peritoneal glands were enlarged and of a deep-purple colour, owing to extravasation, chiefly into the cortical regions. In many sections the entire gland structure was infiltrated with blood, presenting on section a deep plum colour. In six cases they were swollen and tumefied, but not congested. In three of the cases in which there was no intestinal affection, they ap- peared normal. In all of the cases in which the lungs were diseased, the bronchial and sternal, often the lower cervical glands, were swollen and congested. Lungs.—After the intestines, the lungs appear to suffer most severely. They were more or less affected in ten of the cases three of these being unaccompanied by any intestinal lesions. The disease is a Broncho-pneumonia, involving the air-cells and finer tubes, which become obstructed, owing to an enormous proliferation of the cells and exudation into the air-vesicles. In this way lobules are transformed into firm hepatized masses, and by the extension of the process whole lobes are affected. A peculiar feature in this Pneumonia, and one which gave an odd appearance to the sections, is the blocking up of the tubes in the inflamed areas with firm, perfectly white, cheesy-looking matter, composed of closely crowded corpuscles, which have either been pushed up from the air-cells, or have originated in the inflammation of the tubes. In nearly every instance these cheesy or caseous casts of the tubes could be squeezed out in the inflamed areas. Some of the lobules, owing to the great increase and over-crowding of cells, become pale, soft, and friable, either being converted into a uniform cheesy mass, or breaking down into small abscesses. Spleen.—No special affection of the spleen was noted, and it certainly exhibits in the pig a very different behaviour to that which we are accustomed to see displayed by this organ in the acute eruptive fevers of man. In only one instance was it swollen and enlarged—in the state commonly seen in Typhoid and other fevers, and described as Acute Splenic Tumour. 20 On the Pathology of the so-called Pig- Typhoid. Kidneys.—The kidneys also are but slightly affected. In most of the cases the cortical region was pale, owing to slight swelling of the tubules, but nothing was apparent microscopically beyond a granular condition in the epithelial cells. In the pelvis ecchymoses were noticed in several instances. Liver.—In Case 14 the liver was swollen, soft, dark in colour, the cells very granular and fatty. In the rest of the cases there was little or no evident change in this organ. It looked, in fact, remarkably healthy, and on examination the fatty infiltration of the cells was found normal. Blood.—Repeated examinations of this fluid were made in all the animals experimented upon, but no definite changes were observed. The red corpuscles tended to aggregate together into irregular clumps.1 No increase in the colourless elements; no foreign constituents. Conclusions. I. The so-called Pig-Typhoid is a disease sui generis, pre- senting anatomical and clinical features distinct from any other affection. II. It presents no analogies, either pathologically or clinically, with Typhoid Fever in man. III. Neither has it any affinity with Anthrax, as claimed by some Continental writers. IV. If we take the intestinal lesions as characteristic, the disease must be regarded, with Dr. Murchison, as dysenteric in its nature; although the cutaneous and pulmonary affections, as well as certain of the clinical features, meet with no parallel in human dysentery. Printed by Hazell, Watson, and Viney, London and Aylesbury. V Ueber die Entwickelung von Blutkorperchen im Knochen- mark bei pernicioser Anamie. Von Dr. Osier, Prof. a. d. McGill Universitat in Montreal. Der Fall, welcher aufser geringer Schmerzhaftigkeit des Brust- beins nichts Besonderes darbot, betraf ein 20jahriges Madchen. Das Blut zeigte viele Microcyten und grofse unregelmafsige nicht kern- haltige gefarbte Zellen, keine Elementarkornchen (M. Schuj/tzk). Auf Letzteres weise ich besonders hin, weil dies bereits der 5. Fall ist, in welchem ich ihr ganzliches Fehlen bemerkte, wahrend sie bekanntlich bei anderen anamischen und cachectischen Zustanden reichhch vorkommen. In der Leiche war aufser mafsiger Fett- entartung von Herz, Leber und Nieren keine Abnormitat der Organe nachweisbar. Das Mark des rechten Femur, Sternums und der Rippen war von gallertiger Consistenz, nicht fettig, tief rot gefarbt, genau so wie Milzpulpa; dasjenige des Radius war im Centrum fettig, nach den Endpunkten hin rotlich. Die fortgesetzte mikroskopische Untersuchung (Hartnack IX. und XVI.) zeigte folgende Formen: 1. gewohnliche grobkornige mit deutlichem Kern versehene Markzellen von 0,01000—0,01535 Mm.; 2. kleinere Markzellen von 0,00411—0,00588 Mm., deren Proto- plasma weniger kOrnig, als bei den grofseren Zellen war; 3. farblose Zellen von der Grofse der gewohnlichen Markzellen und noch dariiber mit homogener Substanz und feinkornigen Kernen. Dies sind keine in Blaschen umgewandelte Markzellen; das Protoplasma ist hell, durchscheinend gleich dem Ectosarca vonAmoben. Der Unterschied zwischen ihnen und den hie und da im Mark vorkommenden Blaschen ist deutlich. Die Kerne sehr grofs, oft undeutlich, aber mit kor- nigen nicht scharf abgegrenzten Randern. Sie befanden sich zwischen den grofsen Markelementen und mafsen 0,01333—0,02333 Mm.; 4. kernhaltige rote Blutkorper in grofserZahl (8—10 in einem Gesichts- feld von IX. Oc. 3). Sie zeigten folgende Verschiedenheiten: a) aufserst blasse Form, von den unter 3. beschriebenen Formen unter- schieden durch Farbung des Protoplasmas, die oft so fein war, dass sie nur durch Vergleichung mit ganz farblosen Korperchen entdeckt werden konnte; einige waren selbst noch grofser, als die eben be- schriebenen Formen. Abgesehen von der Farbung konnte man keinen Untersehied entdecken und sich leicht uberzeugen, dass es keine Blaschen Avaren, die dnrch Imbibition sich gefarbt hatten, denn das Protoplasma zeigte ein gleichmafsiges, dunkelkornigos Aus- sehen, und zeigte aufserdem sehr ausgesprochen jene den roten Korperchen so eigcntumliche Biegsamkeit und Elasticitat. Ab und zu fanden sich einige wenige Kornchen in dem Zellkorper. Die Kerne waren grofs, oft 2, zuweilen 3 in einer Zelle. Einige der Kerne hatten ,, dumb-bell" Form, sie waren offenbar in Teilung be- griffen, denn die Kerne waren schon geteilt. Ihr Durchmesser war 0,015—0,025, der der Kerne 0,00833—0,01333; b) tief gefarbte Kor- perchen, die gewohnlichen ,,Uebergangsformenl\ Die Mehrzahl der- selben war grofs, zwischen 0,01—0,01941 Mm., die Kerne kornig, excentrisch, aber selten aus dem Zellkorper hervortretend und im Mittel 0,0047—0,00941 messend. In einigen waren statt des Kernes einige undeutliche Kornchen und in 2 tiefgef.irbten, welche 0,015 bis 0,01838 mafsen, konnten keine Kerne entdeckt werden; c) viele dieser tiefgefiirbten Korper waren kleiner, rund oder etAvas elliptisch mit blaschenartigem Kern, der in machen doppelt conturirt erschien. Gelegentlich Avaren 1 oder 2 kleine scheibenformige Korper im Innern dieser Zellen zu sehen, zmveilen im Centrum des blaschen- formigenKerns. DerDurchmesser dieser Formen betrug 0,01, der der Kerne 0,00500. Oft Avar es unmoglich, zu erkennen, ob ein Kern in diesen Korperchen, welche zum Teil scliAver von den grcifseren gewohn- lichen Blutkorperchen sich unterscheiden liefsen, vorhanden war oder nicht. Der Durchmesser derjenigen, in Avelchen kein Kern erkennbar Avar, schwankte von 0,00824—0,00941; 5. gewohnliche rote Blutkorperchen, viele grofs elliptisch oder sehr unregelmafsig gestaltet, jedoch immer abgeplattet, von mafsiger Farbung, 0,0047 bis 0,01 messend. Microcyten in geringer Zahl und Aveniger, als im Blut selbst, oder in der Milz, 0,00176—0,00353 messend; 6. Zellen, die rote Blutkorperchen enthielten, in mafsiger Zahl. Myeloplaxen fehlten ganzlich, ebenso die CiiARCOT'schen Krystalle, selbst als das Mark schon in Zersetzung uberging. Bei keiner fri'iheren Untersuchung von Knochenmark im ge- sunden oder kranken Zustande bin ich einer solchen Reihe von Ent- Avickelungsformen begegnet, AArie hier. In 2 anderen Fallen perni- cioser Anamie, in 2 Fallen von Leukamie, 1 von Pseudo-Leukamie, und 2 von tuberculosen Affectionen (Phthisis und tub. Peritonitis) Avar das Mark hyperplastisch und zeigte stets mehr oder Aveniger zahlreiche kernhaltige rote Korperchen, aber die unter 3. und 4c. oben beschriebenen Formen konnte ich nicht entdecken. Sie schei- nen zAvischen Markzellen und kernhaltigen roten Zellen einerseits und letzteren und geAvcihnlichen roten Blutkorperchen andererseits zu stehen. In der Tat stimme ich vollstandig Nkoia>n l) bei, Avenn er sagt: „Die Beziehung der kernhaltigen roten Blutzellen als „Ueber- gangsformen" ZAvischen farblosen und farbigen Elementen involvirt aber eine Hypothese liber ihren Ursprimg, in Bezug auf Avelche ich *) Arch f. mikr. Anat. XII. S. 796'. mich friiher vielleicht mit zu grofser Zuversichtlichkeit gejiufsert habe und bei deren Beurteilung neuere Untersuchungen mir grOfsere Reserve auferlegen." Und neuerdings sagt derselbe2), dass es nicht umvahrscheinlich ist, dass die EntAvickelung der kernhaltigen roten Korperchen unabhangig von den farblosen Markzellen sei — ein bemerkenswertes Zugestandniss mit Riicksicht auf fruhere positive Angaben fiber denselben Punkt3). Die Befunde im vorliegenden Fall begiinstigen die Ansicht, dass eine UmAvandlung der farblosen Markzellen in rote Blutkorperchen stattfindet, Avelche durch Degeneration der Kerne und Verdichtung des Zellprotoplasmas schliefslich in die geAVohnlichen Blutscheiben umgewandelt Averden. Ich halte dies Avenigstens filr den einzig ver- niinftigen Schluss, der aus der beschriebenen Reihe zu ziehen ist. Die Bedeutung dieser Veranderungen aber fur die pern. Anamie ist noch keineswegs klar. Ist die Veranderung des Marks Ursache und Ursprung der Krankheit und giebt es Avirklich Falle von Pseudo- leukemia medullaris? Diese Fragen Averden erst mit fortschreiten- tlrr Erkenntniss der Function des Knochenmarks und seines Ein- flusses auf das Blut beantwortet werden. *) Berliner klin. Wochenschr. 1878, No. 10. 3) Arch, der Heilk. X. Sep.-Abdr. a. d. Centralbl. f. d. med. Wissensch. 1S7S. No. 2G. Godruckt boi L. Schumacher in Dorlin. Re-printed from '• The Canada Medical $ Surgical Journal" December, 1879. *-2 CROUP OR DIPHTHERIA, WHICH? By William Oslek, M.D., M.R.C.P., Lond. Professor of the Institutes of Medicine, McGill University; Physician to the Montreal General Hospital On Monday morning, Nov. 10th, 8.30 a.m , I was hastily sum- moned to the Infants' Home by a message that a child was dying. On arriving, I found Fritz, a Avell grown boy of 4| years, in a state of urgent dyspnoea, and rapidly becoming cyanotic. I was informed that the child had had a slight cold on Sunday, but had been about, and had taken his food as usual. In the evening the matron noticed that he was somewhat restless in his cot, breathed rather heavily, and had a u croupy" cough. ToAvards morning he became worse, and he was put in a warm bath, and had mus- tard applied, Avith considerable relief. At 7 a.m. he got worse, and they again tried the ordinary remedies, but without affording any relief. I found him in the state above mentioned ; breathing very laboured ; cold sweat on the forehead; skin livid; extreme restlessness : and on inspection of cbest, there was seen retrac- tion of lower zone and epigastrium. The child had had a some- what similar attack about three months before, and another last winter, and has ahvays been regarded as " croupy"—i.e., on taking cold had a cough with a peculiar " bark " or ring. A younger brother died of croup. Seeing that no time was to be lost, I got Dr. Shepherd to perform tracheotomy, Avhich afforded prompt relief; the breathing became quiet, and the natural colour was restored. Pulse full and strong. When the trachea was opened, we could see quite plainly a thin layer of false membrane on the posterior wall. After the operation, the fauces y o were thoroughly inspected, and appeared natural ; no swelling ; no exudation. There is no enlargement of cervical glands. For a couple of hours the child was easier. When seen at 1.30 p.m., respirations were hurried, 60 per min.; pulse, 140 ; and tem- perature high. At 5 p.m., condition the same. Tube was cleansed of muco-pus, but respirations continued very rapid. Colour good. Takes milk well. At 9 p.m., very restless ; res- piration, 55 ; pulse over 140 : skin hot and dry. Has passed a small amount of urine, but it had not been kept. Has been vomiting a good deal. Mr. Rogers kindly watched the child during the night; it Avas restless at times, and kept feverish, but seemed, on the whole, somewhat easier. At 9.15 am. was weaker ; pulse almost uncountable ; respirations over 60 ; tem- perature, 105°. Tube is clear. Unfortunately the nurse had, in spite of instructions, failed to keep any urine. Death occurred at 1.30 p.m. Autopsy.—Face suffused ; lips and finger-tips livid. In thorax, lungs do not collapse. Right side of heart and great veins gorged with blood. Pharynx, larynx, trachea and lungs removed together. Uvula and soft palate someAvhat suffused. Tonsils not enlarged, and of good colour: at upper and back part of left there is a small greyish-white patch, 2 X 3 m. ; near it are two open follicles, with a little exudation in them. In right organ, three follicles are filled Avith greyish-Avhite soft material. No membrane on pillars of fauces, or on upper surface of epi- glottis. Entire larynx is filled up with a greyish exudation, which lines the under surface of epiglottis, the true and false chords, and the arytenoid cartilages, completely closing the rima. It can be lifted as a definite membrane, tolerably com- pact, but loosely composed on its surface. Thickness about 2 m. From the larynx it extends into the trachea as a continuous sheeting as far as the incision. The tissue beneath it is deeply congested and somewhat granular-looking. From the lower margin of the tracheal Avound, it extends down the tube into the bronchi, and can be followed in the latter to branches of the third degree. The membrane here is not so consistent, and is more difficult to remove as a continuous sheeting. Mucosa 3 heneath deeply injected. Lungs, crepitant in front, dark- coloured, collapsed and congested behind. At hinder part of right upper lobe the tissue is very firm, and in spots granular— pneumonic. Heart; right chambers gorged with blood and jelly-like clots ; great veins distended. Spleen a little enlarged ; pulp not very soft. Kidneys much congested : on section, blood drips from the surface. No special alteration of substance noticed. Nothing of note in gastro-intestinal tract. Microscopic examination of grey patch on right tonsil showed a network of fibrils, Avith numerous round cells, leucocytes, and granular debris. The exudation in follicles of left tonsil appeared softer, and was made up chiefly of very closely-packed cor- puscles. In the membrane from the larynx the same elements were found : meshes of fibrin-fibrils, large and loosely arranged, with round cells and epithelial flakes. Here and there groups of micrococci were met with, and some of the cells contain isolated forms. They are not, however, specially abundant, and the same elements occur in numbers on the fur of the tongue. The kidney epithelium was granular, and in cortical tubes swollen. No micrococci found. The capillaries were very full. Remarks.—Croup or diphtheria, Avhich ? I believe it to be the former, for the following reasons : (1.) The sporadic nature of the case ; the child had not been exposed to contagion, and no cases subsequently developed in the Home, although the conditions for the spread of the disease are most favorable.* (2.) The mode of attack, and locality first affected. Up to a couple of hours prior to the first symptoms the child appeared in his usual health, though suffering from a slight cold. The difficulty in breathing came on very early, and was the promi- nent feature throughout; the larynx was primarily affected. Before the effect of the chloroform had passed away after the operation, the fauces and tonsils were most carefully examined by Drs. Ross, Shepherd and myself, and no membrane seen, not • Up to the time of the operation the child was in the same room with about a dozen children, from 3 to 5 years of age. Subsequently, he was isolated. 4 even injection. (3.) The absence of swelling of the neck and fetor of breath, symptoms rarely missed in severe cases of diph- theria. (4.) The situation of the exudation ; primary laryngeal diphtheria is very uncommon. On the other hand, the slight extension in the tonsils in this case does not invalidate the croup view, as in this disease the membrane may also occur in the fauces. The extension of the membrane into the tubes does not tell much either way ; it is seen in both affections. In 17 cases of diphtheria, of which I have post-mortem records, extension of the membrane in the trachea and bronchi occurred in eight of them. (5.) The absence of signs of septic poisoning at the post- mortem. The blood was clotted and natural-looking, no staining of walls of vessels or of tissues about them ; only the usual con- ditions met with in death from asphyxia. (6.) The absence of micrococci in internal organs, especially the kidneys. Their presence in the exudation in larynx does not go for much, when the same elements occurred on tongue. They were not in the same numbers as in diphtheria, in which they swarm in the mem- brane. (7.) The fact that the child had been subject to " croupy" attacks, two of which were accompanied with dyspnoea and lividity. A younger brother also died of croup. Croup I believe to be a non-specific inflammatory affection of the laryngo-tracheal tract, accompanied with a membranous exu- dation. It is never contagious, is usually sporadic, and rarely occurs in adults. Kills by asphyxia ; never by blood-poisoning. Is a local disease, the constitutional manifestations being those of impeded respiration ; is never followed by paralysis. There is never fetor of breath, or swelling of glands of the neck. To this picture the above case corresponds in its essentials. tv CASE OBLITERATION OF VENA CAVA INFERIOR, GREAT STENOSIS OF ORIFICES OF HEPATIC VEINS. BY WILLIAM OSLER, M.D., M.R.C.P, PROFESSOR OF THE INSTITUTES OF MEDICINE IN M'GILL UNIVERSITY, MONTREAL. (From the Journal of Anatomy and Physiology, Vol. xiii.) EDINBURGH: PRINTED BY NEILL AND COMPANY. 1879. CASE OF OBLITERATION OF VENA CAVA INFERIOR. The causes of obliteration of the inferior vena cava in the great majority of cases have been either compression or the extension of thrombi from other veins. A few cases are on record in which the closures could not be referred to either of these causes, and have led some authors to conclude that the vena cava may be the seat of a primitive phlebitis. The occlusion, also, in the majority of instances has affected the vessel below the entrance of the hepatic veins, the cases of Baillie1 and Reynaud2 being the only ones in which these are reported to have been in- volved. The following case bears, in an interesting manner, upon both these points, inasmuch as the obliteration can neither be traced to compression nor to the extension of a thrombus, and had pro- bably lasted some years, the vein being converted into a firm fibrous cord; and the hepatic veins, where they enter the cava, are so far involved as to be reduced to the condition of insigni- ficant orifices. In addition, the case presents features of ana- tomical and clinical interest. For the following clinical notes I am indebted to Dr Johnson Alloway, of this city, under whose care the patient was during his last illness :— 1 Quoted by Hallett, Edinburgh Med. and Surg. Journal, vol. lxix. 1848. 2 Quoted by Hallett, 1. c; and Peacock, Medico-Chirurgical Transactions, vol. xxviii. 4 PROFESSOR WILLIAM OSLER. History.-—J. (Jr., set. 24. " Mother died of cholera, father of ague. Brothers and sisters (two of each sex) strong and well. Has never been a very strong man, always pale and anamie. When a child, was backward in his nutrition, and always con- sidered the delicate member of the family. Was originally a carpenter by trade, but for the past three years has been em- ployed as a packer in a warehouse, a position where he had a good deal of hard work. Has never had syphilis. The only serious illness of which there is any record is an attack of pleu- risy about thirteen years ago, which very nearly proved fatal; side not known. Has suffered from piles. For some years past his legs have been more or less swollen, but he could not say exactly for how long, nor had he suffered any serious in- convenience. During the past three years I have attended him at intervals for dyspepsia and diarrhoea, and once for a severe attack of facial neuralgia. " On December 12th, 1878, he came to me complaining of diarrhoea and intense pain in the lower bowel during passage of stools. On examining rectum, mucous membrane much con- gested and veins enlarged. Two weeks ago, when running up stairs, a varicose vein burst in one leg, and since then he has worn an elastic stocking. For nine days he was confined to the house with symptoms of gastric and intestinal catarrh, only occasional vomiting; once or twice a little blood was noticed— never any blood in the stools. On the 21st (Saturday) he was so much better, that I told him he might go to work on Monday. He was, however, not so well on the following day, and I was sent for, but could not go. On Monday I found that he had had a return of the symptoms, and he complained of his belly being swollen. On examining him (it was for the first time), I found a small amount of fluid in the flanks, the legs were a good deal swollen and pitted as high as the hips, the oedema extending round to the lumbar region. During the next few days the ascites increased rapidly. A distinct bruit was heard over the heart, and is described in a note below * by Dr Howard, 1 "A loud presystolic murmur exists over a large area, of maximum intensity, in the lower sternal region, near xiphoid cartilage ; it is very distinct just inside of left nipple, and faintly audible in left lateral region, and distinctly audible in left vertebral groove, opposite the xiphoid cartilage. The murmur is not audible at the base of the heart where the cardiac sounds are normal. Apex beat at nipple CASE OF OBLITERATION OF VENA CAVA INFERIOR. 5 who saw the patient in consultation with me. At this time he had the appearance of a man suffering from cardiac dropsy. By the 28th the abdomen measured 41 inches round the umbilicus, and to give relief, paracentesis was performed, and about eight quarts of serum removed, of a greenish hue. The urine during the early part of the illness was diminished in amount, not more than 8 to 10 oz. in the twenty-four hours, but afterwards the quantity rose to about 30 oz. daily. On four separate occasions it was tested for albumen, but none was discovered. The diarrhoea had ceased, but he occasionally vomited. On January 6th, nine days after the first tapping, the fluid had reaccumu- lated—measurement at umbilicus, 42 inches. Areins of abdomen distinctly marked, and could be traced like rivers on a map; swelling of the legs not so great. He was again tapped, and over ten quarts of fluid removed. After the operation the margin of the liver could be felt—it was extremely hard. He complained of no special pain during the illness, only of the distress caused by the fluid. Deep pressure over the pancreas was painful, and it was thought that a hard mass could be felt in this situation. The fluid quickly reaccumulated. On the 12th, there was considerable pain over the distended abdomen; symptoms of collapse supervened, and it was thought that peritonitis had set in. The heart's action gradually failed, and he died on the 15th. The swelling of the legs had diminished greatly during the last days of his illness. After death, for the convenience of the friends, the belly was tapped, and about eight quarts of slightly turbid fluid removed." Autopsy, twenty-five hours after death. Body that of a man rather under the average size. Very little fat, but not emaci- ated. Skin of upper part of thorax and in dependent regions livid from post-mortem discoloration. Belly is flat and flaccid, about two gallons of fluid having been removed after death. Legs moderately swollen; veins distinct and prominent, but not remarkably enlarged—some are varicose. Scrotum and penis slightly swollen. Superficial veins of abdomen enlarged to a line, rhythm and impulse normal. Jugulars neither distended nor pulsating. While quite puzzled as to the source and cause of the murmur, I supposed it tc be due to mitral valve disease. No murmur existed along the abdominal aorta." Dr Alloway states that after the tapping the murmur diminished or entirely dis- appeared. 6 PROFESSOR WILLIAM OSLER. moderate degree—scarcely so evident, perhaps, as they were during life, according to the description of the medical attendant. Abdomen.—Entire peritoneum of an intensely livid red colour, from injection of capillaries and veins, gxxx of turbid, brown- coloured fluid remain in the flanks, and a few flakes of lymph float in it. The general surface is, however, smooth and glisten- ing—not rough and dimmed, as in peritonitis. The walls of the intestines are relaxed, sodden, and heavy, and the mesentery is also very thick. Thorax.—No fluid in pleurse; a few adhesions at right apex. Heart, of average size. All the chambers contain coagula; those in the ventricles colourless, firm, closely interlaced with columnar carneae, and extend into the arteries. Right auricle distended with a firm gelatinous clot, which extends into both cavse. Auriculo-ventricular orifices not dilated; all the valves healthy. Muscle substance of good colour. Aorta normal—no atheroma. Lungs, crepitant throughout; collapsed at bases, otherwise healthy. Spleen, double the normal size, very firm, and cuts with great resistance. Capsule not thickened. Pulp dense, trabecular and vessels prominent. Kidneys are large, exceedingly dense and hard to the touch. Capsules peel off with difficulty, portions remaining on the organs. On section, vessels of both cortices and medullse very full, and the veins about bases of pyramids remarkably large. Ureters and bladder natural. Pancreas is unusually dense and firm (so much so, that when first examined it was thought to be the seat of scirrhus). On section, the induration is found to be due to the great increase of fibrous-tissue about the acini. Liver is increased somewhat in size, feels heavier than natural, and is very hard and firm to the touch. Surface is not perfectly smooth, but is mapped out into irregular slightly-projecting areas, which are most distinct towards the anterior border. The capsule is not thickened, nor are there any cicatrices. About the anterior half of the organ, on both surfaces, the capsule is studded over with innumerable small, semi-opaque bodies, ranging in size from a grain of sand to a millet-seed. CASE OF OBLITERATION OF VENA CAVA INFERIOR. 7 They are little fibrous outgrowths from the capsule, and pre- sented a remarkable appearance on the dark brown surface of the organ. The substance cuts with resistance, and the lobules are seen to be very distinctly marked, of good colour, not fatty, and the central veins in many unusually promiuent. There is considerable excess of fibrous tissue in the organ, chiefly about individual lobules and along the course of the portal canals. A striking feature on the section is the number and size of the hepatic veins. Gall-bladder is full of bile; ducts natural, common bile-duct large and patent. Stomach large, and contains the remains of food, together with a thick, dark-coloured mucus. The whole lining membrane is of a deep red colour, about the cardia almost black, from the over- filled capillaries and veins. In the pyloric region there are several large areas of a dark slate-grey colour, and ten to twelve small superficial erosions, with dark bases. The membrane appears of average thickness. Sub-mucous veins are enlarged and pro- minent, particularly on the lesser curve and about the cardia. Small Intestines very dark in colour; walls relaxed and sodden, but the serous coat is smooth. Mucosa is uniformly dark and congested. Large Lntestines contain a small quantity of farces; walls are dark, mucous membrane congested. Numerous large veins about the caput cceci and along the sigmoid flexure and rectum. Mesentery is heavy and coarse-looking. Peritoneum smooth, not so dark as over bowels. On section, veins large; fat every- where traversed by small vessels, and the lobules much more distinct than usual. The glands are dark in colour, but not apparently enlarged. Venous System.1 — Superficial veins of abdomen and thorax not specially prominent, not nearly so much so as in many cases of cirrhosis. Veins of the legs enlarged, a few varicose, but here also the distension was by no means remarkable. 1 The unfavourable circumstances under which the post-mortem was performed did not permit of so thorough an examination of the veins as might have been desired, nor was it until towards the close of the inspection that the nature of the lesion was suspected. The parts from which the sketch was taken were removed and subsequently dissected. 8 PROFESSOR WILLIAM OSLER. Vena Cava inf.—From the right auricle to the diaphragm natural-looking, and filled with a large consistent clot. Orifice looks of normal size. Lntima is clear, and the other coats are not thickened. At the diaphragm this portion of the vein terminates in a sort of cul-de-sac, the floor of which is made up of cicatricial tissue, and on either side two small orifices open into it—the hepatic veins. From this point to the entrance of the left renal the vein is represented by a dense fibrous cord, 62 mm. in length, narrow at the middle (10 mm.), wider at either end, just above the renal measuring 18 mm. The central part of the cord lies between the lobus Spigelii and right lobe, and has tolerably firm adhesions to the liver substance, while at either end the connections are not so close. On section it presents a dense, fibrous aspect, with a peculiar greyish translucency, and no trace of blood-colouring matter. It is solid throughout, and apparently composed of bundles of connective-tissue. A tiny vein penetrates it from below for the distance of 12 mm. The surface of the right lobe in the neighbourhood is rough and thickened, but not more so than is usual at the site of attach- ment to the diaphragm; the tissue of the lobus Spigelii is perfectly natural-looking, even to the very margin of the cord. The obliteration terminates at the left renal, and below this the cava measures 40 mm., and then gradually widens to the bifurcation, above which it measures 70 mm. in circumference. The vessel is opaque, the walls three or four times the normal thickness, and externally marked by a longitudinal striation, which is specially distinct at the upper part. The intima is thickened and rough, and above presents one small calcareous plate; in the middle portion elevated lines run in different directions, giving a reticulated appearance to the membrane, while at the Difurcation there are several sharply-circumscribed atheromatous swellings. The vessel presented the following branches:— Left Penal, which forms a large trunk, 30 mm. in circumference, with thick, opaque walls. It enters the cava somewhat obliquely. A vessel, nearly as large as itself, enters at the posterior superior border, but, unfortunately, its further course was not traced. A second still larger branch enters from below, at right angles, and is described hereafter. CASE OF OBLITERATION OF VENA CAVA INFERIOR. 9 Right Renal, not so large as the left, enters the cava nearly at the same level. Right Spermatic, forming a large branch, 22 mm. in circum- ference, which empties a little below right renal. Lumbar, consisting of three or four greatly dilated vessels. Only three orifices were found in the posterior wall of the cava, but the veins on either side may have united, as is not in- frequently the case. These branches as they pass out over the vertebrae are remarkably large; the little finger could be readily inserted for some distance into them. lilacs, considerably dilated, the left branches rather more than the right. A large vein, almost equalling in size the vena cava (measur- ing 32 mm.), extends along the left side of the aorta from the renal to the iliacs. Above, it enters the left renal just before that vessel crosses the aorta, below, it divides into two branches, one of which, the smaller, somewhat horizontally placed, enters the left common iliac, just below the bifurcation of the cava, the other passes down for a short distance and opens into the external iliac. Posteriorly, this vessel receives four moderate-sized veins. Pelvic Veins are all enlarged and prominent, particularly those about the rectum—haemorrhoidal plexus. Diaphragmatic Veins very much distended, forming a close net- work with the veins in the coronary and lateral ligaments of the liver, and also with those of the lesser curve of the stomach. (Esophageal Veins form a close plexus, which receives many large veins from the cardiac end of the stomach, all the loose connective-tissue about the mediastinum above the diaphragm is exceedingly rich in venous branches. Azygos Major is immensely distended, equalling the vena cava inf. in size, measuring about the centre of its course 62 mm. in circumference. The walls are very thin, but healthy, and the diameter increases a little near the sup. cava, into which it opens by a large orifice, admitting readily the index finger. The inter- costal veins, particularly the lower ones, are very much enlarged. Azygos Minor is also large, but not more than one-fourth the size of the azygos major, into which it empties at the usual site Unfortunately, its connections with the lumbars could not be traced. 10 PROFESSOR WILLIAM OSLER. Int. Mammary Veins are moderately enlarged. Vena cava sup. and its branches—so far as they were traced— present nothing unusual. It did not appear much dilated where it enters the auricle. Portal System.—Mesenteric vein and all its branches are dis- tended with blood, even to the smallest vessels. Splenic vein also large. Portal vein measures 33 mm. in circumference, right branch admits the little finger, walls healthy. Branches in the liver do not appear much dilated. Hepatic Veins.—In many of the lobules the vence centrales are distended, and one of the most striking features on the cut section is the number and prominence of the hepatic veins of all sizes. Two main branches, one in each lobe, pass obliquely towards the cava, enlarging greatly in their course, and finally open by the two small orifices already referred to. Immediately behind the openings the veins are much dilated, but the walls are thin and not atheromatous. The right orifice measures 9 mm. in circum- ference, and its margins are formed by fresh-looking connective- tissue, which at the posterior part forms a sort of imperfect valve. The opening of the left vein is smaller, 7 mm., and situated at the bottom of a small funnel-shaped depression of the cava. Microscopical Examination. Obliterated Vein.—Transverse sections of the fibrous cord show (1), an external zone, 3 mm. in width, separated from the central part by a well-marked line of elastic tissue. This, apparently, represents the vein wall, and is made up of fibrous and elastic tissue, the former in coarse bundle's, often enclosing irregular areas,^which appear to contain transversely-cut muscle bundles; the latter in fine fibres, running in different directions and form- ing at the inner part a dense interlacement. (2) The central portion, composed of closely-compressed bundles of connective- tissue, which even in thin sections, do not present any evident structure, but are homogeneous, staining deeply and uniformly in carmine. In places it is more loosely arranged and distinct, fine fibrils can be seen, often interspersed with fine colourless granules. No crystals or melanin grains, nor are there any traces of an old blood-clot. The cut ends of a few small vessels are seen on the sections. CASE OF OBLITERATION OF VENA CAVA INFERIOR. 11 Liver.—Sections under a low power have a very porous appearance from the number of enlarged veins of all sizes up to half a millimetre. The majority of these are branches of the hepatic vein, but some with thick walls are portal. The intra- lobular veins do not appear so much enlarged, proportionately, as the larger branches. Narrow zones of fibrous tissue surround the lobules, in places broad bands are seen. The degree of cirrhosis is not appreciated until thin sections are examined, when it is seen that the connective-tissue within the lobules is very much increased, extending between the columns of cells and surrounding small groups or even isolated cells. It did not seem more advanced in the central parts of the lobules than at the periphery. The liver cells are granular, not fatty, but in many places compressed and atrophied. In the vicinity of the larger vessels they contain pigment. The spaces between the cords of liver cells appear large, but not to the same degree as in many cases of red atrophy of this organ. Kidneys.—Interstitial tissue between the tubules much in- creased in thickness. Renal epithelium a little more granular than normal, but not fatty. Tubules in cortex not swollen or obstructed. The condition of the Malpighian bodies is the most striking feature in the sections, fully one-half of them being atrophied. The healthy ones are large, capsules somewhat thickened, capillary tufts prominent, and individual loops dilated. The atrophic ones are not one-third the size of the others, stain deeply in carmine, and are surrounded by a very thick fibrous sheath, with the fibres concentrically arranged. The central tuft is reduced to a granular or homogeneous body, often containing oil drops. They can be seen in all stages of degeneration. The small arteries are thickened, particularly in the middle coat. Pancreas.—The excessive induration is due to an unusual amount of fibrous tissue between the acini; the cells do not appear atrophied. Remarks.—The question naturally arises in reading the report of this case, Could the obliteration have been congenital? The absence in the history of any acute illness which may be supposed to correspond to the date of occlusion, and the general backward- ness of nutrition, favour such a view, but there is nothing else 12 PROFESSOR WILLIAM OSLER. to support it. Whatever may have been the primary cause of the obliteration, it must have led to the formation of a thrombus, the final transformation of which is represented by the cord-like structure described above. In the absence of any source of com- pression, or of any pathological state in the branches, we are driven to the conclusion that the initial changes have been local, and confined to the part of the vessel affected. It is difficult, however, to conceive of a localised phlebitis in a trunk like the inferior cava, and still more of an acute process, the effects of which would have been limited to the short distance found occluded. A chronic obliterating endophlebitis is not, so far as I know, recognised. In the remarkable case reported by A. Robin,1 the first symptoms followed violent and prolonged exertion, being ushered in with "fever, delirium, increase in size of abdomen, with violent lumbar and abdominal pain." There is no history, in the case under consideration, of any severe illness except pleurisy, during which, so far as can be ascertained, there was no dropsy. The only possible connection with this attack might have been copious right-sided exudation, with great dislocation of the heart, when the inferior cava might have got a twist (Birch-Hirschfeld). From the state of the vein at the site of the obliteration we can infer that the obstruction has been of some duration, but how long it is impossible to conjecture, for such a dense, fibrous cord, when once formed, might remain unaltered for years. The atheromatous and thickened state of the cava below the renals must be regarded simply as an expression of the strain to which this part of the vein had been subjected. The great increase in the connective-tissue of the liver and other organs is what might have been expected, and is in itself evidence of the long-standing nature of the obliteration. The stenosis of the hepatic veins has affected the portal circu- lation in much the same way as ordinary cirrhosis, interfering with the free flow of blood through the liver, and keeping the abdominal viscera in a condition of chronic congestion, the effect of which is very evident in the induration of the spleen and pancreas. The state of the liver is of interest as showing, in an exaggerated degree, the effects of congestion in the hepatic 1 Archives de Physiologic, 1874, p. 897. CASE OF OBLITERATION OF VENA CAVA INFERIOR. 13 veins, presenting also certain peculiarities. The development of fibrous tissue is very much greater than is usually met with in the most chronic cases of heart disease or emphysema, amounting to a tolerably advanced cirrhosis. The new growth is much more intralobular than in the common form of this disease. Contrary to what might have been expected, the organ was not in an advanced state of red atrophy. The central veins of the lobules did not appear so distended as the secondary and tertiary branches of the hepatic veins. In obliteration of the inferior cava the collateral circulation is usually carried on by the vena azygos, by means of its extensive communications with the lumbar and renal veins, being some- times assisted by the superficial and deep veins of the abdomen and the anastomoses of the haemorrhoidal plexus with the hypo- gastric and inferior mesenteric veins. In the present instance, also, this vein has been the main channel for the conveyance of the venous blood of the lower part of the body to the heart, and has, in addition, provided accommodation for a considerable proportion of the blood of the portal system. This is one of the most interesting features of the case. It certainly might have been expected, with so serious an obstacle to the flow of the portal blood as was offered by the stenozed orifices of the hepatic veins, that the superficial veins of the abdomen and thorax would have attained a maximum degree of distension. In Baillie's case, no mention is made of the state of the portal cir- culation ; in that of Reynaud's the right branch of the hepatic vein was plugged. Veins of abdominal walls very large. In the clinical report the superficial cutaneous veins are stated to have been enlarged, but I learn from Dr Howard that at the time of his visit the enlargement was by no means remarkable, and this agrees with the condition found post-mortem. Nor were the deep abdominal and thoracic veins very much increased in size; and we must, therefore, suppose that the circulation has been carried on chiefly by the azygos. Part of the blood from the lower extremities and pelvis, entering the inferior cava and the large vein lying parallel to it, would find its way through the lumbars, the remainder, with that from the kidneys, would pass to the azygos through the communicating branches with the renals, aud chiefly through the large vessel arising from the upper and 14 PROFESSOR WILLIAM OSLER. back part of the left renal, which, although its course was not traced, from its position and direction, must be regarded as a feeder of the azygos. The vertebral and dorsal cutaneous veins may have participated in carrying on the circulation. It is not easy to determine the nature of the large vessel which passes from the iliacs on the left side along the aorta to the renal. The situation corresponds to the left spermatic, which has in several cases been found excessively dilated, and no other vein corresponding with the spermatic was found on this side. But why the free communication with the iliacs ? The spermatic may have originally sent small branches to the iliac, which have subsequently dilated to such an extent as to appear as the direct continuation of the vessel. It was sug- gested, as some lumbar branches open into it, that it might be the azygos minor, which Henle1 figures as connected with the common iliac; but, if so, why should it empty into the left renal ? The situation and connections correspond exactly with a small vein, mentioned by Hallett2 in his interesting paper, " which passes and establishes a communication between the common iliac vein and renal vein," and which, though not always present,, may be considered normal. In the case of obliterated vena cava which he reports, it was enlarged and joined the ovarian vein. From the absence of symptoms of obstruction in the portal system up to a short time before the fatal illness, we must conclude that a collateral circulation of sufficient activity had been established to compensate for the greatly narrowed streams from the hepatic veins. So far as was ascertained, this had taken place through the diaphragmatic and oesophageal plexuses, both of which were greatly distended. The veins of the falci- form and round ligaments were moderately enlarged. It is not probable that any assistance was afforded to the portal system by the hsemorrlioidal veins through their connections with the inferior mesenteric. The clinical history of this case, though in many respects in- complete, is very remarkable. In the first place, it must be admitted that the obliteration had lasted for some time, and did not occur during the last illness. The cord-like condition of the 1 Anatomie des Mcnschen, Gefasslehre, p. 336. 2 Loc. cit. CASE OF OBLITERATION OF VENA CAVA INFERIOR. 15 obliterated part, the degeneration of the vein in the neighbour- hood, the enlargement of the collateral branches, and the fact that for five or six years his legs were slightly swollen, point to an obstruction of long duration. Cases of occlusion are reported1 in which life has been prolonged and tolerable health enjoyed for many years, an active collateral circulation obviating the effects of the obstruction; and among such this case may be reckoned. A difficulty here arises with respect to the hepatic veins. Are we to suppose that the narrowing to which their orifices have been subjected is of the same date as the closure of the inferior cava ? or have the contracting fibrous cord and sub- sequent changes induced the degree of stenosis met with at the autopsy ? To suppose that the extreme narrowing of these veins is of quite recent date would harmonise well with the clinical history and explain the rapid ascites, but the cirrhotic state of the liver, and the evidence of chronic congestion in the portal system, as well as the absence of recent changes about the hepatic veins, suggest an opposite conclusion. It is not easy to give a rational explanation of the sudden development of the ascites. From the 12th to the 23d of December the patient suffered from symptoms of gastric and intestinal catarrh, and it was only on the latter date that swell- ing of the abdomen was detected. From this time until his death on 15th of January, the ascites became the prominent symptom, twice necessitating tapping the abdomen, each time with the removal of a large quantity of fluid. There was nothing in the condition of the portal and hepatic vessels to indicate any recent change which would explain the rapid accumulation of fluid, so that we must seek for the cause either in the blood or the state of the vascular walls. It may be that the attack of diarrhoea, which lasted from the 12th to the 20th, induced a depraved condition of the blood, or acted upon the portal vessels in such a way as to bring about that increased permeability of the walls, which, according to Cohnheim,2 is the prime factor in dropsy. However that may be, a parallel example is presented by certain cases of cirrhosis of the liver, in which a dropsical con- 1 Robin, Loc. cit. 2 Virchow's Archiv. Bd. 69. AUgcmeine Pathologie, p. 375. 16 PROFESSOR OSLER—OBLITERATION OF VENA CAVA INFERIOR. dition may develop with remarkable rapidity, and even without the common premonitory symptoms of gastric and intestinal catarrh. Such a case has recently been under the care of my colleague, Dr Ross, in the General hospital: the patient, a hard drinker, continued at work, and perfectly well (according to his own account, and after most careful questioning), up to Decem- ber 23d. From this date dropsy of the legs and belly came on rapidly. On January 24, haematemesis set in, from which he died on the 27th. The liver presented an extreme degree of cirrhotic contraction. The absence of albumen in the urine is a point worthy of note, and may, perhaps, be taken as evidence that the renal circulation was not additionally embarrassed during the illness. Reynaud,1 to whose elaborate article I am much indebted, is the only author who dwells upon this symptom, stating that it might be useful as a diagnostic sign of the situation of an occlusion, whether above or below the renals. And lastly, an interesting clinical feature of the case is the murmur described by Dr Howard. There was nothing found in the condition of the heart to account for it. Of possible sources the following suggest themselves:—(1) The vena azygos, though I am not aware of a murmur ever having been described in con- nection with this vessel; (2) The thoracic portion of the inferior vena cava, which formed a sort of appendage from the auricle, and into which the blood might be forcibly driven during the auricular systole, being unopposed by any powerful upstream in the cava. Explanation of Plate. (View from behind.) a, Obliterated inf. cava; B, orifices of hepatic veins ; c, left renal; d, large branch which opens into it at the upper and back part; e, supplementary vein lying parallel to inferior vena cava; /, right spermatic (represented by the artist as too far posteriorly); g, orifices of lumbar branches of inf. cava, and supplementary vein. 1 Nvwatu Dictionnaire de Medecine et de Chirurgie, art. "Caves." Jnuni of^lnafdPhvs. Vol. m, pi. iw. W 3»phul, Sel* F.Hufli, Lift.1 Eton? l/- TWO CASES OF STRIATED MYO-SARCOMA OF THE KIDNEY. By William Osler, M.D., M.R.C.P.L., Professor of the Institutes of Medicine, M'Gill University, Montreal. Tumours containing striped muscle fibres (Myoma strio-cellulare of Virchow; Rhabdomyoma of Zenker) are oncological curiosities. Between twenty and thirty cases are on record, the majority of which have been found in connection with the testicles or ovaries. Eberth1 first described a tumour of this nature in the kidney in 1872, Cohnheim2 a second in 1876, since which date four other cases have been recorded by Marchand,3 Lands- berger,4 Kocher and Langhans,5 and Huber.6 All the cases occurred in children from 7 to 39 months old. The tumours were large, the weights' ranging from 587 to 5500 grammes. In one instance both organs were affected. In" two there were secondary masses in the liver, in one of which muscle fibres were found. All of the tumours correspond very closely in histological characters, being composed of a sarcomatous basis of round cells, traversed by bands of firmer, fleshy tissue, in which the muscle fibres occurred. The following cases have come under my observation in the past two years :— Case I.—Striated Myo-Sarcoma of left kidney. Death with gastro-intestinal symptoms. Ccorge H., aged 19 months, patient of Dr Dugdale. Had been a healthy child. On March 23d, 1878, he was vaccinated in the morning, after which he appeared in his usual health. At two o'clock P.M., he began to vomit and have severe gastro- intestinal symptoms. They yielded to treatment, but the child sank and died at two o'clock the same evening. At the autopsy on the following day nothing unusual was found except a tumour 1 Virchow's Archiv, Bd. Iv. 2 Ibid, Bd. lxv. 3 Ibid, Bd. lxxiii. 4 Berliner Klin. Wochcnschrift, 1877. 5 Deutsche Zcitschr. f. Chir. Bd. ix. 6 Huber, Deutschcs Archiv. f. Klin Medecin, Bd. xxiii. 1878. VOL. XIV. Q 230 PROFESSOR OSLER. of the left kidney, which was removed and sent to me for exa- mination. Organ is enlarged and has the shape of a blunt pyramid, the convex border projecting, the inner surface, with the hilus, pre- senting a tolerably straight line, extreme length over outer border, from one end to the other, 16 centimetres. The capsule is thin, detaches easily, and a large white mass can be seen through the thin layer of cortex on the convex border. On section, the central part of the organ is occupied by a tumour measuring about 7 centimetres in each direction, broadest at the pelvis with which it is in contact, and gradually narrowing towards the outer border, where it is separated from the capsule by a layer of kidney substance 2 to 3 m. in thickness. At the upper and lower ends of the organ the cortex and cones are still to be seen though somewhat diminished in volume. In its growth the tumour has expanded the renal substance in such a way that a progressively diminishing layer covers it from the ends towards the centre. The mass is not encapsulated, but at the margins can be seen penetrating the kidney tissue, strands of which separate the advancing portions. The cut surface of the tumour is greyish-white, and has a porous spongy appearance, from the presence of small irregular spaces. Bands of translucent- looking tissue pass in all directions, crossing each other and dividing the substance into areas which are occupied by a soft granular substance. Some of the strands passing from the deeper parts are 2 m. in thickness. The pelvis and calyces are some- what compressed; the ureter opens directly below the centre of the mass, artery and vein normal. Case II.—Striated Myo-Sarcoma of left kidney. Sudden death from blocking of pulmonary artery and tricuspid orifice with sarcomatous thrombi dislodged from renal vein. C. S., female child, aged 3£ years, patient of Dr Finnie's. Had been ailing for about six weeks with gastric and intestinal symptoms, occasional vomiting, and obstinate constipation. Slight pain in abdomen, and on inspection a tumour was dis- covered in left hypochondriac region, just below the cartilage of the 8th rib. It was soft and apparently fluctuated. Child had not been confined to bed. On getting up one morning and STRIATED MYO-SARCOMA OF THE KIDNEY. 231 walking towards her mother's bed, she was suddenly seized with a " choking fit," and died in a few moments. Autopsy.—Body well nourished. On opening abdomen a tumour is seen on the left side, covered by peritoneum and descending colon and occupying the position of the left kidney. Spleen is pushed up, and the end of the tumour projects beneath the costal border in the axillary line; this superficial portion is quite soft, and apparently fluctuates. Tumour had no attach- ments, and peeled out readily; numerous veins course over it in front. It is ovoid in shape, large and rounded below, pointed above where it is capped by the adrenal. Anterior and upper surfaces dark and haemorrhagic-looking; on the under surface there is natural-looking kidney substance for 2-3 centimetres about the hilus. Renal artery natural. Renal vein of large size, and when slit open, soft pulpy matter is seen oozing from the organ into it. The wall is rough, irregular, and covered with bits of soft greyish tissue. Ureter is pervious, not dilated; pelvis small; calyces at each end compressed. On section through the long axis of the tumour it presents the appearance of a soft rapidly-growing neoplasm. Above and in front, the tissue just within the capsule is deeply infiltrated with blood, and in places occupied by clots ; the greater part of the exposed surface is made up of greyish-white, soft, cerebriform material. At the upper part two pyramids of kidney substance are sur- rounded by the new growth; the remnants of the organ at the under and lower surfaces are not seen on this section. Tumour measures 15 centimetres in length by 7'5 in breadth, and is about the size of a cocoa-nut. Heart of normal size; right auricle contains much blood. Lodged in the auriculo-ventricular orifice is a firm greyish-white mass, 25 m. long 12 m. broad, not adherent, and without any fibrinous flakes upon it. Right ventricle contains dark clotted blood; in orifice of pulmonary artery there is another firm greyish-white mass about the size of a hazel nut, and beyond it in the right branch are two or three smaller bits of the same character. Lungs somewhat congested at bases; no secondary masses. Histological examination.—Case I. Tumour is made up of a soft greyish-white substance enclosed in irregular spaces formed 232 PROFESSOR OSLER. by bands of firmer tissue which pass in various directions through the mass. The former is composed of round cells about the size of colourless blood corpuscles; protoplasm finely granu- lar, and with a single large nucleus. Some of the cells are a little irregular in outline, and in teased bits from the peripheral portions renal epithelium is occasionally seen. A scraping from the tumour or bits picked out from the interspaces consist entirely of the round cells, and the same are seen in sections closely packed together without any apparent intercellular substance. The strands of firmer tissue consist of (1.) elongated spindle cells, the majority of which have prolonged extremities; others are flatter without the long processes and bear a strong re- semblance to unstriped muscle fibres. They are either closely arranged together or are separated by a delicate wavy fibrillar tissue, which in places makes up the chief part of the bands. The cells possess a single elongated nucleus. They are from 0*0625 — 0*1 m. in length. (2.) Striped muscle fibres, occur- ring in variable numbers among the spindle cells and fibrous tissue of the septa, usually in bundles of 20 to 40; more rarely isolated fibres are met with. They do not often cross each other but keep parallel. When isolated they form flattened band-like fibres, ranging from 0*0625 — 0*375 in. in length, and from 0*0075 —0*01 m. in breadth. The majority of them are not more than 0*0075 m. broad, while some of the less perfect fibres are narrower, 0*003 —0*004 m. Most of the fibres have the same diameter throughout, others are larger at the centre and taper towards the ends, which are either square-cut or obtuse, less frequently pointed. The prominent feature is the distinct transverse striation, the substance of each fibre pre- senting cross lines, which are seen to be due to alternate light and dark areas in the tissue, the latter being the broadest. In large well formed fibres the striation is as distinct as in ordinary muscle; indeed, I have rarely seen in any specimen the " sarcous elements" so well marked. The majority of the fibres are nucleated; in some long ones three or four nuclei are arranged one after the other, and are connected together by a granular protoplasm. Scarcely any of the cells are striated in all parts; the nucleus and a central extension remain free, and the stria- STRIATED MYO-SARCOMA OF THE KIDNEY. 233 tion is confined to the outer borders. In wide fibres a longitu- dinal striation can be seen, but a separation into distinct fibrilhe was not met with. The nucleus is central, usually oval in shape, and a nucleolus is sometimes visible. So far as could be ascertained the fibres do not possess sarcolemma. Many cells were partially striated; sometimes a long band-like fibre had two nuclei; one end was distinctly striped, the other had the appearance of a smooth muscle fibre. Sometimes a fibre cell was seen with a small part of the protoplasm striated. A peculiar form of cell was club-shaped with a large nucleus and very plain striae ; others of the same shape were not striated, or had very faint transverse bars near the nucleus. In some places groups of flattened non-striated fibres were met with, which resembled closely involuntary muscle fibres. These appear to be intermediate forms between the fusiform cells, the smooth band-like fibres, and the fully-developed striated ones. Case II. Tumour is made up of soft greyish substance, which consists chiefly of round cells a little larger than colourless blood corpuscles, and with single large nuclei. They are closely packed together with very little intervening tissue, and do not present an alveolar arrangement. Bundles of fusiform cells and connective tissue fibres pass through the structure in various directions, but do not form such definite bands as in the pre- vious specimen. The fibre cells are elongated and have large oval nuclei. Some form flattened bands like smooth muscle fibres. Scattered among these elements in variable numbers are striated muscle fibres resembling those described in Case I. They are not, however, nearly so abundant, but in almost every specimen taken some examples were met with. In the mass which had lodged in the right auriculo-ventricular orifice they were very plentiful. They present similar characters to those above described; flattened, nucleated cells, with transverse striation. In some the striae are scarcely visible, in others only part of the protoplasm is striated. In this specimen the fibres did not form such large bundles, nor were they so long. • 1~>~ V CASE OF CONGENITAL AND PROGRESSIVE HYPER- TROPHY OF THE EIGHT UPPER EXTREMITY. By William Osler, M.D., M.R.C.P., Professor of the Institutes of Medicine in M'Gill University, Montreal. 1 Iypertrophy of one extremity or of one side of the body must be ranked among the very rare abnormalities of development. Trelat and Monod in their memoir,1 published in 1869, were only able to collect twelve cases, apart from instances of hypertrophied fingers and toes, which are much more common. Since that date the only other case to which I can find reference is one reported by Ewald in Virchow's Archiv (1872), in which the left hand was affected. Of the cases summarised by Trelat and Monod, in one it was confined to the right upper extremity, in six both upper and lower limbs of one side were affected (4 on the right, 2 on the left side), and in all the leg much more than the arm ; in two the leg alone was involved; in one the right side of face, and in one the right side of head and face. With the exception of a case of Mr Adam's (Lancet, 1858) all of these are reported by continental writers. I am indebted to my colleague Dr Drake for the opportunity of examining the following case, and for permission to publish the notes. A. B., aged 8 years and 10 months, a well grown, healthy-looking girl, the eldest of a family of four; parents healthy. The mother states that while pregnant her brother met with an accident by which his hand was severely crushed, necessitating the amputa- tion of several fingers. She did not see him until six weeks before her confinement, when the hand had healed, but the appearance of it gave her a great shock, and, of course, she attributes the deformity to this cause. Dr F. W. Campbell, the family physician at the time, informs me that the enlargement of the arm was quite noticeable at birth; but his attention was chiefly directed to the hand, which was deformed, with the fingers strongly flexed, and attempts were made to remedy this condition by the use of a straight splint. Not long after the ease came 1 Archives Generates de Medicia, 1869. hypertrophy of the right upper extremity. 11 into Dr Drake's hands, and has been under his observation ever since, and he bears testimony to the gradual and progressive growth of the limb with the development of the child. The mother thinks that the arm is larger in proportion, and more noticeable now than in infancy. The present condition is as follows:— When stripped the child presents a remarkable appearance from an abnormal development of the right upper extremity, which, in contrast to the limb on the left side, looks like that of a medium-sized man. The enlargement extends to the muscles of the shoulder. Sides of face and abdomen symmetrical, legs of equal length and size. Chest is well formed, expansion good, equal un both sides ; right half measures 4 centimetres more than the left. Right pectoralis major is hypertrophied, and stands out very prominently when contracted. Right shoulder is^-eonsiderably larger than the left, and when she stands strai&bfr'is on a higher level. The deltoid is greatly developed, Jife trapezius less so. Scapulae equal in size; no marked diffip#ence in their muscles. Iiight clavicle is a little longer tln^Tthe left (6 mm.), sterno- cleidomastoid muscles of equalj^eT The following are the comparative measurements:— Chest, ju^t below nmftfe, circumference, 56 centimetres. Chest, right hal^30 centimetres; left half, 26; difference, 4. Upper extremity from tip of acromion to styloid process of radius, right, 42 centimetres; left, 37; difference, 5. Clavicle, length, right, 11*5 centimetres; left, 10*9; difference, *6. Humerus, length, right, 24*1 centimetres; left, 21; difference 3*1. Arm, circumference, biceps extended, right, 18*5 centimetres; left, 15*6; difference, 2*9. Arm, circumference, biceps strongly flexed, right, 20*3 centi- metres; left, 15*9; difference, 4*4. Humerus, width across condyles measured with pair of com- passes, right, 7 centimetres; left, 6; difference 1. Fore-arm, circumference, thickest part,right, 21*2 centimetres; left, 17; difference, 4*2. Wrist, circumference, right, 15*5 centimetres; left, 12; difference, 3*5. Hand, circumference, right. 20*3 centimetres.; left, 15*7; difference, 4-6. 12 HYPERTROPHY OF THE RIC'HT upper extremity. Hand, across metacarpal joints, right, 9-5 centimetres; left, 7; difference, 2*5. Middle metacarpal bone, length, right, 5 centimetres; left, 6. Middle finger, length, right, 8 centimetres; left, 8*5. Index finger, length, right, 7*7 centimetres; left, 7; difference, •7. Thumb, first joint, circumference, right, 9; left, 6*5; difference, 2*5. The muscles of the humerus are strongly developed, the biceps particularly so, and it stands out in bold relief when flexed, feel- ing also much firmer than the corresponding muscle of the other side. The fore-arm presents a very substantial muscular appear- ance, and affords a striking contrast to the child-like aspect of the other arm. The wrist is thick and solid; the hand square and thick, short in proportion to its size, with large and prominent knuckles. The palmar surface presents a thick pad of fat, over which the skin is loose and more creased than usual. The ball of the thumb is large, and all the muscles are strongly developed. The fingers are small in proportion, and are kept in the semi- flexed position, which gives a somewhat deformed appearance to the hand. With the exception of the middle finger, they can all be fully extended, and it has a moderately free range of motion. When born the fingers were much more flexed, and the power over them has only been gradually acquired by use. The position of semi-flexion does not trouble her in the least, as she can at will extend the fingers sufficiently for all practical purposes. Skin on the limb is normal. Temperature on both sides equal. Sensibility perfect. No perceptible difference between the brachial pulses. Beat of the left radial is if anything more distinct than that of the right. Arteries are not apparently en- larged. Muscular power of hypertrophied limb is greatly in- creased. It could not be accurately measured with the dyna- mometer, as the instrument could not be properly grasped in the hand, but the difference was most marked on comparing the grip of the two hands, that of the right being very firm and powerful compared with the left. She is naturally right-handed, and uses the limb for sewing, writing, and all ordinary duties. ^7 CASES OF CARDIAC ABNORMALITIES. ON THE CONDITION OF FUSION OF TWO SEGMENTS OF THE SEMI- LUNAR VALVES by y WILLIAM OSLER, 3I.D., M.R.C.P., Lond. Professor of the Institutes of Medicine, McGill University. Physician to the Hospital. (From the Montreal General Hospital Reports, Vol. I., 1880.) PRINTKD BY THK GAZETTK PRINTING COMPANY, * MONTREAL. CASES OF CARDIAC ABNORMALITIES BY WILLIAM OSLER, M.D., M.R.C.P., Lond., Professor of the Institutes of Medicine, McGill University. Physician to the Hospital. Case i.—General Dropsy of the Fat us—Dropsy of the Pla- centa— Premature Closure of Foramen Ovale—Compen- satory Enlargement of Ductus Arteriosus. (Plate.) The following clinical notes of the case have been kindly furnished by Dr. Ross :— " Mrs. X. was expecting* to be confined for the second time in March, 1879. Her first child, born in 1878, is strong and healthy. No trouble with the accouchement, but the mother suffered severely from subsequent metritis. Dur- ing the second pregnancy she was always timid and nervous. Quickening took place at the usual period, but she thought the movements never felt as strong* as with the other child. In the latter months she complained of a feeling of great weight, and sometimes coldness, in the abdomen, and movements ceased. No foetal heart sounds could then be heard. After the seventh month she increased very rapidly in size, until the abdomen at last was as large as that of a woman carrying* twins. The day before she was confined she had a violent rigor, accompanied by intense lumbar pains and vomiting ; soon followed by high fever and very rapid pulse. This state of things con- 2 CASES OF CARDIAC ABNORMALITIES. tinned during the whole of the next day, and delivery took place with the patient's temperature at 103d 1\, and pulse at 140. The labour was of about four or live hours' dura- tion. The quantity of liquor amnii was A'ery great. At the first vaginal examination, when the os was not fully dilated and the head was high, it was thought that the breech was presenting, but as the part descended the head was clearly recognized by the hairs which could be felt, but no suture could be made out, the scalp feeling thick and indenting somewhat with the finger. When born, it was at once seen that the peculiarities observed were due to general cedema of the foetus. The cord was much swollen and cedematous. The placenta followed in a few minutes. It was Aery large, soft, and of great weight; unfortunately, it was not preserved for subsequent examination. I might further state that Mrs. X. went through a severe attack of troublesome sep- ticemia, affecting several joints in a very painful manner, but fortunately none of them suppurated. She made ultimately a good recovery, and at the present moment is once more in the family way—and, it is to be hoped, will have 'better luck this time.'" Autopsy.—Male infant, 43 cm. long; girth of abdomen, 33 cm.; of thorax, 33 cm.; of head, 34 cm. Whole body much swollen and in a condition of extreme anasarca. Skin glistening and tense, reddish in colour. At the examin- ation, 15 hours after birth, rigor mortis present; limbs were quite lax when the child was sent to me immediately after delivery. Head much enlarged and disfigured; fontanelles and sutures only felt on deep pressure, after which the skin remains pitted. Eyes closed, eyelids much puffed; nose scarcely to be seen on profile, owing to swelling of cheeks. A clear fluid oozes from the nostrils ; upper lip large, lower one natural. Ears oedematous and project but little. Neck enlarged ; thorax of good shape ; belly not very pro- BY WILLIAM OSLER, M.D. 3 tuberant. Attached portion of cord large ; 2*5 cm. from the belly wall measures 7 cm. in circumference ; vessels in it distended. Penis and scrotum swollen and tense. Legs and feet greatly swollen, the skin of the latter glistening and tight. Arms and hands in a similar state of extreme oedema. On making the preliminary incision, a layer of cedema- tous tissue is cut through 1*5 cm. in thickness in thorax, rather less on abdomen, and a quantity of clear serum fol- lows the section. The panniculus adiposus is infiltrated and presents a very peculiar appearance, the isolated lobules of fat, opaque white in colour, being scattered through a translucent, gelatinous-looking tissue. On opening the peritoneum, a considerable quantity of fluid escaped—about two pints. Position of viscera normal. Intestines pale and shrivelled. Umbilical vein large and 'distended with blood. In thorax, about two ounces of clear serum in each pleura. Heart enlarged; circumference at base 7*5 cm., of which 5 cm. are formed by right ventricle. Length of right ventricle, from auriculo-ventricular groove to apex, 4*2 cm. Right Auricle much distended ; when slit open from tip of appendix to point midway between the orifices of the cavse, it readily admits a ball 6*8 cm. in circumference. Chamber contains fluid blood and one small clot. Musculi pectinati extend over the whole internal surface, with the exception of the septum and the part between the orifices of the veins. Wall measures 1*5 m. in thick- ness. Eustachian valve large and well formed; its inner attachment extends as a prominent ridge along the lower and anterior wall of the annulus ovalis. From this chamber the foramen ovale is seen to be occupied by a thin membrane which apparently closes it completely. The fossa and annulus are well marked ; on the posterior 4 CASES OF CARDIAC ABNORMALITIES. margin of the latter is a dark spot 2*5 m. in length, which on section proves to be a spot of apoplexy. On carefully running a probe round the margin of the fossa, it is found to pass through a valvular opening at the tipper and back part. When examined from the left auricle, the membrane closing the orifice is seen to overlap the margin at the upper and back part to an extent of from 3 to 4 m. At this part it is not attached to the annulus, so that a valvular orifice is left which measures 8 m. in length and is capable of being lifted up to such an extent as to measure 5 m. in the transverse direction. The portion of auricular septum formed by this membrane, and corresponding to the foramen ovale, measures s by 10 m. The membrane itself is thin and translucent, crossed by numerous fine trabeculoe. The supplementary portion appears thicker than the rest, and the free edge is rounded. The orifice of the superior cava measures 1*7 cm. in circumference, that of the inferior 27 em Right Ventricle dilated and hypertrophied. Chamber J measures, from pulmonary ring to apex, 3*3 cm. Column® carnete prominent and large. Walls thick, especially at the base, where there are very thick muscular bundles— here it is 8 m. ; towards apex thinner, 2 to 4 m. Tricus- pid valves normal, orifice 3*2 cm. in circumference. Conus { natural. Pulmonary artery, springing from the venticle, is large, and appears to pass as a considerable trunk directly into the upper part of the descending aorta, which looks, in fact, like a continuation of it. This appearance is due to an enormously enlarged ductus arteriosus, which almost equals the aorta in size:—External circumference of aorta, ascending* portion, 17 cm. ; of ductus arteriosus, 1*6 cm. Length, 2*2 cm. It enlarges slightly on entering the aorta, and immediately above this the vessel is somewhat constricted, measuring only 13 cm. in circumference. Left Auricle small, compared with the right. No hvper- BY WILLIAM OSLER, M.D. 5 trophy. Nothing of note, further than what is stated above with reference to the foramen ovale. Left Ventricle also small in comparison with the right chamber; measures from aortic ring to apex 2*2 cm. Valves healthy. Mitral orifice 2*5 cm. in circumference. Muscle substance of whole heart of good colour, and fibres healthy. On visceral layer of pericardium are numerous small ecchymoses. On slitting up the anterior part of the neck to get out the trachea, a large extraATasation of blood is exposed beneath the skin in this situation, chiefly in the form of dark, fresh-looking clots, extending from the clavicles and sternum to the lower jaw. A careful dissection was made of the veins and arteries, but no rupture was found. Lungs small, pale-red in colour, airless, occupying small space in the pleurae, being compressed by the fluid. Ecchymoses on both layers of pleura. Spleen large, of a reddish-purple colour. Measures 9 cm. in length by 4 cm. in width. Surface rough and granular. On section, firm, uniform. Kidneys and suprarenals healthy and of normal size. Only a trace of fluid in the bladder. Liver is large, extending far into the left hypochondriac region, measuring 16*5 cm across, 7 cm. in antero- posterior direction. On section, healthy-looking, but congested, and on examination with hand-lens the terri- tories of the small hepatic—intra-lobular—veins are seen to be chiefly injected. Stomach contains a tenacious dark material. Small intestines, filled in upper part with greyish mucus, below with meconium. Large bowel distended with same material. Testicles.—Left at the internal ring; right almost in scrotum. Umbilical arteries look large. 6 CASES OF CARDIAC ABNORMALITIES. Umbilical vein admits a probe 1*6 cm. in circumference. Ductus venosus much dilated, forming a large sinus 2 cm. across at the under surface of the liver; from the posterior part of this the ductus passes off as a tube 1*2 cm. in diameter. Remarks—The condition of general dropsy of the foetus does not appear to have received much attention at the ! hands of obstetric physicians. Very few cases are now on record ; none appear in Pathological Society's Transac- ; tions; only three in the Obstetrical Society's; none have i been reported in the Archiv fiir Glynaecologie Mr. Clay, < of Manchester, has reported two cases.1 Three other instances have been mentioned to me by practitioners in this city—one by Dr. McCallum, a second by Dr. Ross, and a third, quite recently, by Dr. Rodger. All were accompanied with dropsy of the placenta. The points of interest in connection with this case are the premature closure of the foramen ovale, the condition of general anasarca of foetus and placenta, and the probable causal connection between these conditions. Closure of the foramen ovale to the extent met with in this case is certainly an abnormal condition in the foetus. No doubt, u a small amount of blood found its way through the narrow slit of communication, but that this was trifling in J quantity is shown by the dilatation and hypertrophy of the right chambers of the heart and the compensating enlargement of the ductus arteriosus. These conditions <■ can be explained in no other way than on the view that the foramen had been virtually closed for some time, and, in consequence, the blood from both cavac had to follow the course of the adult circulation, necessarily increasing J the work of the right heart, and gradually leading to * enlargement of the ductus arteriosus. 1 Reprint from " Zeitschrift der Kaiserl : Kamigl : Gesellschaft der Aerzten zu Wieu," 1860. I am much indebted to Mr. Clay for kindly sending me a copy of his communication. ■ BY WILLIAM OSLER, M.D. 7 Premature closure of the foramen ovale has not often been noted. Dr, Peacock' was only able to collect three cases, and since that date I have found but one other, reported by Mr. Lawson Tait,2 and in it the foetus and placenta were dropsical. The dropsy of placenta, amnion, and foetus had doubtless resulted from a common cause. Was this the premature closure of the foramen ovale ? We can suppose that obstruction in the central organ would be quickly felt in the distant placental vessels—just as in the adult it is first manifested in the vessels of the feet__ and a condition of passive oedema be brought about. The hydramnion could be explained in the same way. The general anasarca of the foetus resembles a renal rather than a cardiac dropsy, which in the adult is never so extensive. In the discussion on a case of Dropsy of the Foetus in the Obstetrical Society, Dec. 5, 1877, Dr. John Williams, of University College, suggested an ingenious explanation of the foetal dropsy, as follows :—" As the ' kidneys appear to be almost inactive at this time, it is not unreasonable to suppose that the placenta acts also as a renal organ, separating excrementitious matters from the foetal circulation. If this be true, oedema or thickening of the placental tissues would interfere with this excretory ac- tion and give rise to the accumulation of excrementitious material in the foetal blood, and give to that fluid charac- ters similar to those found in Bright's Disease, with general anasarca as a consequence." The same line of argument is ably followed in two editorials in the Lancet, Feb. 5th, April 25th, 1876, and the explanation certainly fits those cases in which the foramen ovale has been found prema- turely closed. True, we might suppose, as suggested by Dr. Williams, 1 On Malformations of the Human Heart. 2nd Ed., 1866. 2 Obstetrical Society's Transactions, 1875. 8 CASES OF CARDIAC ABNORMALITIES. a primary disease of the placenta by which the blood current in the umbilical vein would be so -much diminished in force that on reaching the right auricle the velocity became greatly reduced, so that " overcome by the force of the stream from the superior cava it flowed into the right ventricle." This could hardly happen, for the admixture of the two currents is very slight, and moreover in our case it would not account for the great ! hypertrophy of the right heart. Of the other cases recorded, the foramen ovale was found open in Dr. Bassett's ; 1 in Dr. Protheroe Smith's i the heart is stated to have been normal, and in one of Mr. Clay's cases the organs are said to have been healthy. No record is made in these cases of the state of the umbilical vessels, a stenosis of which at any part might induce these changes, as in case referred to by Fehling. :i In one of the numbers of the Centralblatt, f. d., Med. . Wissenschaften of this year, there is a brief abstract of a paper by Kleb's, in which it was stated that he believed dropsy of the foetus was induced by foetal leukaemia. Unfortunately, the number containing the abstract has been mislaid. I have no memorandum of the condition of the blood in my notes, but I am almost certain that it was examined for nucleated red blood corpuscles, and if there had been an excess of white it could scarcely have *•] been overlooked. The spleen was certainly much enlarged, and firm ; the lymphatic glands were normal. Whatever may be the cause, the condition of general dropsy of the foetus is one of very great interest, and it is to be hoped that practitioners wTho may happen to meet 1 with cases will inspect most carefully the condition of f the foramen ovale and the umbilical vessels. 1 Obstetrical Society's Transactions, 1877. 2 Obstetrical Society Transactions, 1875. 3 Archiv. fur Gyn;ecologie Band. X. BY WILLIAM OSLER, M.D. 9 Case ii.—Extreme Stenosis of Orifice of Pulmonary Artery— Slight Stenosis of Tricuspid Orifice—Septum Ventricu- (orum perfect—Great Hypertrophy of Right Ventricle. (Plate.) J. C, aet. four months, well-nourished and of average size. Had been noticed from birth to have a somewhat leaden hue, but nothing special was observed, and he throve like any other healthy infant. During a slight attack of bronchitis he became much more cyanotic, and died suddenly after a few days' illness. Autopsy, ten hours after death :— Nothing of special note in abdominal cavity. In Thorax, heart in pericardium of large size, pushing aside the lungs. Heart greatly hypertrophied. Circumference at base 13 cm., of which 8 cm. is formed by the right, 5 cm. by the left ventricle. Right auricle greatly distended, appearing* as large as a small-sized orange. Contained a firm gelatinous clot. From apex of appendix to opposite wall it measured 6 cm. A small billiard ball fits into the chamber. Trabeculae much developed in both sinus and appendix. Foramen ovale almost closed, only a narrow slit remaining. Tricuspid orifice from the auricle looks small, the valves thick and roughened, presenting in spots reddish gelatinous swellings. From this side only two segments are seen, a large anterior and a small posterior one. Length of orifice, 1*4 cm.; diameter, 7 m. From the ventricle, segments appear contracted and thick, the edges red and swollen ; a small, colourless, pedunculated vege- tation is seen on edo*e of posterior segment. Chordae ten- dineie much thickened and shortened; only seven exist; the two near the septum are particularly thick and short. Right Veulricle—Length of chamber, 4 cm. Endocardium thick and opaque. At the upper part of septum the cavity projects towards the left ventricle; septum is com- 10 CASES OF CARDIAC ABNORMALITIES. plete. The columnae carneae and musculi papillaris are very slightly developed; round and oval pits or depres- sions are seen over the ventricular surface. The conns arteriosus is contracted, measuring only 17 cm. in circum- ference close to the rimr. Great difficulty was expe- rienced in passing a probe through the pulmonary orifice, and on slitting up the artery it is seen that the segments of the valve have coalesced, leaving only a narrow orilice, through which a probe *9 of a millimetre in diameter can pass. The margins of the valves are fibrous, and the edges of the tiny orifice firm. The sinuses of Valsalva are large, appearing dilated. Pulmonary artery a little distance above valve measures 25 cm. in circumference. Interior healthy, except at one spot, near ductus arteriosus, which is atheromatous. Orifice of ductus arteriosus small, and tiny bristle can be passed through into the aorta. Left auricle presents nothing wTorthy of note. Left ventricle appears much smaller than the right. Length of chamber from aortic ring* to apex, 4 cm. Mitral and aortic valves healthy; orifices of normal size. Aorta natural-looking. A small funnel-shaped dilatation exists at orifice of ductus arteriosus. Measurement of the walls :—Right Ventricle—Outer wall at base, behind posterior segment of tricuspid, 1 cm. Anterior wall, middle, 1*3 cm. Close to septum, where excision has extended from base to apex, 27 cm. Left Ventricle—Anterior wall, near septum, 1 cm. Case hi.—Atresia of Pulmonary Orifice—Hypertrophy of Right Ventricle—Imperfection of Septum Ventriculorum —Patent Ductus Arteriosus. (Plate.) A. B., male infant, aged 13 days, cyanotic from birth. Body well nourished and of fair development. Skin of face of leaden hue, chest and abdomen darker. Umbilical cord at birth very small. The child suffered from paroxysms of dyspnoea, and died in convulsions. F BY WILLIAM OSLER, M.D. . 11 Nothing special in abdomen. In thorax heart in pericar- dium occupies an unusually large area in anterior part of chest. Heart large, all the chambers dilated and full of dark clots and blood. Length from root of aorta to apex 4 cm., circumference at base 12 cm., of which 7*5 cm. formed by right ventricle. Right auricle dilated ; endocardium natural. Foramen ovale partially closed, an oval aperture remaining, 5 m. long, 3 m. broad; behind this, separated from it by a thick process, is another tiny orifice in the septum. Superior and inferior cavae large. Auricular surface of tricuspid valves studded with numerous gelatinous vegetations about the size of millet seeds. Tricuspid orifice looks large. Right ventricle : Length of chamber 3 cm., circum- ference 5*5 cm. Tricuspid valves healthy. Conus arteriosus narrowed to a small funnel-shaped tube which ends in a cul-de-sac, corresponding to which, on the exterior of the heart, is attached a narrow, cord-like vessel. Behind and to the left of the tricuspid orifice, occupying a position between the conus and left segment of the tricuspid, is a mass of beaded, gelatinous vegetations, from the apex of which a cord passes to either wall of the ventricle, anchor- ing it in this position. On inspection these vegetations are seen to spring from a thin membrane which forms the upper part of the ventricular septum; on pushing this back, an orifice is seen in the septum measuring 9 m in transverse, 7 m. in vertical diameter. The lower border of this opening is formed by the muscular wall of the sep- tum, which is here 5 m. in thickness, the endocardium about it thickened, and upon the free edge are some fresh beads of endocarditis. The upper part of the orifice is bounded by a thin translucent membrane, which extends in a valve-like form into the right ventricle, where by its beaded extremity it is anchored by the afore-mentioned chordae tendineae. This imperfection of the septum is 12 CASES OF CARDIAC ABNORMALITIES. limited to the anterior part, the posterior portion is closed by a thin membrane, and to this the adjacent segment of the tricuspid valve is attached. Walls of right ventricle measure—anterior wall, middle, 9 m., at base 12 cm. Muscle substance pale and fatty. Left auricle about half the size of the right. Left ventricle dilated, measures from aortic ring to apex 3 o cm., circumference 6 cm. Valves healthy. Mitral and aortic orifices about normal size. Muscle substance not so pale as in right ventricle. Aorta is large, 2 cm. above valves measures 2*7 cm. in circumference, From under surface of arch a large ductus arteriosus springs, which joins . the pulmonary artery at its bifurcation ; the vessel is 8 m. in circumference. The pulmonary artery after leaving the heart passes as a narrow tube for 7 in., widening gradually until it reaches the point where the ductus arteriosus joins the main branches. In its narrowest part the artery admits a probe 1 m. in diameter. Main divisions of pulmonary artery appear of full size. Lungs present scattered patches of collapse. Nothing abnormal in the other organs. Case IV.—Descending Aorta, with Left Subclavian, given off from Right Ventricle—Innominate and Left Carotid Arteries from Left Ventricle—Ventricular Septum Imperfect—Fusion of Segments of Semilunar Valves. Specimen was procured from a foetus at the 8th month, which presented numerous other malformations—enorm- ous umbilical hernia, spina bifida, hydrocephalus, talipes, \ &c. Heart somewhat larger than the child's fist. Plight auricle of moderate size, contains blood and clots; cavae normal. Eustachian valve large ; foramen ovale open, ^ but a thin, translucent membrane can be drawn up from the posterior border of the annulus, and half closes the BY WILLIAM OSLER, M.D. 13 orifice. Tricuspid valves present two bead-like haemorr- hagic nodules. Right ventricle larger than the left, walls 2 to 8 m. in thickness ; conus arteriosus normal. From this chamber a large vessel is given off, 8 m. in wTidth at the root, passes over the vessel emerging from the left ventricle, across the left bronchus and then descends as the thoracic aorta. Seven millimetres from its origin it gives off small pulmonary branches to the imperfectly developed lungs, and, just before it reaches the spine, the left subclavian, which passes vertically up to the 1st rib. There is no communication with the vessel arising from the left ventricle. Left ventricle is smaller than the right, but the walls are thicker—3 to 5 m. Mitral orifice and valves normal. A vessel is given off from this chamber, which passes up upon the trachea for 1*2 cm. and then bifurcates, forming the innominate and left carotid arteries. The vessel is only about half the size of that given off from the right ventricle. The septum between the ventricles is imperfect. There is a small orifice, the size of a goose quill, situated in the upper and back part of the septum ; to its upper border the left segment of the tricuspid valve is attached, and can be drawn down so as almost to close it. Left auricle is small; pulmonary veins normal. Semi- lunar valves in both vessels are abnormal ; in the branch from the left ventricle there are only two; in that from the right, there are only two of full size, and a tiny, imperfect one between them. Remarks.—Cases ii. and iii. illustrate much more com- mon varieties of cardiac abnormalities. Thus, of 181 cases of malformation of the heart, Peacock1 found stenosis or atresia of the pulmonary artery in 119. The point of interest in connection with Case ii. is the extreme degree of stenosis without imperfection of the 1 On Malformations of the Heart. 2nd Ed., 1866. 2 14 CASES OF CARDIAC ABNORMALITIES. ventricular septum or patency of the foramen ovale. In the ureat proportion of cases in which this lesion is 1 n<*t with, the septum is imperfect and some of the blood can pass freely from the right to the left ventricle. Often, too, the foramen ovale and ductus arteriosus are op en. In this instance, the lungs received blood through a pul- monary orifice narrowed to *9 m., the enormously hyper- trophied right ventricle compensating, in some degree, for the stenosis ; the constant lividity of the child expressed the defective arterialization of the blood. Whereas life may be prolonged for years with stenosis of the pulmo- nary artery, provided the septum of the ventricle is open, death takes place early if the latter condition does not co-exist. Rokitansky' states that three months is the longest period to which he has known life to be prolonged J when the stenosis is unaccompanied with imperfection of the septum. In this case the child lived for four months, and was a well-nourished, plump infant. In Case iii. there was complete obliteration of the pulmonary orifice, with imperfection of the septum ventriculorum, the foramen ovale being almost closed. The lungs received blood from the aorta through an enlarged ductus arteriosus. The child lived only thirteen days. The valvular fold which passed from the upper margin of the orifice in the septum, and was anchored by two chordae tendineae, must have materially interfered with the transmission of blood from the right to the left j ventricle. Case iv. is remarkable from the fact that the descending >» aorta is given off from the pulmonary artery, the vessel of the left ventricle supplying only the innominate and left carotid, there being no connection between the two main ) trunks. This is a somewhat unusual anomaly. It is as if the part of the aorta between the left carotid and the duc- 1 Die Defecte der Scheidewande des Herzens. Wion, 1875. BY WILLIAM OSLER, M.D. 15 tus arteriosus was deficient, the ascending and descending aortae being separate trunks. \Ve may suppose this abnor- mality to have been produced by an obliteration and final disappearance of the outer part of the 4th left embryonic arterial trunk, which normally completes the aortic arch. This section of the arch, called by Rokitansky the isthmus aortae, appears especially liable to errors of devel- opment or disease, resulting in a constriction of the tube or obliteration. Many such cases are now on record. As to the mode of origin of the malformations described in Cases ii. and iii., there are two chief theories, 1st, that they result from inflammatory changes—endocarditis— taking place at an early period; 2nd, that they depend upon errors of development. On the first view, the steno- sis or obliteration of the pulmonary orifice is brought about by inflammatory processes, just as narrowing of the orifice occurs in the adult by chronic valvular endocar- ditis. If the change takes place before the complete separation of the ventricles, the septum is prevented from closing, the blood current being forced to pass through this orifice on account of the impediment at the pulmo- nary ring. By the supporters of the second theory it is rightly urged, that, as the septum closes about the end of the second month, we would have to suppose an endocar- ditis limited to the pulmonary valves in an embryo not more than 2*5 cm. (an inch) in length, and whose heart could not be above a few millimetres in size,—a supposi- tion scarcely conceivable. On the developmental view, the obliteration or narrowing of the pulmonary artery depends on an unequal division of the primitive trun- cus arteriosus out of which this artery and the aorta are formed. The septum truiici grows in such a way as to cut off an exceedingly narrow anterior or pulmonary channel which may subsequently become completely closed. This is the view supported by Rokitansky in his last work, whereas he was formerly an advocate for the 16 CASES OF CARDIAC ABNORMALITIES. older theory. He believes, however, that the mal- formed vessel may be the seat of inflammatory chanuvs, which aggravate the mischief. In Case ii. the stenosis looked much as if it had been produced by a fusion of the segments of the semilunar valves, the result of an inflammatory process. The artery itself was not at all narrowed. The tricuspid valves are also affected, the margins having united, and the orifice is, in consequence, somewhat narrowed. There is nothing in these condi- tions which might not have been caused by a fcetal endocarditis occurring during the latter half of intrauter- ine life. I think that in such a case the position and size of the vessels being normal, and with evidences of endo- carditis in the tricuspid valve,s, it is quite unnecessary to fall back on the supposition of an error in the division of the primitive arterial trunk to account for the stenosis of the pulmonary orifice. It may be otherwise, however, in Case iii., where there is complete obliteration, and I am fully prepared to admit the important part played by deviations from the normal processes of development in producing cardiac abnormalities. ON THE CONDITION OF FUSION OF TWO SEGMENTS OF THE SEMI- LUNAR VALVES BY WILLIAM OSLER, M.D., M.R.C.P., Lond.. The peculiar condition of blending of two of the cur- tains of the semi-lunar valves has long attracted the attention of Pathologists. The cases here recorded have come under my notice within the past three years, and they illustrate several points in connection with the pro- bable origin and consequences of this affection. Case i.—Fusion of Anterior and Left Posterior Segments— Ulcerative Disease of United Segment—Hypertrophy of Left Ventricle. (Plate, Fig. 1.) J. S., aet. 26, a stout, well-built young man, was admit- ted to the hospital on August 23rd with symptoms of valvular disease of the heart. Had worked as a black- smith. No history of sudden attack. Has had shortness of breath and palpitation for more than a year. There was a double murmur at the base. Left ventricle hyper- trophied. Feet and legs became oedematous, skin of upper part of body slightly jaundiced. Death with ordinary symptoms of chronic valve disease. 18 MALFORMATION OF SEMI-LUNAR VALVES. Autopsy.—Heart: weight, 690 grams. Right auricle dilated and full of dark clots. Right ventricle also dilated; measures 13 cm. from pulmonary ring to apex. Anterior wall 5 m. in thickness. Left auricle large. Mitral orifice admits a ball 14 cm. in circumference. Left ventricle dilated and hypertrophied; length from aortic ring to apex, 14 cm.; anterior wall, central portion, 1*8 cm. in thickness; towards apex, 15 cm. Mitral valves slightly thickened; chordae tendineae appear of normal length. Musculi papillares flattened; apices fibroid. Aortic valves incompetent; ring measures 8 cm. in cir- cumference, and is guarded by only two valves, between which there is an irregular interval. (Fig. 1.) The right posterior segment is large, 3*5 cm. along its free border, where it is slightly thickened. The body of the valve, except at one spot, is translucent. Anterior and left posterior segments have merged, forming a single, large, imperfect valve, having a free border 3*5 cm. in length, the end nearest the right posterior segment being loose, only anchored by a cord 1 cm. in length, which is attached to the wall of the artery. On either side of this cord a con- siderable portion of the valve is wanting, and the edges are fresh-looking and sharp. The united segment is thick, especially at the free border, and it is also a little foreshortened. From the external side the sinuses of Valsalva are distinct but the raphe between the seg- ments only extends to their bases. On the ventricular surface a faintly-marked groove indicates the line of sepa- ^ ration. Aorta a little atheromatous in ascending part. < Nothing of special note in the other organs. No infarctions. f BY WILLIAM OSLER, M.D. 19 Case II.—Fusion of Anterior and Left Posterior Segments— Hypertrophy and Dilatation of the Heart—Sudden Death from Rupture of an Aneurism of Branch of Left Middle Cerebral Artery. (Plate, Fig. 2.) M. B., aet. 20, a small but moderately well-built young man. Death took place suddenly, with symptoms of an apoplectic attack. No history could be obtained from the people with whom he lived of any previous attack or of heart disease. Autopsy.—Heart considerably enlarged. Right cham- bers full of dark clots. Right ventricle somewhat hyper- trophied ; posterior wall measures 9 m. in thickness. Valves normal. Tricuspid orifice 10*5 cm. in circumfer- ence. Left Ventricle.—Length from aortic ring to apex, 9 cm. Wall, at posterior part, 2 cm. ; at apex, 1*2 cm. in thickness. Muscle substance of a good colour. Mitral valves healthy; circumference of orifice, 9*5 cm. Just above the anterior mitral segment, between it and the aortic ring, there is a spot of fresh endocarditis about half the size of the thumb- nail, and covered with small, soft vegetations. Aortic valves incompetent. On slitting* up the orifice only two valves are seen, the anterior and left posterior having fused. The right posterior segment presents a normal appearance, retaining its shape, though large in proportion to the other, measuring along its free border 3*3 cm., depth 1*6 cm. The substance and free edge are a little thickened and opaque. On the ventricular surface are three small fresh vegetations, and at the centre there is a small depression leading to a tiny perforation of the valve. The sinus of Valsalva is large. The united segments from the ventricular surface appear as one valve, which is, compared with the other, foreshortened and shrunken. The free border measures 3*2 cm., depth 1*3 cm. From the aortic side two sinuses of Valsalva are seen, 20 MALFORMATION OF SEMI-LUNAR VALVES. separated by a ridge, which extends to the base of the united segment, and as a small line up the aortic surface. The free border is round and smooth on the ventricular side ; on the aortic margin there is a row of reddish, gelatinous-looking Aregetations. At one angle there is a small fenestration of the valve. The orifices of the coronary arteries are seen behind the united segments, one at the upper part of each sinus. Aorta is healthy, wall looks thin. Width, 3 cm.—above the valves, 5*4 cm. Spleen shows traces of three old infarctions. Kidneys.—Puckered remains of two infarcts in the left, in the right organ a large wedge-shaped one undergoing fibro-caseous change. The aneurism of the left middle cerebral artery is described in another place. Case hi.—Fusion of Anterior and Right Posterior Segments. F. Gr., aet. 42, a medium-sized, well-nourished man, blacksmith by trade, a hard drinker, and for several years a consumer of chloral. Death took place suddenly, and details of antecedent circumstances could not be procured. ■ Autopsy.—Heart large ; left ventricle dilated and hyper- trophied. Mitral valve normal. Circumference of aortic ring 9*6 cm. Two valves only are seen, the anterior and the right posterior segments having fused together, forming one large valve, measuring 46 cm. along the border. Nor- mal segment measures 3*6 cm. On the ventricular surface the united segment is a little roughened and thick about the centre. A depression is also seen at the attached mar- gin ; a slit-like fossa is seen at one angle, looking like a closed fenestra. Body of the valve thin in the centre, a little thickened at margins. From the aortic side two distinct sinuses of Valsalva are seen behind it, but the median raphe only extend about one-third of the way up the valve, spreading out in this situation into irregular BY WILLIAM OSLER, M.D. 21 fibres. Slight atheroma about orifices of coronary arteries. Arch of aorta normal. Kidneys large and very full of blood. Other organs normal. Case iv.— Fusion of Anterior and Right Posterior Segments, (Plate, Fig. 3.) A. B., let. 42, a strong, robust man, patient of Dr. Reddyr who has reported the case in C. M. Sf Surg. Journal, 1877. First complained on June 8th of uneasy sensations about the chest and shortness of breath on exertion. Attributed them to overwork during a short business trip to England. No history of rheumatic fever. Heart slightly enlarged ; double murmur, loudest at base. Throughout July,. August, and September remained in same condition. In the latter part of October dropsy set in. Rough systolic murmur heard at base, and diffuse diastolic murmur over the entire cardiac region. Hypertrophy of the heart has increased. During November he suffered with all the symptoms of ordinary cardiac dropsy, and died on the 30th. Autopsy—G-eneral anasarca. Heart weighs 750 grams., being greatly hypertrophied. Right chambers dilated and full of clots; walls of right ventricle increased in thickness. Left Ventricle—Chamber dilated; measures 10 cm. from aortic ring to apex. Walls 2 cm. in thickness. Aortic orifice, 8 cm. in circumference. Valves incompe- tent, permitting of free regurgitation. Two segments only are present, the anterior and the right posterior having joined together. The single valve, the left posterior, is large, measuring 4 cm. along the straight margin and 1*6 cm. in depth. It is a little thickened and opaque towards the attached border. Its sinus of Valsalva is large. The united segment is considerably smaller than the other and is incomplete, a V-shaped piece being absent at one end. 22 MALFORMATION OF SEMI-LUNAR VALVES. The straight border passes for 3 cm. and terminates in a rounded anule, which is continuous with the V-shaped defect. The edge of this segment is round and thickened and the whole valve opaque; measurement along middle of surface, 13 cm. On the aortic side the segment pre- sents an indistinct frenum about the centre of the attached marjrin, which also serves to divide the sinus of Valsalva incompletely into two, the one behind the imperfect side of the valve being small, the other of fair size. The arch of aorta is considerably dilated; intima covered with yellowish masses of atheroma. Heart muscle pale, and on examination is found to be fatty. Case v.—Fusion of Anterior and Right Posterior Segments— . Ulcerative Disease and Laceration of Left Posterior i. Valve—Aneurism of United Segments. (Plate, Fig. 4.) The notes of this case have unfortunately been mislaid* ",i but the House Surgeon informs me that he had the usual symptoms of severe aortic valve disease. Xavier T., aet. 45 ; admitted October 24th. Autopsy.—Body that of a medium-sized man, of slight muscular development. No anasarca. Heart large and hypertrophied. Right chambers distended with clots; those of the ventricle partially de- colourized. Left ventricle firmly contracted; a small, firm clot is attached to chordae tendineae. Chamber is considerably dilated. Walls in anterior part 2 cm. in j thickness. Mitral valves a little opaque and thick. | Aortic orifice measures 8 cm. in circumference. Valves- ! incompetent; water pours through with great freedom. ! On slitting open the artery only two valves are seen, the representatives of the anterior and right posterior segments having united, forming one large segment measuring 4.5 cm. along the border. From the aortic surface of this f BY WILLIAM OSLER, M.D. 23 valve two small aneurisms arise ; one, near the centre, about the size of a small cherry, is filled with blood clot and presents two perforations ; the other, near the left posterior segment, is not so large, but passes deeply beneath the endocardium, and also communicates with the ventricle by two small orifices, The free margin of the valve is thickened and rough. From the aortic surface two sinuses are seen, separated by a semi-calcareous raphe, which terminates halfway up the valve in a thick tuberous end, covered with small vegetations. The sinus behind the right posterior part of the united segment is the largest and gives off the aneurisms. The left posterior seg- ment is torn across nearly to the attached margin. When the separated portions are placed together thev measure only a little less than the large segment. They are greatly thickened by atheromatous deposit, and flap up and down when the heart is moved. The sinus of this valve is large. The Aorta is normal. Lungs large, and contain spots of apoplexy. Case vi.—Fusion of Right and Left Posterior Segments. G-eorge Gr., ict. 40 ; a large, somewhat corpulent man. Death from typhoid fever, after five days residence in Hospital. No heart symptoms. Autopsy.—Heart a little enlarged. Right chambers dis- tended with blood. Left ventricle large ; walls thicker than normal. On slitting up the aorta the two posterior segments are seen to be united, forming a large segment, 4 cm. along free border, 1*5 cm. in depth. From the ventricular surface it is smooth, a little thickened about the centre and free border; thin and natural looking in the rest of its extent. A slight indication is seen below of the sepa- ration between the component parts. From the aortic side the two sinues of Valsalva are seen separated by a raphe which extends as a ridge along the arterial wall. The 24 MALFORMATION OF SEMI-LUNAR VALVES. sinus behind the part formed by the right posterior segment is much larger than the other, which has one coronary artery just above it. The intima of the vessel in this sinus is rough and atheromatous. The normal valve measures 3*3 cm. along the free border, and is perfectly natural. Aorta presents scattered patches of atheroma in the arch. Case vii.—Fusion of Two of the Semi-lunar Valves at Aortic and Pulmonary Orifices. Fcetus at eighth month. Heart and arteries described in Case iv. of " Cases of Cardiac Abnormalities." On opening vessel of left chamber only two semilunar valves are seen—a large one, 9 m. in width, towards | the right; a smaller one, 8 m., towards the left. Both are thin and natural looking. Behind the larger segment a median raphe passes down on the arterial wall as far as the attachment of the valve, and imperfectly divides the sinus of Valsalva. The right coronary artery is given off 4 m. above the margin of the valve. On slitting up the artery of the right ventricle only two valves are seen, each measuring 10 m. along the free border. They are situ- ated to the right and left, and posteriorly do not meet, a small space of 2 m. intervening, which is occupied by an imperfect valvular fold, the margin of which is below the level of the larger valves. Remarks.—There can be very little doubt that this con- \ dition is congenital, as in case vii. Dr. Peacock and others have also found a similar appearance in the fcetus, often in connection with other abnormalities, and cases are reported \ of its presence at all ages. W^hether due to inflammation or some primaryr malformation of the valves is more diffi- cult to say ; I incline to the latter view. In the blended valves of case vii., a fcetus at the eighth month, there wTas no trace of endocarditis or thickening of the segments, \ BY WILLIAM OSLER, M.D. 25 and many instances are on record of individuals dying at various ages, in whom the fused segments did not show any evidence of past morbid change, as, for example, in case v. I do not think that any of the cases in this series sup- port the view that the affection may originate either by the tearing down of the angle of attachment, or by the adhesions of two segments as the result of disease. If the condition was brought about in this way, we would expect the fused segments to be, in most cases, very much larger than the single one. In four of the above cases the fused segment measured about the same as the normal one ; in case Hi. it was 1 cm. longer ; in case vi. 7m. In only one was there any indication at the attached ventricular margin of a separation of the fused segment, i.e., of the existence of the somewhat triangular space which normally is seen between the bodies of the seg- ments, when viewed from the ventricle. In this case there was a shallow groove, corresponding to the attach- ment of the raphe on the aortic surface. There was no special thickening of the central part of the united cur- tain, such as might be expected if formed by the tearing down of the angles of attachment. It is worth noting that in all the cases there was a dis- tinct raphe dividing the sinus of Valsalva behind the united • segment ; in some it stops at the base of the valve, in others, passes up its aortic surface for a short distance. This might be supposed to point to an origin of the affection subsequent to the formation of the individual valves, otherwise it is difficult to explain the very constant presence of the raphe. Our knowledge of the development of the semilunar valve is at present very imperfect. Dr. Peacock supposes that they " may be formed by the folding together of the ventricle and artery at the orifice of the vessel, and the subsequent looping up of the band into separate por- 3 26 MALFORMATION OF SEMI-LUNAR VALVES. tions."1 The malformation here in question would be produced by a failure in this process of '* looping up." However brought about, the condition is a dangerous one from the special liability of the united curtain to disease, and also from the tendency to reguritation, owing ' to the imperfect adaptation of the segments. Of the six cases in adults, in five death was caused, directly or indirectly, by the valve affection; in three with symp- toms of chronic aortic valve disease; in one sudden death, probably by syncope; and in one by apoplexy— ] rupture of an intra-cranial aneurism. ] 1 Transactions of the Pathological Society, 1877. EXPLANATION OF PLATES III and IV. PLATE III. Fig. 1.—Atresia of Pulmonary Artery. With patent Ductus Arteriosus. P.A. Pulmonary Artery. D.A. Ductus Arteriosus, Case III. p. 186. Fig. 2.—Ductus Arteriosus and Arch of Aorta in Case of General Dropsy of Fcetus. A. Aorta. P.A. Right branch of Pulmonary Artery. D.A. Ductus Arteriosus, appearing as a direct continuation of the Pulmonary Artery. The aorta is narrowed just above the entrance of the duct. Case I. p. 177. PLATE IV. Illustrating Case of Stenosis of Pulmonary Orifice. Fig. 1.—Shows the Pulmonary Artery laid open, the narrowed orifice, and distended sinuses of Valsalva. Fig. 2.—Shows the stenosis of tricuspid orifice and the greatly hypertro- phied right ventricle. Case II. p. 185. ,ATE III. Matt. Gen. Hospital Reports. 1 DA W.RapW del. Mintern Bros imp Plate IV Mont Gerv.Hospital Reports.\£fc£. A.H.Foord del. Mintern Bros,imp. EXPLANATION OF PLATE IX. Fig. 1.—Fusion of the anterior and left posterior segments. Ulcerative disease of united curtain. Case I. p. 231. Fig. 2.—Fusion of anterior and left posterior segments. Case II. p. 235. Fig. 3.—Fusion of anterior and right posterior segments. V-shaped defi- ciency in united curtain. Case IV. p. 237. Fig. 4.—Fusion of anterior and right posterior segments. Aneurisms of united segment. Ulcerative disease and laceration of other valve. Case V. p. 238. V Mont. Gen. Hospital Reports TlFljli 2. '(* j ^ .V ■%ik. Fitf:l. Fid: 4. r u- ^ ^"iV ifp/' Fig: 2. \^ m J|^»r*«i^t«lp Fig:3. A.S.Foard, del. Mintem Bros imp. PATHOLOGICAL REPORT MONTREAL GENERAL HOSPITAL No. II. WILLIAM OSLER, M.D., M.R.C.P., Lond. Professor of the Institutes of Medicine, McGill University, Physician and Pathologist to the Hospital. From the Montreal General Hospital Reports, Vol. I., 1880. MONTREAL: THE GAZETTE PRINTING COMPANY. 1880 The first Pathological Report from the Hospital was issued in 1878. The present comprises a selection from 225 post-mortems performed between October 1877 and October 1879. The autopsies are made by the students attending the Hospital under my personal supervision, and the notes are dictated on the spot. During the winter session a " Demon- stration Course," in imitation of Virchow's celebrated course at the Berlin Pathological Institute, is held every Saturday morning, at which all the specimens in morbid anatomy collected throughout the week are demonstrated to the senior students. In this way I am enabled to devote more time in the post-mortem room to the instruction of the student in the details of the method of performing autopsies,—a very important branch of his education, and one too much neglected in the schools; while at the Saturday morning class, the specimens can be more systematically demonstrated and the material be made more instructive to a larger number of men. The limited time at my disposal has often compelled me to regard the cases more from the standpoint of the teacher than the scientific investigator. CONTENTS. I. NERVOUS SYSTEM. S 1. Wound of Central Part of 1st and 2nd Left Frontal Convolu- tions. 2. Bullet Wound of Right Frontal Lobe. Entire absence of Cerebral Symptoms. II. CIRCULATORY SYSTEM. 1. Cases of Aneurism of the Aorta. 2. Aneurism of Innominate. Rupture of Saccular Dilatation of Aorta into Pericardium. 3. Aneurism of Splenic Artery. Perforation of Colon. 4. Small Aneurism of Renal Artery. 5. Four Cases of Intra-Cranial Aneui'isms. 6. Aneurisms of Branches of Pulmonary Artery in Wall of Cavities. Death from Haemoptysis. T. Two Cases of Hypertrophy of the Heart. 8. Perforation of Pulmonary Artery by Ulcer of Left Bronchus. Sudden Death from Haemoptysis. 9. Instance of Four Pulmonary Valves. 10. Bayonet Wound of Left Subclavian. 11. Fatty Degeneration of the Heart in Diphtheria. Sudden Death on the 13th da}'. 12. Two Cases of Thrombosis of Pulmonary Artery. III. RESPIRATORY SYSTEM. 1. (Edema of Right Lung; Hydrothorax of Left Pleura. Con- tracted Kidneys. 2. Intense CElema of Left Lung. Morphia Poisoning. 3. Pneumonia. Ulcerative Endocarditis. Meningitis. 4. Pneumonic Phthisis. 5. Miner's Phthisis. G. Note on the Occurrence of Membrane in the Trachea and Bronchi in Cases of Diphtheria. IV. DIGESTIVE SYSTEM. (a). Stomach and Intestines. 1. Foreign Body in (Esophagus. 2. Three Cases of Cancer of the Stomach. 3. Three Cases of Ulcer of Stomach. 4. Three Cases of Duodenal Ulcer. 5. Typhoid Fever; rapidly fatal with Nervous Symptoms. 6. Perforation of Appendix vermiformis. (b). Liver. 7. Hydatid Cyst. 8. Primary Cancer. 9. Cirrhosis; Collateral Circulation through an Enlarged Umbilical Vein in Round Ligament. 10. Pylephlebitis. V. URINARY SYSTEM. 1. Scald of Thorax; numerous Fatty Spots in Kidneys. 2. Remarkable Atrophic Kidneys. 3. Large Cirrhotic Kidneys. 4. Sarcoma of Right Kidney. VI. GENERATIVE SYSTEM. 1. Dermoid of Ovary. 2. Cancer of Uterus—Stricture of Ureter ; Pyonephrosis. 3. Ruptured Follicle in Right Ovary—Peritonitis. 4. Abdominal Pregnancy. 5. Cryptorchidism us. VII. LYMPHATIC SYSTEM. 1. Tumour of Axillary Glands, extensive Metastases. 2. Sarcoma of Retro-Peritoneal Glands. 3. Sarcoma of Deep Cervical Glands, involving the Thyroid, and simulating Goitre. PATHOLOGICAL REPORT. NERVOVS SYSTEM. 1.— Wound of the Central Part of the 1st and 2nd Frontal Convolutions on Left Side. H. C, sot 21, while working a circular wood-saw at 2 p.m., December 3rd, neglected to adjust the bolts, and the saw flew up, striking him on the left shoulder and head. He was unconscious for about ten minutes. When brought to Hospital he was pale and weak, quite conscious, no para- lysis. The wound in the skull oozed. Slept well during the night of the 3rd. Passes urine without difficulty. The wound in the shoulder has removed the greater part of the deltoid muscle, the head of the humerus, and the acromion process. The skull wound extends in an oblique direction from above the outer angle of the left orbit across the frontal, through the anterior superior angle of the right parietal, and terminates about the centre of this bone. Length of wound in integument 22 cm., in bone 18 cm. It has penetrated through the membranes, and at the central part the brain substance is lacerated and exposed, and can be seen pulsating. December 5th. Noon.—Passed a restless night. Has been unconscious since 7 p.m. Incontinence of urine. No paralysis. Pupils are equal. Moves the left arm and leg about in an irregular manner. Muscles of the left side of face twitch occasionally. Moves the right leg, but not the arm of this side. On attempting to separate the lids of the left eye, great resistance is offered. 6th.—Loss of power on right side, but occasionally move's the right foot. There is hyperaesthesia of left side of the face. Still offers resistance to opening of left eye. 7*30 p.m.—Temperature (which has ranged from 100° to 103°), in right axilla 102*0°, in left 106*5°. Complete 6 PATHOLOGICAL REPORT. immobility of the whole body ; no twitching of muscles. Died at 1015 p.m. Autopsy.—Wound in skull corresponds with description given above. In dura mater over left frontal region there is a large rent, 7 5 cm. long, 3*5 cm. wide, extending from the longitudinal sinus downwards and outwards to a point a little anterior to beginning of fissure of Sylvius. Blood clots and portions of brain substance fill up the rent. On slitting up the longitudinal sinus, it is found unaffected; where the laceration touches it there is a small mural thrombus. On removing the dura mater, a slight extravasation is seen to extend beneath it. The pia mater is stained, but not much injected. Over the ascend- ing frontal and the parietal convolutions of left side, and over right frontal convolutions, are flakes of lymph, but the meningeal affection is not extensive. The laceration of brain substance is confined to the 1st and 2nd left frontal convolutions, which are completely destroyed in their central portions. The wound extends obliquely, and is from 2 to 3 cm. in breadth, nearly 2 cm. in depth, and involves more of the anterior part of the 2nd than of the 1st convolution. The laceration in the latter stops short a little before the longitudinal fissure. The central part of the 1st frontal convolution on the right side, in an area the size of a small walnut, presents a number of extrava- sations, about which the tissue is deeply injected. The pia mater over it is inflamed and covered with lymph. Nothing abnormal in central parts or at base. 2.—Bullet Wound of Right Frontal Lobe—Entire Absence of Cerebral Symptoms. C. G-., set. 22, was admitted to Hospital on March 8th, suffering from the effects of a bullet wound, situated above and a little in front of right ear. It was stated to have been caused by the accidental discharge of a pistol. J BY WILLIAM OSLER, M.D. 7 When seen by Dr. Drake, shortly after the accident, he was perfectly conscious, not paralyzed, and gave a rational account of the whole affair. A probe was inserted into the wound, and it passed freely into the frontal lobe in the direction of the bullet. He was a little dazed, and had ringing in the ears immediately after the accident, but was able to walk 'about. Had vomiting at intervals for 36 hours after the accident, and during the straining a little blood would ooze from the wound. Pulse 60. No elevation of temperature. Second day after admission complained of frontal pain. Pupils dilated, equal, and responded freely to light. From this time he progressed favourably; only head symptom was an aching pain on right side. Alter a residence of nearly three weeks in Hospital, symptoms of phthisis manifested themselves, and it was ascertained that he had previously suffered from haemoptysis, with cough, and occasional night sweats. He left the Hospital on the 27th of April with well-marked disease at apices of lungs, but with complete absence of any cerebral symptoms. The disease of the lungs having steadily progressed, he subse- quently entered the Hotel-Dieu Hospital, and died on the 12th of August. As illustrating the entire absence of all permanent brain disturbance, it may be mentioned that two days before his death he wrote a letter to his mother clear in diction, well composed, and hopeful in character. Autopsy.—Extensive phthisical disease of both lungs. On reflecting the scalp an oval-shaped opening is observed just above the extremity of the great wing of the sphenoid, involving the edges of squamous and parietal bones. It is almost closed by firm fibrous membrane. On remov- ing skull-cap, dura mater normal on outside. Its inner surface on right side is of deep yellow colour, and this extends to the right surface of the falx, and right half of tentorium. The pia mater in this extent is also stained, but not so deeply. Several fragments of the inner table 8 PATHOLOGICAL REPORT. are attached to the dura mater at the site of the wound. The bullet entered the brain substance in the right infe- rior frontal convolution, just in front of the ascending branch of the Sylvian fissure. From this point the course of the bullet was upwards and forwards, passing out at the inner suriace of the frontal lobe and lodging between the brain substance and the falx, where it lay surrounded by a firm membrane. It was situated 6 cm. in front of, and in a line with, the anterior extremity of the corpus callosum. A firm membranous canal marks the course of the bullet, and the brain substance about this is somewhat softened. Drs. Fenwick and Bell. circulatory system. 1.—Cases of Aneurism of the Aorta. Of a number of cases of Aortic Aneurism, the lol lowing present points of interest:— (a.)—Aneurism of Abdominal Aorta—Perforation of Duo- denum. A. B., set. 60, a patient of Dr. Howard's, had suffered with severe lumbago pains in tho back. Only a few days before death he was examined, and an abdominal aneur- ism discovered. Death took place by haemorrhage from the stomach and bowels. Autopsy.—Body that of a well-built, muscular man. Nothing of special note in viscera of chest and abdomen. Heart of average size ; no valvular disease. Arch and thoracic portions of aorta present scattered patches of atheroma. At lower part of abdominal portion, about 1 cm. above the bifurcation, there is a large irregular open- ' ing leading to a sacculated aneurism, which projects from the front part of the vessel. The orifice is transversely ;; BY WILLIAM OSLER, M.D. 9 placed, and measures 5 by 3 cm.; the upper margin is sharply defined, the wall of the vessel appearing to terminate at this part, The sac of the aneurism is about the size of an orange, and is full of clots and laminated fibrin, the latter arranged chiefly at the upper and lower regions. The third portion of the duodenum crosses the front of the tumour obliquely, and is closely attached to it. After washing out the sac it is seen to communicate with the bowel by a ragged orifice, 3 by 2 cm., situated about the central part of the transverse portion of the duodenum. The iliacs pass off immediately below the sac, and are healthy. Both stomach and intestines contain blood. (ht)—Small Aneurism of Aorta, compressing Left Bronchus. John H., aet 35, a boiler-maker, admitted July 30th,with cough and difficulty of breathing. The following notes have been furnished by Dr. Ross. Patient had been in his usual health until between two and three months ago, when he began to have difficulty of breathing, and a cough, which has lately become so bad that he is unable to lie down at night. He has severe fits of coughing, and expectorates a considerable quantity of yellow muco-pus. The voice is hoarse and rough, and the cousrh is of somewhat the same character. There is deficient expansion of the left side of the chest; moderate dulness over whole of corresponding lung ; the breathing in it very feeble, and accompanied with moist rales at base ; over right lun£, exaggerated breathing. Heart sounds normal; organ of normal size. After some days he had a violent and sudden attack of dyspnoea, with lividity, which was relieved by stimulants. The cough, with expectoration and dyspnoea, persisted ; ultimately, moist rales over all the lung ; great depression, with fever 10 PATHOLOGICAL REPORT. and profuse sweating: and death took place on 11th of August. Autopsy.—Body that of a medium-sized, moderately well-nourished man. In thorax 10 oz. of turbid fluid in left pleura. Heart.—Right chambers distended with blood; wall of left ventricle a little thicker than normal. Aorta dilated and atheromatous in ascending parts, and presents several small pouches. From the first part of the thoracic portion, immediately at the termination of the arch, an aneurism, the size of a large walnut, projects forwards, and compresses the left bronchus. The sac, which is almost obliterated by firm layers of fibrin, communicates with the vessel by a small orifice. On slitting up the trachea and bronchi, the tumour is found to compress the left branch, diminishing its calibre at least two- thirds. At one spot it has ulcerated through, and the fibrinous laminae of the sac are freely exposed. The left lung is heavy, upper lobe slightly crepitant, and very oedematous ; lower lobe airless. In the bronchi there is a large amount of purulent fluid. (c.)—Aneurism of Thoracic Aorta—Rupture into Left Pleura. David K., aet. 48, a sailor, admitted 18th of September, under Dr. Ross, with pain in left side and palpitation of the heart. Has had pain about margins of left costal cartilages for over 12 months. Has now, in addition, severe pain in the dorsal region on both sides, but most intense on the left. It is of a scalding character, increased by lying down and relieved by firm pressure. Skin along course of lower dorsal nerves markedly tender. Xo tenderness on pressure over the spine itself. On exami- nation of chest, signs of moderate effusion in left pleura. He was tapped, and three pints of clear serum removed. This gave temporary relief, but the pains soon became as severe as before. Heart a little displaced to the right, ! * i BY WILLIAM OSLER, M.D. 11 otherwise normal. No murmur to left of spine posteriorly. Death occurred suddenly, on 21st of October. Autopsy.—In abdomen, viscera displaced downwards and to the right; diaphragm on left side on a level with costal border. In thorax, left pleura full of serum and clots, 40 oz. of the former, !>4 oz. (by weight) of the latter. Lung of this side compressed. Heart somewhat enlarged; valves normal. On removal of heart and lungs, a large aneurismal tumour is seen to occupy the posterior medias- tinum, involving about two-thirds of the length of the thoracic aorta. The bursting has taken place through a rent in the pleura, 5 cm. in length, situated immediately over the heads of the 6th and 7th ribs of the left side. On removing the tumour, the posterior wall of the sac is found to be the deeply eroded vertebrae, 5th, 6th, 7th and 8th, together with the heads of the corresponding ribs, that of the 7th on the left side being almost eaten away. The bodies of the affected vertebrae are fully one- half destroyed ; the intervertebral substance is not so much involved. The sac is very large, fusiform in shape, and contains numerous laminae of fibrin with much coagulated blood. The oesophagus is displaced forwards but not compressed, nor is there any pressure on the bronchi. (d).—Aneurism of Arch of Aorta—Great Hypertrophy of the Heart. J. M., aged 40, admitted July 14th, 1878. Had been a soldier for 15 years, serving in various parts of the world. Since his discharge in 1865, has worked as an ordinary ^ labourer. In April, 1876, began to suffer from cough and \ dyspnoea, and noticed a pulsation in front of chest; he continued at work until July of that year, when he entered the Hospital for the first time. Has lived a hard life; never had syphilis ; had rheumatic fever when a lad. 12 PATHOLOGICAL REPORT. Since the first symptoms appeared he has not been able to work much ; the present is his fourth term of residence in the Hospital, and he has been two or three times in the Hotel-Dieu. There is great hypertrophy of the heart, apex beat 4 " cm. outside of nipple line. Impulse forcible ; no murmur. Great prominence of sternal end of right clavicle; visible pulsation in right infra-clavicular region; feeble impulse felt in same locality, stronger one in episternal and supra- clavicular regions. Complains chiefly of pain and dyspnoea. Latterly he became very much wasted, and died exhausted on September 10th. Autopsy.—On opening the thorax, aneurism occupies the position indicated during life, and is closely attached to the chest wall; the cartilage of the 2nd rib and part of the bone being atrophied from pressure. Heart greatly enlarged. Right auricle contains clots, some of which are firm and colourless. Superior cava and its branches are normal. Right ventricle much dilated, measuring 15 cm. from pulmonary ring to apex, walls 5 to 8 m. in thickness. Tricuspid orifice enlarged Septum bulges very much towards this chamber. Left auricle large ; endocardium very opaque. Left ventricle somewhat rounded in shape, much dilated and hypertro- phied. Length from aortic ring to apex 12 cm. Circum- ference 19 cm., walls 15 to 20 m. in thickness ; papillary muscles and trabeculae much developed. Mitral orifice slightly enlarged. Aortic valves normal. Aorta.—Ascending part dilated, measuring 11 5 cm. in circumference; intima rough and atheromatous. The aneurism projects from the right side of the arch, ^ involving the vessel as far as the innominate. The sac is about the size of an orange, and is almost filled with firm laminated clots. The intima of the aorta is pro- longed for a short distance into the sac ; in the rest of its extent the wall of the sac is thin, and has torn in BY WILLIAM OSLER, M.D. 13 one or two places. The posterior wall of the arch below innominate is rough, and numerous clots adhere to it. Branches of arch normal. Descending aorta thickened and atheromatous. Left vagus is stretched, but can be readily dissected away from the back part of the aneurism. Left recurrent can also be easily followed. Nothing of special note in the other organs. 2.—Aneurism of Innominate—Rupture of Saccular Dilatation of Aorta into Pericardium. James W., aged 40. Has always been a healthy man, but has done very heavy lifting in his work as undertaker. Admitted April 14th, with pulsating tumour under right clavicle ; severe paroxysms of pain in that region ; cough and husky voice. Tumour can be felt on deep pressure in the episternal pit. Radial pulses equal. Veins of right arm, and right side of neck, somewhat enlarged. Left Hospital and died suddenly on July 4th. Autopsy.—On opening thorax, lungs collapse ; no fluid in pleurae Pericardium looks large, and on section the heart is seen to be enveloped in a clot of blood which, when removed, about filled the two hands. Surfaces of membrane natural- looking. Heart flabby ; right chambers contain blood and clots. Left ventricle a little large. Mitral valves thick at the edges; aortic valves opaque and stiff, but are competent. Aorta.—Ascending portion of arch dilated, especially in two saccular pouches just above pulmonary artery. The walls of these dilatations are very thin, and in one there is found a small rupture, about the size of a pin's head, through which the haemorrhage has taken place into the pericardium. The whole arch is considerably dilated ; the intima rough and atheromatous. The orifice of the r innominate is slightly dilated, that of the left carotid 2 14 PATHOLOGICAL REPORT. very much so. On tracing up the innominate, a sac- culated aneurism is found springing from the right side ' of the vessel, with which it communicates by a narrow orifice 2 by 15 cm. The sac is the size of a large orange, and the cavity is more than half filled with dense, decolour- ized laminae of fibrin. The wall of the vessel appears to end a short distance from the orifice. The right pneumogastric nerve is involved in the wall of the sac The subclavian and right carotid arteries are normal. Remarks.—This case is interesting from the fact that Dr. Fenwick proposed to ligature the carotid and subcla- vian arteries on the left side for the cure of the aneurism, but was unable to obtain the patient's consent to the operation. So far as the aneurism itself was concerned, no case could have been more favourable; the sac was already half-filled with dense lamiine of fibrin, and the orifice of communication was small; but the saccular pouches above the aortic valves would probably have been a serious element of danger, and might have burst with the increase of pressure after the application of the ligature to the arteries. Death took place suddenly, though the opening into the pericardium was very small, just admitting the head of a pin. 3.—Aneurism of Splenic Artery—Perforation into Transverse ■ Colon. E. C, aet 30, came under the care of Dr. Drake on Oct. 6th. He had been ill for several months, suffering with attacks of epigastric pain and occasional vomiting*; symptoms which led his physicians in New York to diagnose gastric ulcer. There was a deep-seated tumour .< in left hypochondriac region, extending for some distance into the epigastrium, the dulness of which merged with that of the spleen. There was no pulsation, but it wa.s BY WILLIAM OSLER, M.D. 15 thought on one occasion that a bruit was heard over it. The chief symptoms, while under observation, were vomiting, severe epigastric pain, occasional hematemesis, and, within the last week, severe haemorrhage from the bowels, which carried him off. . Autopsy, 24 hours after death.—Belly much swollen, and, when opened, about two pints of fluid were removed from peritoneum; coils of intestines distended and cov- ered in spots with flakes of lymph. A tumour occupies the left hypochondriac region, and extends to the level of the navel, being situated between the stomach above and the transverse colon below, both of which organs are firmly adherent to it. It was removed in connection with these parts and the spleen. On section is seen to be an aneurismal tumour, about the size of a cocoa-nut. The greater curvature of the stomach is closely adherent at the upper part, and the sac was opened by a free incision through this organ. The peripheral part is occupied by dense, laminated fibrin, the central and dependent regions by recent clots. The pancreas is adherent to the lower and posterior part. On tracing the splenic artery from the aorta, a probe passes directly from it into the sac, com- municating with the central portion by an oblique canal through the laminae. The artery is somewhat dilated at the site of rupture and presents an irregular deficiency of the wall, beyond which the vessel is thick and runs in the wall of the sac. The proximal part of the artery is normal. On cleaning out the sac an oval orifice, 2 by 1*2 cm., is seen at the lower part, which communicates with the transverse colon near the splenic flexure. It is partially plugged with a fibrinous clot. The edges of the orifice are smooth, and for a short distance about it the sac wall has given way so that the intestine is freely exposed. The spleen is small and flattened, closely enveloping the sac. Heart presents nothing abnormal. Remarks.—Aneurism of the splenic artery is very rare. 16 PATHOLOGICAL REPORT. In thirty-nine instances of aneurism of the branches of the abdominal aorta collected by Lebert, it occurred in ten. In the present instance, the situation and large size of the tumour, together with the absence of pulsation and general characters of the symptoms, did not point towards aneurism, and tho tumour was believed to be splenic. After hearing a bruit over the mass on one occasion, the question of aneurism was discussed. 4.—Small Aneurism of Renal Artery. In a case with some arterial degeneration and slight contraction of the kidneys, there was a small saccular aneurism, the size of a large pea, on the left renal, just before the bifurcation. The sac had firm walls continu- ous with those of the vessel. No other aneurism in the smaller or larger arteries. 5.—Four Cases of Intracranial Aneurism. (a.)—Aneurism of the Left Middle Cerebral Artery, projecting into a Cyst, probably the remains of an Infarction— Rupture—Aortic Valve Disease. A. 11., aged 20, a small, but well-built, young man. Death took place suddenly during the evening of the 25th of March, 1878. Brain.—Left hemisphere looks larger than the right, the convolutions are flattened, and not so vascular. On section, at the level of the corpus callosum, a large clot occupies the brain substance immediately external to the lateral ventricle in the left side, involving the lenticular nucleus, internal capsule, small part of the thalamus opticus, and laterally reaching nearly to the convolutions of the central lobe. It does not penetrate the ventricle. At the base, vessels of the circle of Willis not atheromatous. BY WILLIAM OSLER. M.D. 17 On tracing the vessels in the left Sylvian fissure, nothing is met with until far in on the under surface of the parietal lobe close to the angle between the convolutions of this and the central lobe. Here a main branch of the vessel appears adherent, and on dissection a nodular mass is surrounded by brain substance in part of its extent, but within is in contact with the apoplectic region. After carefully washing and removing it from the brain sub- stance, an oval body is left, about the size of a cherry, and into this the artery appears to pass. On injecting water into tho artery, it escapes from the anterior and upper end of the mass, at which point there is a small rent, 4 m. in length. On slitting up the artery, it is found to expand into a small aneurism, about the size of a pea, with very thin walls. A branch passes out to the right, not far from where the main vessel enters, so that the aneurism appears as if formed at the fork of a vessel. The oval mass, which is situated immediately beyond, and in close connection with the aneurism (indeed, the latter occupies the anterior end of the former), is soft, fluctuating, with tolerably firm, opaque-white walls. "When opened the contents are reddish-brown in colour, pulpy, and look like brain matter mixed with blood. After removal of the contents, the cyst is about the size of a cherry; walls 2 m. in thickness. At the anterior end the aneurism projects into it. and the central part of the projection is rough and fibrous, but no communication exists between the cyst and the aneurism. The Heart is hypertrophied, and there is fusion of two of the segments of the aortic valves. Described as case ii at page 235. 01 -2 18 PATHOLOGICAL REPORT. (b.)—Endarteritis and Aneurismal Dilatation of Left Verte- bral and first part of Basilar Arteries—Rupture. J. B., aged 36. a saloon-keeper; found dead in his bed. Eighteen months before he had been attended by Dr. Roddick for a hard chancre, which was followed by severe secondary symptoms. He had, however, com- pletely recovered. Body that of a well-built, muscular man. Brain.—In the removal of the organ, a large extravasa- tion is seen at the base, and a considerable amount of serum escapes. A uniform coagulum extends beneath the arachnoid, from the optic commissure in front to the lower part of the medulla behind, concealing all the parts beneath save the ends of the nerves, which pass out through it. Laterally, it extends into the Sylvian fissures; posteriorly it encircles the medulla, and fills the hinder part of the 4th ventricle, and at the back part of the cerebellum it forms a large baggy swelling beneath the arachnoid. It also follows the course of the posterior cerebral and cerebellar arteries, infiltrating the meshes of the pia mater along these vessels. On removing the arachnoid, the clot is found to be thin and superficial over the pons, thicker over the perforated spaces, while over the crura and medulla it forms a thin sheet. On tracing the vessels a very great disparity in size is seen between the vertebral arteries. The left is very small, only 7 m. in circumference; the right large, 1*2 cm. in circumference, and wTith thickened walls. The first part of the basilar is also dilated, and its wall thick and opaque. On injecting water into the left vertebral, an oozing is seen just at the point of union of this vessel with the basilar, on the outer side, at a spot where there is a slight prominence on the wall. When the left verte- bral is slit up, it measures at its widest part 17 m., the coats are thick, intima smooth, but beneath it are patches BY WILLIAM OSLER, M.D. 19 of opacity. In some places there is a peculiar greyish transluceney. Just above where this vessel joins the basilar is a shallow dilatation on the wall, and in the centre of this is a small perforation through which an average sized bristle can pass. At the central part of the basilar arterv, the interior is much thickened, and the lumen of the tube is considerably narrow7ed. The carotids are a little stiff, but not evidently athero- matous. The middle cerebrals present a few small spots of opacity on the intima. Heart is healthy. Aorta not atheromatous. Small arteries of various viscera not affected. On microscopical examination there were no special features in diseased arteries, which would warrant the conclusion that the process was syphilitic. (c.)—Aneurism on Left Middle Cerebral Artery—Old Apopletic Cyst—Numerous Miliary Aneurisms. R. C, ait. 55, patient of Dr. A. A. Browne's; ill for over eighteen months with obscure cerebral symptoms. At autopsy, old apopletic cyst, with firm walls, in which, and in neighbouring brain tissue, were numerous miliary aneurisms. No large dilatations in the vessels near the cyst. Vessels at the base very stiff and atheromatous; just beyond the first division of the left middle cerebral there is a saccular aneurism about the size of a large pea, communicating with the vessel by a round orifice. The wall of the sac is thick, and appears to be an extension of the tunics of the vessel. It had not ruptured. A smaller and more irregular dilatation exists in one of the main branches of the right middle cerebral. Heart valves not diseased. 20 PATHOLOGICAL REPORT. (d.)—Aneurism of Anterior Communicating Branch of Circle Willis; Rupture. Mrs. G-., aet. 40, died suddenly in a shop, and was brought to the dead-house of the Hospital. No history was obtained of her habits of life. Autopsy.—Body that of a well-nourished woman. Xo- thing of note on external examination. On removing the calvaria dura mater looks natural. When stripped off, superficial extravasations are seen bounding the longitu- dinal fissure and extending along the sulci. They are numerous in the lateral region in the course of the branches of the Sylvian arteries. When removed, the base of the organ presents a uniform clot extending beneath the arachnoid from the medulla to the olfactory bulbs. The white ends of the nerves project through^ and relieve the otherwise uniformly dark-red colour. The clot passes out the Sylvian fissures, and covers the upper and lateral surfaces of the cerebellum. It forms a thin sheeting, thickest over chiasma. It has not hurst through the arachnoid at any point. The clot was care- fully brushed away and the vessels inspected. They are not thickened, but present one or two small spots of atheroma on the basilar and middle cerebrals. A slight fulness wras noticed about the anterior communicating artery, and on injecting water with a hypodermic syringe through the carotid, it flowred out in a tiny stream from the front of this vessel, revealing at the same time a small aneurismal dilatation springing from it. The circle of Willis was then carefully removed, washed, and spread upon a glass plate ; the anterior communicating artery is seen to be very wide, and projecting from it, between the anterior cerebrals, is a aneurismal pouch, about the size of a small split pea. Its walls are very thin, and on its under surface there is a small slit-like rupture 1*5 m. in length. When opened from the anterior communicating BY WILLIAM OSLER, M.D. 21 artery, a small smooth-walled sac is seen, very thin towards the anterior part. On the upper wall there is a small spot of atheroma, and another on the anterior com- municating ; they are greyish-white inVolour, intima over them smooth. Other vessels carefully examined, but nothing special found ; the strio-lenticular arteries were much coiled. Nothing special was found in the dissection of the Abdomen; lacteals beautifully injected with chyle over intestines—duodenum and jejunum—and mesentery. In Tli<>rax, viscera normal; right lung universally adherent. Heart of natural size ; valves normal. Tricuspid orifice large, 13*5 cm. in circumference. Aorta rough and uneven from atheromatous change; branches not much affected. Kidneys a little granular on surface. Right organ is very loosely attached and is very movable; it can readily be displaced to the brim of the pelvis. Remarks.—Aneurismal dilatations on branches of cere- bral arteries are not at all uncommon. Within the past ten years several observers have taken the trouble to collect and summarize the facts connected with them. Thus, Dr. Hutchinson reports one and analyses 84 cases ; Dr. Bartholow describes an original case and analyses 114 ; and lastly, Dr. Peacock reports 3 cases and tabulates 86. The points of interest which have been brought out in connection with this accummulating record are: their comparative prevalence in young persons with valvular disease, and their probable origin in embolism. The statement of Sir William G-ull' that apoplexy in young persons is very frequently caused by the rupture of small intra-cranial aneurisms, has been borne out by many sub- 1. Pennsylvania Hospital Reports. Vol. ii. 1369. 2. Am. Journ. of Med. Science, 1872. 3. St. Thomas's Hospital Reports. 1876. 4. (jiiy's Hospital Reports. 1859. 22 PATHOLOGICAL REPORT. sequent observers; and in Case a I remarked to my class, before proceeding with the autopsy, on the probabilitv of finding a ruptured cerebral aneurism, as the lad was known to have heart disease. The embolic origin of these aneurisms has been discussed of late, and is probably true in those associated with endo- carditis. The frequency with which they occur with heart disease,—25 out of 89 in Dr. Peacock's table, the prefer- ence displayed for the arteries of the left side, and the occurrence of accompanying embolic lesions in the spleen and kidneys are suggestive facts. The way in which embolism causes aneurism has not been determined. The view commonly advanced is that the arterial wall is softened at the point of plugging and gradually dilates. Ponfick' thinks that the hard particles of a calcareous embolus injure the wall and weaken it; Goodhart,- on the other hand, believes that the embolus is, in the majority of cases, derived from an ulcerative endocarditis, and carries with it infective properties, leading to inflammation and softening of the arterial wall. In Case a the connection of the aneurism with a cyst is worth noting. Was this cyst the result of an embolus? It looked very much like a spot of red softening in process of healing, and the sac of the aneurism projects directly into it, while passing out, somewhat at right angles, is the continuation of the vessel. It is too large to have been caused by the pressure of the aneurism itself. 1 am inclined to think that it preceded the formation of the aneurism, in which case it has probably resulted from an embolus plugging a branch of the vessel at this point. Of five cases of intra-cranial aneurisms which have come under my notice, Case a is the only one occurring in a young person and in connection with heart disease. 1. Virchow's Archiv. 1873. 2. Path. Soc. Transactions. 1877. BY WILLIAM OSLER, M.D 23 The other instance, not given in this series, is recorded in my first Pathological Report, 1878, and occurred in a woman aged 4<> : the aneurism involved the right middle cerebral, and was the size of a bean. In 4 of the 5 cases death was caused by bursting of the sac, in 3 death was sudden; the woman with aneurism of the right middle cerebral lived 36 hours after the onset of the paralysis. Aneurism of the anterior communicating branch occurred in only 5 of the cases tabulated by Dr. Peacock; the sac in this case appears to have been smaller than in the other recorded instances. 6.—Aneurisms of Branches of Pulmonary Artery on Wall of Cavities—Hcemoptysis in Chronic Phthisis. (a.) Mary T., yet. 50, ill for many months; died suddenly from hemoptysis. Lungs —Cavities at apices; that of left lung the size of a large orange, thin-walled, and presents at its lower and inner aspect, close to the root of the lung, an aneurismal dilatation of a branch of the pulmonary artery. It is as large as a marble, and is quite close to the main trunk of the artery, being given off directly from one of the three main sub-divisions going to the upper lobe. The orifice of the sac is larger than a goose quill. It lies in a definite hollow, which looks as if it might have been formed by the constant throbbing of the sac. It measures 2*8 cm. in length, 45 cm. in circumference. The portion near the root is covered with the lining membrane of the cavity, and two small trabeculoe cross it. The anterior portion looks arterial in character. At the apex there is a small lacer- ation through which water flows into the cavity when injected into the sac. On the under surface of the sac is a small spot of ulceration with a yellow base. 24 PATHOLOGICAL REPORT. (b.) J. A., set. 26, the subject of chronic phthisis Death from haemoptysis. ( Right Lung.—Cavity the size of an orange at the apex. At the posterior part of the lung, at the level of the root, is another cavity the size of a hen's egg, full of soft clots, of a dark colour. On washing these away an aneurismal sac is seen projecting into the cavity, oval in shape, 25 cm. in length, 1*8 cm. in width, lying with its long axis transversely to that of the thorax. Its anterior surface is smooth, rounded, and internally is thickened by laminae of fibrin. The posterior surface is very thin and presents several small openings, through which the haemorrhage had taken place. 7.— Two cases of Hypertrophy of the Heart (a.) William B., aet. 63, a large, powerfully built man, carpenter by trade, was admitted into the Hospital Sept. 18th, complaining of cough and dyspnoea. Has been a healthy man, accustomed all his life to hard work, and until about two years ago had drunk freely. In October, 1877, caught cold from wearing wet clothes, and was off work for five weeks. In May was laid up with cough, and had, at the same time, swelled feet.' Was in Hospital for five weeks. Has worked continuously since that time until the 12th of September, when he had to give up on account of the shortness of breath and swelled feet. On examination, chest measures 80 cm.; expansion, 2*5 cm.; both sides equally well. Percussion over lungs normal. Nothing special on auscultation. Heart's dulness begins at 4th rib and extends fully 1*5 cm. outside of nipple line. Action rapid; sounds muffled ; no murmur. Urine rather dark-coloured; no albumen. He has a troublesome and frequent hacking cough; expectoration of a bright red colour and like currant jelly. Sits up in bed most of the time. Legs BY WILLIAM OSLER, M.D. 25 and feet oedematous ; small amount of fluid in the belly. On 24th dull and heavy ; dyspnoea more urgent. Expecto- ration bloody. In evening became insensible, almost pulse- less, and extremities cold. From this state he was roused with stimulants. 25th.—Insensible and quiet. (Edema is extending. Expectoration remains the same. Dyspnoea became more exaggerated, and he died on the 29th. Autopsy.—Body presents the appearance of a man dead of heart disease. In abdomen, small amount of fluid. In right pleura, 60 oz.; in left, 30 oz. clear serum. In pericardium, 8 oz. Heart large, weighs 710 grams, (ca. 25 oz.) Right cham- bers distended with large, jelly-like clots. Ventricle dilated, measuring from pulmonary ring to apex, 12 cm. Circum- ference, midway between pulmonary ring and apex, 12 cm. Tricuspid orifice dilated, 15 cm. in circumference. Segments of valve healthy; pulmonary valves normal. Left auricle large, and contains blood, with clots. Left ventricle dilated and contains gelatinous clots; those about the trabeculae are colourless. Length of chamber from aortic ring to apex, 10 cm.; circumference, at middle, 17*5 cm. Anterior wall, central part, 2*2 cm. in thickness. Papillary muscles a little fibroid at apices. Mitral orifice 125 cm. in circumference; vah^es a little thickened at edges. Aortic ring 8*2 cm. in circumference; valves competent, a little thickened, and one calcareous nodule at attached margin. Muscle substance is somewhat pale ; fibres are moderately fatty, and present also many brown granules. Aorta is not dilated; 5 cm. above valve it measures 8*7 cm. in circumference; intima smooth, not atheromatous in ascending part of arch. A few patches in transverse part of arch, and in thoracic portion, and a large one in right common iliac. Lungs present large spots of apoplexy. Anterior borders emphysematous. Tissue on section presents coarse appear- ance of brown atrophy. 3 26 PATHOLOGICAL REPORT Kidneys.—Right 130 grams.; left, 175. Capsules detach with slight difficulty : surfaces a little puckered and irregular. Several cysts the size of marbles. On section cortices not diminished; vessels full; small arteries moderately distinct. Liver, nutmeg. Brain presents nothing abnormal; arteries at base opaque, but not rigid. (b.) Thomas L., aet. 68, a strong, well-built man for his age, carpenter by trade, was admitted to hospital May 14th, with shortness of breath, cough, and anasarca. Has always been a healthy man ; worked hard at his trade ; no history of intemperance. Began to be troubled with shortness of breath upon exertion about a year ago. Six months past feet began to swell, and he had often to sit up at night in order to breathe freely ; spat a little blood at this time. Becoming worse, was admitted to hospital in September for heart disease, and was discharged in six weeks much improved. Has not been able to do much work during the winter, on account of the shortness of breath. About a month ago his legs began to swell, and since then the dropsy has gradually extended. When admitted, dropsy of legs, scrotum, and belly. In chest, signs of effusion into pleura behind Percussion clear over anterior parts of lungs. Heart dulness extends as high as upper border of third rib; diastolic murmur heard at the base. Arteries atheromatous. Urine in normal quantities; trace of albumen. Chest was tapped on two occasions, and he left the hospital on Aug. 10th, much improved. On Oct. 11th, he was admitted moribund, and died the next day. Autopsy.—Body that of a short, moderately stout man. (Edema of legs and subcutaneous tissue of trunk. In abdomen, slight amount of fluid. Membrane much thick- ened. Right pleural layers universally adherent. Peri- cardium contains 8 oz. of fluid. Heart greatly enlarged. \ BY WILLIAM OSLER, M.D. 27 right chambers dilated, and contain gelatinous clots, with blood, 18 oz. being removed in the preliminary inspec- tion of these cavities. In left ventricle only small amount of blood ; 4 oz. removed from left auricle. Right ventricle measures from pulmonary ring to apex 12*5 cm.; walls 6 to 10 m. in thickness. Tricuspid orifice dilated; heart cone 15 cm. in circumference, passes through freely; valves normal. Left ventricle measures from aortic ring to apex 12*5 cm.; walls 1*8 to 2 cm. Mitral orifice 12 cm. in circumfereuce; valves a little thick at edges. Papillary muscles firm at apices. Aortic orifice 8*5 cm. in circumference ; valves a little stiff. Aorta slightly dilated, and presents several patches of atheroma. Muscle substance of heart a little pale, and on examination many of the fibres are fatty and m a state of brown atrophy. Lungs.—Left is compressed posteriorly, crepitant above and emphysematous at anterior border. Right lung heavy, very slightly crepitant, and on section, contains much blood and serum; no infarcts. Kidneys.—Right weighs 173 grams.; capsule not adherent; surface smooth; on section, cortex in good proportion ; small arteries at base of pyramids not very distinct; no cysts. Left organ smaller, weighs 160 grams. Capsule detaches readily ; surface presents numerous small cysts. On section, certain areas of cortex are riddled with small cysts. Pyramids look natural. Liver, nutmeg. Nothing special in other organs. Smaller arteries of the body atheromatous, not calcareous. Remarks.—Fatal cases- of heart disease are met with now and then in which it is exceedingly difficult to account, in a satisfactory manner, for the occurrence of the hyper- trophy and dilatation. The patients die with all the symptoms of chronic valvular disease—dyspnoea, dropsy, haemoptysis, etc. At the autopsy there is no aflection of the valves, perhaps only moderate arterial degeneration, the kidneys are not specially fibroid, and there is not sufficient pulmonary trouble to account for the general 28 PATHOLOGICAL REPORT. hypertrophy of the heart. Three such cases have come under my notice in the past three years and I have another at present under observation. In the two cases just reported, neither the condition of the valves of the heart, of the lungs, or of the kidneys, afford satisfactory ground for supposing that the hypertrophy and dilatation were caused by any interference with the functions of these organs. In the first case one kidney was reduced in size, and the surface of both were a little puckered ; the lungs contained numerous haemorrhagic infarcts, and were emphysematous in anterior borders. The arteries were not atheromatous ; indeed, for a man of his age, the aorta was remarkably free from changes. In the second case, kidneys were of normal size ; one was cystic. The lungs were emphysematous in front; the arteries were sclerotic, and the aorta somewhat dilated. In both there was general hypertrophy with dilatation of the heart, the valves being a little thickened, but otherwise normal. The degree of enlargement of the organ was about that met with in cases of hypertrophy from valve disease. The mitral orifices were moderately enlarged, 2 cm. beyond the standard ; the tricuspid orifices somewhat more, 3 cm. in excess of Bizot's measurements ; but in neither case, perhaps, was the excess out, of proportion to the increased size of the chambers. Now, in the absence of the usual and well recognized causes, what conditions are there which might be supposed to have given rise to hyper- trophy and dilatation of the heart in these cases ? There is no evidence of disturbed innervation, which appears capable of inducing enlargement of the organ, as in cases of nervous palpitation and in Graves' disease. All circumstances which tend to produce, and keep up, a state of high tension in the arterial system may lead to dilatation and hypertrophy of the heart. It is in this condition that we must, I think, seek for the explanation of the disease in these cases. Among such circumstances BY WILLIAM OSLEli, M.D. 29 severe muscular exertion takes a prominent place, and the writings of Albutt, Meyers, DaCosta, Seitz and others on the subject leave no room for doubt that hypertrophy of the heart may arise from this cause. I have dealt with the question at length in commenting on the first case referred to \ which resembled these in the absence of valvular disease and the method of termination, and which occurred in a very powerfully built man (aet. 38), of intemperate habits, an old soldier, and a blacksmith by occupation. In the cases here reported, the patients were large, muscular men, carpenters by trade; one of intem- perate habits, the other doubtful ; no history of syphilis, and it appears quite legitimate to connect their habits of life with the disease. The intemperance in Case a is a factor not to be lost sight of, as the action of alcohol in mcreasng arterial tension is recognized, and it is worthy of note that many of these cases have been in hard- drinking, intemperate men." This view, however, is open to the just criticism that there is no direct evidence in its favour; and the question also at once suggests itself: How is it, seeing that the majority of men earn their bread by the " sweat of their brow," that these cases are not more common ? Still it is only right to take into consideration the facts of well developed muscles and hard work at a trade which often necessitates severe exertion, sometimes in constrained positions, .when the usual conditions causing dilatation and hypertrophy of the heart are absent; more particularly with the evidence collected in favour of this view by the above named gentlemen. Having so recently., written on the subject, in the paper referred to, I will not again, at present, enter into the 1. On a case of Hypertrophy and Dilatation of the Heart, probably caused bv prolonged muscular exertion.—Canada Medical and Surgical Journal, March, 1878. 2. Traube. Gesammelte Beitrage. Bd. hi., 1878. H 30 PATHOLOGICAL REPORT. question, though one of very great interest. I will only remark that in Case b the arterial sclerosis might be re- garded as the cause of the heart disease; or, with Traube, both might be looked upon as effects of a common cause, viz., increased arterial tension in consequence of muscular exertion and the abuse of alcohol. 8.—Perforation of Pulmonary Artery by Ulcer of Left Bron- chus—Sudden Death from Haemoptysis—Chronic Bron~ chilis, Emphysema, Phthisis. A. M., aet. 54. Had been asthmatic for several years, and subject to severe paroxysms of cough and dyspnoea. Face always dusky, breath short and wheezy. Never had haemoptysis. On the morning of the 15th of April, 1879, he coughed up a quantity of blood, somewhat over a pint, and fell back dead. Larynx contains a small amount of blood. In trachea, there are small clots and frothy blood. The mucous membrane is thickened, rough, and irregular, particularly towards the bifurcation, and whole tube looks unusually thick and stiff. The orifices of the mucous glands are very distinct. On slitting up the bronchi, the left is found filled with clots and blood ; the right is almost free. When washed, the mucous membrane, parti- cularly that of the left, is much thickened—2 to 3 m.—and rough from the projection of little masses like coarse granulations, which are more numerous on the posterior than the anterior parts. The main division of the left bronchus, with its branches passing to the upper lobe is specially affected, and the granulations are very numerous and large at the points of bifurcation. On the upper and outer wall of this division of the left bronchus, just before its bifurcation into the tubes for the upper lobe, there is a reddish spot on the mucosa, 7 m. in diameter, projecting slightly towards the lumen of the bronchus, and for a BY WILLIAM OSLER. M.D. 31 millimetre or more about it the mucosa appears ulcerated. The reddish spot is composed of a soft yielding membrane, the surface of which is a little rough, and when depressed it is below the level of the bronchial mucous membrane, and looks like a small ulcer upon it. The loss of substance is best seen at the edges, and here the cartilages are seen to be deficient. On inspection it is found that this reddish membrane forms a septum between the bronchus and the pulmonary artery, and, at the lower part, rupture has taken place by a slit-like orifice 25 m in length. From the side of the artery—left branch, main division, close to bifurcation—there is seen a circular reddish spot on the yellowish-white intima, 5 m. in diameter, a little depressed, membrane roughened, but not covered with fibrin, and at its lower margin is the slit above referred to. Lungs.—The left presents a thickened pleura over upper lobe; on section this part presents three cavities of moderate size, in communication with dilated bronchi; and all containing clots. The anterior margin is firm, contains groups of tubercles, the surrounding tissue being in a state of gelatinous infiltration. Lower lobe in latter region presents an infarction the size of a walnut, some- what triangular in shape, brownish-red in colour, dry, not softening, and the pleura over it inflamed. On slitting up the branch of the pulmonary artery passing to this part, one or two roughened spots are seen on the intima, but they do not look recent. The embolus was not discovered. The rest of this lobe is emphysematous. The right lung is large, borders rounded, tissue spongy and soft to the touch. On section there are a few groups of tubercles scattered through the lobes, and the tissue is extremely emphysematous. Heart.—Right ventricle moderately hypertrophied, and tricuspid orifice dilated. Spleen enlarged, weighs 383 grams. 32 PATHOLOGICAL REPORT. 9.— Instance of four Pulmonary Valves. The cas>' from which this specimen was obtained, pre- sented no features of special interest. Pulmonary ring measures 7 cm. in circumference, and is provided with four well-formed valves. They are smaller than normal, measuring respectively 2, 1*8, 1*8, and 14 cm. along the free border. The largest one is a little thickened ; all are fenestrated ; two of them present at both angles very large perforations. 10.- -Bayonet Wound of Left Subclavian Artery at its Origin. J. McE., aged 24, stabbed with a bayonet on the eve of the 12th of July, by one of the Volunteer guards at the City Hall. On external inspection, the only point of note is a wound 2 by 1 cm., situated in front, and a little to the outer side, of the external axillary fold. The edges are contused and lacerated, and, on pressure, blood exudes. On removing the sternum, left pleural sac is found full of blood, partly coagulated, of which two quarts were removed. The lung was compressed and flattened. On tracing the external wound it is found to penetrate part of the deltoid muscle, passing just in front of the axillary vein, then beneath the pectoralis minor, and enters the chest immediately below the 1st rib, 7 cm. from the ster- num, grooving the border. It then passes directly through the upper lobe of the lung, penetrates the pleura covering the posterior mediastinum, and cuts across the left sub- clavian artery 1*2 cm. from its origin on the arch, severing the vessel in three-fourths of its extent. The tissues of the posterior mediastinum are infiltrated with blood. BY WILLIAM OSLER, M.d/ 33 11.—Fatty Degeneration of Heart in Diphtheria—Sudden Death on the thirteenth day. E. A., tct. 11; admitted, under Dr. Ross, on 16th of January, with diphtiicria; membrane upon tonsils, uvula, and pillars of fauces ; pulse, 120 ; temperature, 104°. By the 24th the throat had almost healed, temperature normal; voice is nasal, and there is a slight regurgitation of fluids through nostrils. 25lh.—Not so well, is irritable and restless; skin of legs, particularly on front of thighs, hyper (esthetic. Temperature normal. At 5*30 p.m., after sitting up on the bed-pan for a few moments, gave a long sigh and fell back dead. Autopsy.—Larynx and pharynx free from exudation. Heart moderately contracted; valves normal. Right auricle contains a large, white, tolerably firm clot, which almost fills the chamber, and extends into the correspond- ing ventricle. It does not pass into the pulmonary artery. Muscle substance of fairly good colour, but when exam- ined with the microscope is found in a state of advanced fatty degeneration. Very many of the fibres appear made up of closely set, dark, fat granules, no trace of contractile substance remaining; in others the process is less advanced, but I have never seen more extreme degeneration than is shown by numerous fibres from the ventricle in this case. Kidneys moderately congested. 12.— Two Cases of Thrombosis of Pulmonary Artery. (a.)Fracture of Patella—Pleuro-Pneumonia (?) seven weeks after— Thrombosis of Pulmonary Artery. Dr. Rodger, under whose care the patient was, has furnished notes of the case, from which the following has been condensed:— 34 PATHOLOGICAL REPORT. J. B., aet. 45; a tall, powerfully-built man. Fractured his patella on the 20th of December. On 4th of February initial symptoms of pleurisy; moderate fever; respira- tions 40. On the 5th, faint pleuritic friction on right side posteriorly and a few rales. *llh.—Temperature 100*3°; Is restless and complains of a sense of suffocation or tightness in the chest, and difficulty of breathing has increased. No dulness to be detected posteriorly. 10M. —Still complains of sense of tightness on chest. Has continued feverish. Temperature to-day 101°. Pain in side very severe ; had a hypodermic of morphia in the evening. Respirations 40 in the minute. 12th.—Had a bad night. Temperature, 102*3°; respirations, 50. Diminished resonance at angles of scapulae ; breath sounds indefinite. Heart's action tumultuous ; no murmur. Had a slight syncopal attack in the afternoon on sitting up. 14ath.—Summoned early in the morning, patient having been very restless. Pulse, 120. Temperature, 100°; respirations, 45. Complains of severe pain at lower end of sternum and also immediately below right nipple, and of the feeling of tightness before referred to. At midnight patient said he felt better, and was about to have a poultice applied when he was seized with a syncopal attack, and died in a few minutes. Autopsy, 16 hours after death. Patella fractured in transverse direction; segments united by fibrous tissue. Under surface of the bone is rough ; some of the synovial folds are injected, in spots almost haemorrhagic, others are infiltrated with a greenish- yellow serum. Heart of average size. Right auricle contains a gela- tinous clot, decolourized at upper part. Chamber does not appear distended ; endocardium is stained. Right ventricle contains a small, tolerably firm, buff-coloured clot, closely interwoven with the chordae tendineae ; there is also a small quantity of dark blood. Valves normal. BY WILLIAM OSLER, M.D. 35 Tricuspid orifice of moderate size. On slitting up the pulmonary artery a firm thrombus occupies the trunk, being adherent to the lower wall; it extends into the right and left branches, not entirely filling their lumina, but is closely adherent where it is in contact with the intima. On further dissection, the thrombi can be followed into many of the branches of the 3rd and 4th degree. They are all reddish-brown in colour, firm, more or less adherent to the walls, not laminated, and of leathery consistence throughout. Left auricle contains a small amount of blood. Nothing special about left ventricle ; a small clot fills the mitral orifice. In Right Pleura, half a pint of turbid serum. Lymph over lower lobe of the lung and on the corresponding parietal layer. One or two small patches on pleura of upper lobe. Lungs.—Upper lobes crepitant and of good colour. Right lower lobe is heavy, and dark in colour posteriorly. On section a quantity of blood and serum oozes from the surface, and in one or two spots the tissue is firm and of a lighter red colour, as if becoming hepatized. No localized sub-pleural infarctions. Left lower lobe also dark and slightly crepitant. No hepatization. Nothing of note in the other organs. (b.)—Thrombosis of Branches of Right Pulmonary Artery. Catherine C, a^t. 70, admitted 23rd of June, with cough, dyspnoea and swelled legs. Patient is an old woman of spare habit of body, tem- perate, but with stiff arteries and an hypertrophied heart. About two weeks ago she caught cold and her legs began to swell. On 24th, when examined, the following facts were noted :—She sits up in bed; face somewhat suffused ; respirations hurried; pulse weak and irregular. On inspection, chest barrel-shaped, expansion slight. On 36 PATHOLOGICAL REPORT. percussion, dulness in lower part of mammary, infra- axillary and infra-scapular regions of right side, clear note over remainder of chest. On auscultation, fine rales are heard over dull region; expectoration bloody. Heart— Action rapid, irregular ; no murmur. Urine scanty ; 8 oz. since admission. Xo albumen. Temperature, 99*5°. Dyspnoea increased, and the patient died on the morning of the 25th. Autopsy.—Body that of an old, poorly-nourished woman. In right pleura, 14 oz. of turbid blood-stained fluid; in left, 10 oz. Heart is large and chambers are distended with blood. Right auricle full of gelatinous clots, colourless at upper surface; in appendix they are buff-coloured, closely adherent, and interwoven with the musculi pectinati. Right ventricle is dilated ; walls of average thickness. A gelatinous clot fills the chamber and extends to the pulmonary orifice, but it is not very closely adherent to the valves and chordae. Tricuspid orifice admits readily the heart cone of 15 cm. circumference. Left chambers contain dark clots ; ventricle is large, wall hypertrophied, measuring 1*4 to 1*6 cm. muscle substance pale and streaky. Mitral and aortic semilunar valves opaque and stiff ; the latter competent. Weight of organ, 430 grams. In its re- moval 24 oz. of blood escaped. On slitting up pulmonary artery and its branches, a thrombus is seen to occupy the branch passing to the lower lobe of the right lung. It is firm, buff-coloured, closely adherent to the wall, and can be followed into the branches for a considerable distance, in some instances preserving its characters in vessels 3 m. in diameter, in others being softer and not so closely adherent to the intima. Right Lung.—Upper and middle lobes crepitant, but contain an excess of serum, which oozes freely from the cut surface. Entire lower lobe is solid, airless, and dark in colour, particularly at anterior and lower borders. BY WILLIAM OSLER. M.D. 37 Pleura covering it is turbid and presents a few flakes of lymph. On section, the tissue is firm, of a deep, purple- black colour, and in a state of haemorrhagic infarction ; the upper margin of the lobe is slightly crepitant. Left Lung is crepitant, and contains much blood and serum. At the anterior margin of lower lobe there is a wedge-shaped infarction, and the branch of the pulmonary artery in it contains a thrombus. Both organs emphysematous. Kidneys small, fibroid, and present numerous cysts in the cortical regions. Arteries are atheromatous ; arch of aorta is slightly dilated. Remarks.—These two cases present several points of interest. The cause of the thrombosis in both is obsure, and on looking over the reports of cases in the Journals and Transactions, I have been surprised to find how frequently the same admission is made. In the first case, a healthy man fractures his patella, on December 20th, and did well until the 4th of February, when symptoms of pleurisy set in, with moderate fever. On 7th, sensation of tightness in chest and difficulty of breathing, which continued for a week; respirations 40 to 45 per minute ; heart's action tumultuous. Death sudden, on 14th. We must suppose the thrombus to have been in process of formation during the week preceding death, and the rapid breathing and sense of suffocation were probably caused by it, as they were quite out of proportion to the pleuritic trouble. In the second case, an old woman with contracted kidneys, stiff arteries and hypertrophied heart, is brought to the Hospital with consolidation of lower lobe of right lung, and dies in 36 hours. In neither case is there any satisfactory reason for the occurrence of the thrombosis; perhaps, in Case b, a fibrinous concretion may have been dislodged from between the musculi pectinati of the right 4 38 PATHOLOGICAL REPORT. auricle, and plugged the branch of the pulmonary artery passing to the right lower lobe, but the appearance of the obstructing clot was that of a thrombus. The occurrence of hiemorrhagic infarction in one case and its absence in the other is noteworthy, but it would take too long to enter here upon the consideration of the explanation offered of this interesting but not uncommon peculiarity. RESPIRATORY SYSTEM. 1.—(Edema of Right Lung ; Hydrothorax of Left Pleura— Contracted Kidneys. R. F , a stout, old man, was sent to the Hospital from the House of Refuge, suffering from dyspnoea, which became more and more urgent. He refused all treatment, and died writhin 30 hours of admission. Autopsy.—Slight cedema of legs. Five pints of clear fluid in left pleura; on right side membranes are intimately united. Heart.—Chambers on right side filled with clots par- tially decolourized. Tricuspid orifice dilated. Left ventricle moderately hypertrophied. Valves competent Lungs.—Left, emphysematous at apex and anterior border. Lower lobe collapsed, and dark in colour. On section, a moderate quantity of serous fluid escapes from .upper part of the organ. Pleura over it smooth. Right, large, heavy, and sodden, pits on pressure, and when handled crepitates faintly. The pleuritic adhesions, which entirely cover it, are infiltrated with serum. On section, entire organ from apex to base intensely oedematous, quantities of clear fluid flowing from the cut surface. Blood vessels are not injected, but the tissue has a trans- lucent gelatinous look from the amount of serous infiltra- tion. BY WILLIAM OSLER, M.D. 39 Kidneys.—Diminished in size; substance very firm. Cortices slightly wasted. Small arteries moderately pro- minent. Aorta very atheromatous; small arteries thickened and firm. 2.—(Edema of Left Lung—Morphia Poisoning. A. B., aged 40. Disappeared on Saturday, December 14th ; found in his own shed, lying coiled up at the bottom of a sleigh, on his left side, with a sheet drawn over him. Autopsy.—Body that of a tall, muscular man. Limbs stiff from the frost. Face suffused. Slight post-mortem discolouration of the skin. In thorax, a few adhesions between the pleural mem- branes on both sides. Heart of normal size ; right chambers distended with blood. Tricuspid orifice large, admitting four fingers to 2nd joint. Right ventricle is dilated, walls relaxed ; clots are partially decolourized, and extend into the pulmonary artery. Left chambers contain very little blood; ventricle contracted, walls thick, cavity small. Valves normal. Aorta contains blood ; intima not stained. Lungs.—Right, crepitant throughout; some oedema in posterior parts, and the tissue is here dark from contained blood. Left, heavy, dark-purplish in colour, non-crepitant, except at anterior margins. Pleura smooth. On inflation, air vesicles expand in places. Portions excised sink. On section, an extraordinary quantity of bloody serum escapes, and the tissue has a gelatinous, infiltrated appear- ance. Surface is smooth, not granular, and of a deep- claret colour. It presents a remarkable contrast to the other lung. Bronchi contain frothy serum. Kidneys.—Left organ contains a good deal more blood than the right. Nothing special in the other viscera or in the brain. 40 PATHOLOGICAL REPORT. In the analysis of the contents of the stomach a small amount of morphia was found. Remarks.—The condition of the left lung in this case was remarkable. I have never before seen an oriran so infiltrated with bloody serum ; it had a uniform purplish- red, gelatinous appearance, except at anterior border. Death undoubtedly was caused by morphia; and the only explanation which suggests itself of the condition of the lung is, that, lying coiled up on his left side, he went to sleep under the influence of the drug and death took place slowly. The gradually weakened heart propelled feeble charges into the pulmonary artery, and by hypostasis an increasing quantity reached the left lung, until a state of extreme congestive oedema was produced. Medico-legally the case is interesting. In a subsequent case of morphia poisoning—during a pneumonia—there was no special oedema at bases of lungs. 3.—Pneumonia— Ulcerative Endocarditis—Meningitis. Mary —, aet. 29 ; admitted October 22nd in an uncon- scious state. History of attack defective; but she had been drinking hard. When examined, on 23rd, she was unconscious; pupils moderately dilated. No twitchings or paralysis. Slight dulness at right apex, with rales. Temperature, 104°. She remained in this state on the 24th and 25th. Systolic murmur over heart. On the 26th temperature went up to 107°. and death took place in the afternoon. Autopsy.— Lungs.—Right, heavy and firm, particularly in upper parts. On section, upper lobe, with exception of extreme apex, in state of red hepatization ; surface bathed with a blood-tinged serum, and air vesicles filled with visible granules. Toward the anterior border the process is more advanced, the tissue grey in colour, and bathed with a BY WILLIAM OSLER. M.D. 41 sero-purulent fluid. Upper part of lower lobe also hepa- tized ; lower part congested and oedematous, and scattered areas of consolidation are seen in it. Left organ crepitant throughout; congested and oedematous in posterior parts. Heart.—Left ventricle of normal size, walls a little thicker than natural; endocardium smooth and glistening. Endocardium on ventricular surface of anterior segment of mitral valve is granular, being covered with minute vegetations. Towards the right side of the valve they are larger and extend to some of the chordae tendineae, passing down the entire length of several of them. On the auricular surface of the valve there is a soft, white patch, 1 by 1*2 cm., covered in part by a thin membrane, and in rest of extent rough and divided into a number of elevated pro- jections. In one of the aortic valves there is a slight defect, owing to the fact that the free margin at one end is attached to the aorta considerably below the level of the others. Above the sinuses of Valsalva are several small pouches of the arterial wall, the largest the size of a marble. The intima about them is swollen and translu- cent ; that of the arch is normal, with exception of patches of gelatinous swelling in neighbourhood of great vessels. Brain.—Nothing of note about soft parts or calvaria; dura mater normal. On removal of organ, tissues at the base appear somewhat matted together, and there is a slight opacity and thickening of the membranes in front of the commissure, and along the longitudinal fissure. Over perforated spaces arachnoid is clear, but the pia mater is oedematous. Sylvian fissures opened with difficulty. No lymph at the base ; arteries are full. On removing dura mater the cortex presents patches of lymph arranged somewhat symmetrically on the hemispheres, chiefly in neighbourhood of longitudinal fissure. Elongated patches exist on the 1st and 2nd frontal convolutions of left side, and another along the fissure of Rolando. On the right side, in the latter situation, is a much larger patch. About 42 PATHOLOGICAL REPORT. them there is a good deal of gelatinous oedema of the membranes. Vessels of pia mater are full, the small ones over the convolutions very distinct. The sulci are broad and the membranes covering them (edematous. At pos- terior margin of corpus callosum and extending on to the upper surface of cerebellum is a thick layer of lymph. On slicing the organ, substance moist, of good consistence. Nothing special in the ventricles. Remarks.—The occurrence of meningitis in pneumonia is, in the experience of English writers, a rare complica- tion. Huguenin,' however, states that it is not uncommon in Zurich. A similar case to the present is reported in the Pathological Report for 77-78. In both the inflam- mation was of the upper part of the right lung, and in both the patients had been subjected to depressing influences. It is a common experience here that .apex pneumonia in debilitated persons is very often accom- panied with delirium, usually of an active character. In the cases referred to it was more of the nature of deep stupor; no special head pain was complained of in either ; and they bear out in this respect the diagnostic proposi- tion laid down by Traube,-' in commenting on a case very similar to the one here reported, that " in the course of pneumonia a meningitis may develop without headache, and which gives intimation of its presence only through deep stupor." Huguenin deals with these secondary inflammations of the meninges under the term " metastatic," and suggests that in pneumonia " the puriform, broken-down material gets into the arterial current, is carried by it to the pia, and there sets up purulent inflammation." In the majority of cases, he states that the pneumonia was in the stage of purulent infiltration. In the instance here recorded the 1. Ziemssen's Encyclopedia. Bd. xii. 2. Gesamellte Beitrage. Bd. iii., 426. 1878. BY WILLIAM OSLER, M.D. 43 affected part of the lung was chiefly in the stage of red hepatization : in the other case referred to, entirely so. It may be that the meningitis was secondary to the ulcerative endocarditis, in which case its embolic origin is more intelligible. For another and, perhaps, more plausible view of the nature of these secondary meningeal affections, see paper by Dr. Greenfield in St. Thomas's Hospital Reports, 1878. 4.—Pneumonic Phthisis. G-eorge 11., iut. 20, a negro ; admitted to Hospital August 261 h with fever, cough and weakness. One sister died of consumption. Was tolerably well up to three weeks before his admission, when he got a severe wetting, since which time he has been feeling very ill. He did not " lay up," but attended as an out-door patient; there is no positive evidence of an attack of acute pneu- monia of the ordinary type. During September he had high fever, night sweats, coughed a great deal, and rapidly emaciated. On the 1st of October, when he came under Dr. Ross's care, there were signs of a large cavity at the apex, while over the rest of the lung there were dulness and feeble blowing breathing. The fever per- sisted, and the prostration became more marked ; death took place on October 19th from haemoptysis, Autopsy.—Nothing of special note in inspection of abdomen and thorax. Lungs.—Left, pleura thickened; layers united at apex, covered with recent lymph in lateral region. Organ firm, solid and heavy, weighing 1,490 grams. On section a large cavity is exposed at the apex, containing clots and a reddish-yellow, very glutinous pus. The walls are exceed- ingly irregular, lined by rough, caseous masses, and crossed in spots by vessels and bronchi. No aneurismal dilatation on any of the vessels detected. The cavity occupies about 44 PATHOLOGICAL REPORT. a third of the upper lobe. The rest of the organ is firm and airless, with the exception of a small margin at lower part. On section it presents a uniform, opaque-white colour ; surface is dry, tissue breaks readily. Vessels and bronchi pervious, and about them there is a little gela- tinous-looking tissue. On close inspection the individual air cells can be seen, but in most places very faintly. All parts present the same dry, cheesy appearance. Right lung, weight 540 grams. ; full in volume ; crepi- tant, except at part of apex, which presents a small cavity surrounded by infiltrated, gelatinous-looking tissue. Tis- sue of middle lobe near root is in state of gelatinous oedema Lower lobe contains several small caseous masses and a few firm nodular bodies like tubercles. Bronchial glands enlarged, tumid, moderately pig- mented, not caseous. In ileum, glands of Peyer swollen, some as large as small peas. Remarks.—This case is one which presents several points of great interest. I had never before met with exactly the same morbid appearance in the lungs, and the question at once arose, Is it a sequence of pneumonia, or is the process tuberculous ? The entire illness lasted somewhat over two months, and began after a wetting,' but not with the symptoms of ordinary pneumonia. When he entered the Hospital there was consolidation, with signs of breaking at the apex. The history is defec- tive, and if the primary attack was pneumonic, it must have been subacute. A sister had died of phthisis, so that a family predisposition to pulmonary disease may be pre- sumed. As to the condition of the left lung, the term caseous pneumonia best describes it. I have never seen such an extensive area of cheesy degeneration as pre- sented by the lower lobe—uniform, solid, anaemic and dry ; no trace of normal lung tissue (except narrow rim at border), and no nodules. In the extensive excavation of BY WILLIAM OSLER, M.D. 45 the upper lobe, the walls of the cavity are formed by breaking down cheesy substance. The microscopical examination shows the air cells occupied with a granular debris, mixed with cells in various stages of degeneration. The whole appearance is what might be supposed to proceed from an unresolved pneumonia, which had gone on to caseation, and in the upper lobe to extensive softening. The caseous areas which arise in connection with tuberculous phthisis are never, in my experience, so extensive, and do not involve a wThole lobe in such a uniform manner. The disease in the right apex may have been secondary, or there may have been originally trouble at the apices. 5.—Miners' Phthisis. J. T., ;rt. 60, native of Cornwall, admitted April 16th. Father, a miner, died at the age of 63, of consumption. Has worked in mines since the age of 14; in lead and tin until 15 years ago, when he came tp America; and since then in copper, zinc and plumbago mines. Has enjoyed good health during the greater part of his life. Is a moderately temperate man. About three months ago noticed a slight cough, which has persisted ever since. He has failed gradually in health and strength, and has not been able to resume work. April 18th.—Examined for the first time. An elderly, moderately emaciated man; appears to prefer the sitting posture. Face and hands a little suffused, as if capillaries were over-full. Chest.—On inspection right side somewhat sunken in front, and does not expand so freely as the left. On per- cussion, dulness for three fingers' breadth below right clavicle, clear over 3rd and 4th ribs, dulness again below, merging with that of the liver. Clear note at left apex in front and over both bases behind. On auscultation, cav- 46 PATHOLOGICAL REPORT. ernous breathing at right apex, with a loud click at end of inspiration. Expiration is prolonged and accompanied by whistling rales at the left apex and at the bases. Breath sounds are feebler in left than in right scapular region. Expectoration viscid and glairy. Heart's impulse cannot be felt, dulness much diminished. Sounds nor- mal. Pulse 90, feeble; temperature normal. Bowels regular; urine dark-coloured. During the evening he sank rapidly, respirations became shorter, hearts action feeble, and he died about midnight. Autopsy.—In abdomen, liver depressed, reaching nearly to the navel. In thorax, left lung extends over beyond the middle line; right lung universally adherent. Heart.—Right ventricle dilated and hypertrophied; chamber measures from pulmonary ring to apex 15 cm.; wall, about middle, 7 m. in thickness. Left ventricle appears of normal size. Valves healthy. Weight of organ, 445 grams. Lungs.—Moderately dark in colour. Left crepitant, except at one area behind. Pleura covering the lung uniformly dark, except at the posterior part of lower lobe, where it is thickened and of an opaque-white colour. Entire upper and anterior part of lower lobes emphyse- matous. A number of small firm spots can be felt, and these on section of the organ are seen to be dense fibroid areas, excessively pigmented. Except in these spots, and about the vessels and bronchi, the lung tissue is not of a dark, but rather of a slate-grey colour. Behind in an elongated area, extending through both lobes, measuring 18 by 6 cm. and 4 5 cm. in depth, the lung tissue is con- verted into a firm fibrous mass of inky blackness. On section it cuts with resistance, surface smooth, but in places there are small irregular spaces as if the tissue were breaking down. They contain dark-coloured fl uid, but could not be traced in connection with bronchi. BY WILLIAM OSLER, M.D. 47 Right Lun%.—Pleura very much thickened over antero- lateral regions. On section of the organ a cavity, the size of an orange, half-filled with purulent matter, is found at the apex, occupying chiefly the posterior part. The extreme apex and the entire anterior margin are com- posed of dense, firm, excessively pigmented fibrous tissue, which also surrounds the cavity in its lower and anterior parts. Middle lobe is emphysematous, lower lobe crepi- tant ; on section numerous fibroid and pigmented areas as in other lung. At its anterior margin it is compressed by an encapsulated pleurisy. No caseous masses in either lung. Mucous membrane of bronchial tubes thickened; they contain a good deal of secretion. Bronchial glands pigmented and hard, none caseous. Nothing of special note in the other organs. Remarks.—The cavities which form in the late stages of this disease appear to arise by the disintegration of the fibroid areas, as seen in the large fibrous mass at the back part of the left lung in this case. This is peculiar, as we usually regard the presence of this tissue in a diseased lung as conservative and protective. It may be that dilated bronchi play an important part in their production. 6.—Note on the Occurrence of Membrane in the Trachea and Bronchi in Diphtheria. During the past three years, diphtheria of a severe type has been raging in this city. Thus, for the two years ending May 1st, 1879, 75 cases were admitted to Hospital, of which 34 died. It must be remembered that, as a rule, it is only the severe cases which are brought to Hos- pital, and a considerable number were sent in to have tracheotomy performed as a dernier ressort. In 18 of the cases an inspection of the body was made. As to the situation of the membrane, in the great propor- tion both pharynx and larynx were involved ; in three, no 48 PATHOLOGICAL REPORT. laryngeal membrane ; in one it was confined to larynx and trachea. (This case had come from a house in which other cases had occurred.) In one the membrane had cleared away; death having occurred suddenly on the thirteenth day. In one case, which recovered, the mem- brane extended over the entire mucosa of the mouth, involving the lips. In eight of the cases the membrane formed a continuous sheeting, extending down the trachea and into the bronchi, to the tubes of the 3rd and 4th degree. This is the point of greatest interest in connec- tion with the series, and explains, to some extent, the high mortality. The membrane in the bronchi was not so firm as that in the trachea, and the tubes passing to the middle and lower lobes were, as a rule, more involved than those passing to the upper parts of the organ. DIGESTIVE SYSTEM. (a.)—Gastro-Intestinal Canal. 1.—Foreign Body in (Esophagus—Ulceration—Perforation j —Retro-pharyngeal and (Esophageal Abscess. Jane Gr., aet. 56, was brought to the Hospital in a dying j condition, and, being friendless, no account could be obtained of the onset of the illness. During the 18 hours she was in hospital, she did not complain of any special difficulty in swallowing. Autopsy, 24 hours after death.—Body that of a large, corpulent woman. Face and upper part of body swollen and emphysematous, and dependent parts very dark in colour. In abdomen, signs of old peritonitis, particularly in pel- vis. In thorax, tissues at upper part of anterior medias- tinum infiltrated with pus, and a similar condition is seen about the structures at the root of the neck. Tongue, pharynx, oesophagus, and larynx removed together. The BY WILLIAM OSLER, M.D. 49 tissues in front of the spine from the base of the skull to a level with the bifurcation of the trachea are infiltrated with pus, and in a foul, sloughy state. It also extends laterally about the oesophagus and the sheaths of the great vessels of the neck, passing forward beneath the muscles. On slitting open the pharynx and oesophagus, a bone is seen imbedded in the anterior wall of the latter, immediately below the cricoid cartilage. It is a piece of mutton-chop bone, measuring 3 by 2 cm., and is firmly imbedded ; the sharp end, towards, the right, has perfor- ated the mucous membrane only ; the other end, the entire wall, which is ulcerated at this part. At pyloric end of stomach are several minute losses of substance in the mucous membrane. Nothing of note in the other organs. 2.— Three Cases of Cancer of Stomach. (a.)—Diffuse Sub-mucous Cancer of Stomach—Small Patch of Ulceration — Perforation — Secondary Mass in Left Supra-renal Capsule. Robt. C, aet. 43. History of failing health for months. Gastric symptoms not at all prominent. No tumour to be felt. G-reat emaciation. Death from peritonitis. In abdomen, intestines dark and relaxed; six pints of dirty, offensive fluid removed. A few flakes of lymph on peritoneum ; very little injection of the vessels. An oval perforation is seen in the anterior wall of the stomach, midway between the greater and lesser curvatures, and rather nearer the cardia than the pylorus. Stomach small; orifices free ; when laid open, mucous membrane of whole organ raised in tuberous nodules of irregular form, some small, others large, with broad bases. The largest are in the fundus and greater curve. On section, it is seen that the sub-mucous tissue between the 5 50 PATHOLOGICAL REPORT. nodular masses is also involved over the greater part of the organ. On the anterior wall, about 4 cm. from the cardia, is a perforation the size of a three-penny bit. For 1 cm. about it the mucosa is ulcerated. No other spot of ulceration exists. The left supra-renal capsule is enlarged, and partially involved in cancerous disease. About it also are several small firm nodules. Nothing special in the other organs. (b.)—Cancer of Stomach—Extensive Ulceration of Anterior Wall—Left Lobe of Liver projecting into the Organ. Sarah W., aet. 43. Ill for six months with all the ordinary symptoms of cancer of stomach. Moderate emaciation. G-eneral cedema—slight in trunk. In abdomen, parietal peritoneum adherent to omentum in epigastric region. About two quarts of turbid fluid removed. Omentum retracted and puckered. Left lobe of liver and stomach firmly united together. Stomach of average size. Orifices free. On slitting it open along the greater curvature, a large ulcerated surface is seen on the anterior wall and lesser curvature, nearer the pylorus than the cardia, and about the size of the palm of the hand in extent. On pouring water upon it, part of the left lobe of the liver is seen to project through the centre, while the peripheral parts are in a soft, sloughy state. The walls at the margins of the ulcer are infiltrated and thickened, but not to a very great extent. No secondary masses in other organs. (c.)—Cancer of Stomach—Flattened Mass, not Ulcerated— Secondary Masses in Mesenteric Glands, Pancreas and Gall-bladder. Mary J.,aet. 60. Fairly well-nourished. Admitted into BY WILLIAM OSLER, M.D. 51 the Hospital March 14th. Ill for ten months. G-astric symptoms not marked. Great pain in epigastrium, in which region a prominent tumour could be felt. Jaun- diced for some weeks before death, which took place ten days after admission. Autopsy.—On opening abdomen, transverse colon crosses just above level of navel, and is full of hard faeces ; a great part of the tumour, evident externally, was due to this cause. There is a nodular mass outside the pyloric end of stomach, composed of enlarged glands. The head of the pancreas is large, and the mesentery forms a pro- jecting mass, containing numerous cancerous glands, and is especially thick at the root and in region of the pan- creas. Stomach.—The pyloric zone for a distance of 5 cm. from the ring is firm, thickened, and the seat of cancerous disease. The orifice is a little contracted, admitting the index finger with difficulty. The disease occupies the lesser curve, and the anterior and posterior walls, leaving only a narrow portion, 2 cm. in breadth, unaffected. From the region of the lesser curve it projects into the duodenum for 1 cm. in the form of irregular fringes. The-cancer is flat, with smooth, unulcerated surface, but here and there crossed by small fissures. On section it is seen to involve the entire mucous membrane, but the muscular coats are intact. The affected area forms a sort of flattened groove passing towards the pylorus, while the unaffected portion of mucosa forms a deeper and narrower channel, sharply bounded by the edges of the cancerous mass. In hepatico-duodenal ligament, common bile duct is pervious, bile enters duodenum on pressing along its course. Portal vein is a good deal narrowed close to head of pancreas, by pressure of cancerous glands in this locality. All the tissues in the ligament are matted together, and close to the hilus of the liver there are several enlarged glands, which press upon the hepatic 52 PATHOLOGICAL REPORT. ducts. The neck of the gall-bladder is involved in a secondary mass. The Pancreas is enlarged, very firm and dense', and is the seat of secondary disease. Liver presents several small nodules at posterior border. Mesentery greatly enlarged, owing to the presence of numerous cancerous glands, some of which are as large as small apples. Some are undergoing caseous degenera- tion ; others are firm and hard. Only a few have a true cancerous aspect. 3.— Three Cases of Ulcer of Stomach. (a.)—Simple, Round Ulcer. A. R., a well-developed man, patient of Dr. James Kerr, suffered for over a year with well-marked symptoms of ulcer of stomach. Several attacks of haematemesis ; death occurred during one of them. Stomach of average size. On lesser curvature a thick- ened mass can be felt, made up of indurated omental tissue and fat; beyond, in posterior wall, there is a slight puckering. When the organ is opened, this is found to correspond to an oval loss of substance, situated in the lesser curvature, 7 cm. from the pylorus, and extending more towards the posterior than the anterior wall. Its long diameter, which is at right angles to lesser curve, measures 2*8 cm., breadth 2 cm.; edges are rounded, cleanly cut, and formed by mucous membrane. They are under- mined to a variable distance, 2-6 m. The ulcer is toler- ably deep, the base made up of dense fibrous tissue, rough and irregular from the presence of bands, and the ends of obliterated, as well as open, vessels. These are very numerous, four presenting gaping orifices. On injecting water into the gastric artery, it flows in a full stream from the larger of the orifices. The base at the curvature is BY WILLIAM OSLER, M.D. 53 thick from the condensed tissue behind it, but on the posterior wall it is thin and translucent, and at this part the outline of a bifurcation of the gastric artery can be clearly seen. The zone of pylorus, extending for 25 cm. about the ring but not involving it, is thickened by an hypertrophy of the muscular coats, in some spots 1 cm. in thickness No affection of the mucosa. Nothing of note in the other organs. (b.)—Multiple Ulcers {simple) at Cardiac End of Stomach— Old Fibroid Tubercles in Lungs. D. M., aet 55. History of dyspepsia for three or four years ; never haematemesis. Had had a cough for some months. Died somewhat suddenly during an attack, apparently, of congestion of the lungs. Stomach.—Immediately below the cardiac orifice, on the posterior wall, is an ulcer 14 cm. in diameter; base fibroid, of a greyish-white colour; edges firm, not much elevated. Mucous membrane about it puckered. On peritoneal surface is a firm mass of fibroid tissue. In the fundus, towards the posterior wall, at a distance of 2 to 4 cm. from the large ulcer, are five smaller ones, the largest the size of a three-penny bit; edges firm, bases greyish-white, and peri- toneal surface a little thickened. Mucous membrane in other parts of the organ healthy, but covered with a tena- cious mucous. Lungs.—An excess of blood and serum in posterior parts. At apices there are fibroid areas, that in the left lung large and tissue about it much pigmented. No caseous masses. Throughout upper lobes numerous groups of firm miliary granulations, grey in colour, and very dense. They exist in groups of from 50-80, for the most part isolated, only a few had merged together. Not many in other lobes. Bronchial glands not enlarged. No caseous masses. 5* 54 PATHOLOGICAL REPORT. Examination of the ulcers gave no evidence of a tuber- culous origin. (c.)—Ulcer in Stomach—Fibroid Phthisis—Hypertrophied and Dilated Right Heart. Katherine H., aet. 39. History of cough for over 10 years; always worse during the winter. For the past three years has had occasional attacks of haemoptysis. Admitted suffering from dyspnoea, with dropsy of legs and belly; enlarged liver and spleen. At Autopsy, fibroid induration, with cavities, in upper half of both lungs ; hypertrophy and dilatation of heart, particularly of right chambers. Amyloid liver and spleen. Stomach, at cardiac end, presents elongated lines of hae- morrhagic infiltration of the mucous membrane. About the middle of the posterior wall is a yellow slough, 6 by 10 m., involving the mucous coat. Its surface is soft, and is on a slightly lower level than the surrounding mucosa. At the pylorus, close to the ring, there is an ulcer, 25 by 8 m., and extending to a depth of from 3 to 4 m., exposing the muscular coat. No plugged vessels could be traced in connection with either of these spots. Veins of the sub- mucosa are much enlarged. 4.— Three Cases of Simple Ulcer of Duodenum. (a.)—W. B., aet. 40, patient of Dr. F. W. Campbell. Chief symptoms : vomiting, coming on very irregularly ; attacks of pain; haemorrhage from stomach and bowels. The condition was diagnosed ; death took place from haemor- rhage. Autopsy.—Moderate emaciation. In abdomen, stomach appears a little dilated; lower coils of small intestine dark-coloured. Nothing special in thorax. Stomach somewhat dilated ; walls of moderate thickness. BY WILLIAM OSLER, M.D. 55 Mucous membrane pale ; at the cardiac end, thin. Pyloric orifice is narrowed, admitting the little finger to the 2nd joint. When slit open, there is no special thickening ; but the mucosa is puckered, and presents an elevated ridge. Duodenum.—Part immediately outside the ring much narrower than adjacent regions, measuring only 3*7 cm. About 10 m. from the pylorus there is an oval ulcer on the mucous membrane 2 5 by 1*8 cm., extending in direction of axis of gut, and occupying chiefly the posterior section of the tube. It is deep, with rounded edges, which, toward the upper and back part, are undermined for about 6 m. In places the floor of the ulcer is quite 6 or 7 m. below the level of the mucosa, and presents a tolerably smooth, fibrous appearance. The head of the pancreas forms the base of the lower three-fourths, the upper part is protected only by the thin muscular walls of the first piece of the duodenum, the peritoneal surface of which, at the site of the ulcer, is puckered and cicatricial. Imme- diately in the centre of the floor is a small, dark, blood- stained elevation, consisting chiefly of fibrin. On injecting water through the hepatic artery, small clots are washed out at this point, and the water flows freely into the ulcer through an opening in the gastro-epiploica dextra, 2 m. across, and with smooth edges. The papilla of the bile duct is 6 cm. below the ulcer. Nothing else of note in intestines. {b.)^Y. W., set. 72, patient of Dr. Wilkins. Well- marked symptoms of ulcer, supposed to be gastric. Death took place slowly, after many months illness. Autopsy.—Body much emaciated. In abdomen, peri- toneum dull and lustreless ; two pints of turbid fluid, mixed with lymph, removed. Stomach appears dilated. (Esophagus presents in its terminal part an oval area, 3*5 by 1*2 cm., from which the mucous membrane has been 50 PATHOLOGICAL REPORT. completely removed by the action of the gastric juice. In the centre a thin external layer alone remains. Stomach moderately dilated, and contains a dirty-looking, highly acid fluid. Mucous membrane pale ; that of the fundus thin, owing to post-mortem solution. At the pyloric end it is thick, and presents numerous mammillations. The pylorus is greatly narrowed, admitting only the top of the little finger as far as the root of the nail. On slitting open the ring and the duodenum, the following condition is observed : pylorus not thickened ; ring prominent, but not more so than is often seen. Immediately external to it is an irregular ulcer extending round the greater part of the circumference of the gut, and presenting an imper- fect division into two portions, the larger of which occu- pies the lower part of the tube, resting upon the pancreas, the other being placed above and to the right. The extreme length of the ulcer is 3*7 cm., the breadth ranges from 6 to 13 m. The'edges are round, and somewhat undermined. The base is formed of firm fibrous tissue, of a greyish-white colour. Close to the lower edge there is seen, on the floor, a small nodular body, looking like the end of a closed artery. The mucous membrane of the duodenum near the ulcer is greatly puckered, particu- larly the upper part. The bile papilla is about 5 cm. below the ulcer. Nothing of special note in the other organs beyond the atrophy of extreme emaciation. (c.)—Mrs. R. S., aet. 48 years; a stout, well-nourished person. The following notes have been furnished by Dr. Rodger, under whose care the patient was.:—r *' She had been married upwards of twenty-four years, but never had been pregnant; had always menstruated regularly, but had ceased about three years ago. " The only illness of consequence that she ever had, was about fifteen years ago, when she was laid up in bed BY WILLIAM OSLER, M.D. 57 for about six weeks, with what was called an attack of inflannnation of the liver. No jaundice was perceptible at that time. Ever since, however, she has been troubled with dyspepsia, obstinate constipation, and more or less pain or feeling of discomfort in the region of the stomach. Her condition to-day, March the 18th, 187!>. is that of a person suffering from a well-marked attack of jaundice ; skin and conjunctivae deeply tinged; urine dark and stools pipe-clay in colour ; tongue coated ; loss of appetite ; no increase of temperature. She states that she has not felt well all winter, but was always able to attend to her household duties. " Patient came to my office for about four weeks ; still, at the end of that time, symptoms had not improved. " On April 24th, visited the patient at her house. Exam- ination revealed no enlargement of the liver, and only slight tenderness on firm pressure over the organ. Heart and lungs healthy. " Has noticed considerable blood at stool during the past few days, and faeces still pipe-clay in colour. No haemorrhoids. Dr. G-. W. Campbell saw the case in con- sultation, and gave a very unfavorable prognosis, though the exact nature of the disease was doubtful. " All treatment adopted proved of no avail; the patient rapidly became emaciated, and continued deeply jaun- diced. Several severe attacks of epistaxis have occurred lately, and to-day (May 30th) has passed more blood than usual by stool. " At three p.m., May 31st, commenced vomiting blood, and continued to do so frequently all afternoon, in spite of treatment. The haemorrhage from stomach and bowels became excessive, and death followed in a few minutes." Autopsy.—Body that of a well-nourished, moderately stout woman. In abdomen, coils of intestines, dark- coloured, from staining of mucosa; peritoneal layer smooth. Liver dark-coloured ; the ascending colon, the stomach and 58 PATHOLOGICAL REPORT. duodenum are closely adherent to the under surface of its anterior margin. Nothing special in thorax. Stomach, duodenum, pancreas and liver removed together. Stomach dilated and contains dark-coloured clots and remnants of food ; mucosa dark and blood-stained, otherwise unaltered. Pylorus normal. Immediately outside its well marked ring, in the upper and back part of the duodenum, is a large orifice 3*5 cm. in length, 1*5 cm. in breadth. It is partially blocked wTith clots, on the removal of which an oblong cavity is disclosed, occupying the under surface of the liver, in the position of the gall-bladder. The edges of the orifice are smooth and round, and the two fingers can be inserted into the cavity as far as the second joint. A good deal of thickening exists about the duodenum, where it is attached to the gall-bladder. Mucous mem- brane is not, however, puckered, and in the rest of its extent is normal. The following is the condition of the tissues in the hepatico-duodenal ligament:—Portal vein uninvolved, normal in size. Common bile duct pervious, and can be traced down to the upper margin of the ulcer, where it appears to open; at least, the probe-pointed scissors cut down freely and exposed the orifice at this situation, and it could not be further traced. It has probably been cut across by the ulcer. Walls are thick- ened. Branches in the liver normal. The cystic duct joins it by a small orifice, into which the plrobe can pass for 1*2 cm., and then meets with an obstruction on the wall of the sac. The hepatic artery when slit up is natural- looking ; on following up the branches, a probe inserted into the main division of the right branch, which passes backwards and outwards, enters the upper end of the gall- bladder, and on slitting it open the wall is seen to be ulcer- ated through in a space 3 by 2 m., and the vessel commu- nicates freely with the sac*. The gall-bladder was then exposed, and is found in a condition of ulceration. Only towards the upper part is there any trace of mucous mem- BY WILLIAM OSLER, M.D. 59 brane ; in the rest of its extent the wall is rough, ulcerated, and, in places, sloughing. There is a deep prolongation towards the hilus of the liver, the tissue of which at this part is exposed and sloughing. It is here where the ulceration of the artery has taken place. The ascending colon, close to the flexure, is adherent to the gall-bladder, and between the two there exists a circular orifice of communication, 7 m. in diameter, with rounded edges. There is no appearance about the ulcer or the gall-bladder to indicate a cancerous source of the disease. Liver a little enlarged ; tissue very dark-coloured. A distinct triangular-shaped notch exists at the site of the gall-bladder, and the parts above are cicatrical. Scattered throughout the organ are numerous small isolated masses presenting the characteristics of secondary cancer; one only is as large as a walnut. In looking for the primary disease, the parts about the right ovary are found matted, tore readily on removal, and appeared in a diseased con- dition. Only a very small bit could be surreptitiously removed, and this, unfortunately, did not give any clue to the nature of the disease about the ovary. 5.— Typhoid Fever—Rapidly Fatal, with Nervous Symptoms. Ellen C, tet. 24 ; domestic servant. Was admitted to Hospital, under care of Dr. Ross, March 14th, at midnight. Illness began twenty-four hours before admission with chills and fever, followed by vomiting and purging. Employer states that she had not looked well for some days previous. When admitted she was delirious and in a state of extreme depression, resembling collapse. When spoken to, answers questions and then sinks again into a dull, heavy condition. Vomiting. Diarrhoea. Pupils equal and of normal size; surface livid and cold ; pulse extremely small and weak, not very rapid, but can scarcely 60 PATHOLOGICAL REPORT. be counted. Breathing shallow, but regular. Every few minutes there are convulsive jerkings of the head and limbs. Does not complain of any pain. Temperature, 104 . 15th.—Unconscious all the day. Vomiting and purging continue. The limbs are in a semi-rigid state and resist flexion; jerkings not marked. Pupils dilated. Pulse extremely feeble. Temperature, 105.° She remained in this state until 11 p.m., when death took place, just 48 hours after onset of severe symptoms. Autopsy, 12 hours after death. Body that of a small- sized, well-nourished woman. Nothing of special note in inspection of abdomen and thorax. Heart normal; blood fluid. Lungs crepitant; a good deal of blood in dependent parts. Spleen somewhat enlarged, weighs 185 grams.; pulp, soft and dark-coloured. Nothing abnormal in stomach. Duodenum and jejunum contain yellow, semi-fluid, contents ; mucous membrane healthy. Lower half of ileum presents the following appearance : Bowel not very vascular, submucous vessels moderately full; capillaries of mucosa not injected. Solitary glands are enlarged and prominent; many are as large as . split peas and of an opaque white colour. Peyer's patches are enlarged and swollen; five or six upper ones, from 3 to 5 cm. in length, are greyish-white in colour. Surfaces unbroken or only pitted in one or two spots. Five patches, within a foot of the valve, are in a more advanced state; the largest, 6 cm. in length, has an irregular cribriform surface, the pits reddened, the margins and unruptured follicles greyish-white. The others are not so open. Very little swelling or injection of the mucosa about the patches. Mesenteric glands very little, if at all, swollen. Large bowel normal. In Brain—Vessels of pia mater full; nothing special in the substance. BY WILLIAM OSLER, M.D. 61 6.—Perforation of Appendix Vermiformis—Circumscribed Abscess — Perforation of Ileum — Hemorrhage from Bowels. A. B., aet. 45 (under care of Dr. A. A. Browne). In Febru- ary, 1*78, had a severe " bilious attack," lasting about three weeks, and from which he got quite well. On April 24th, 1879, had another attack, chief symptoms being severe vom- iting, flatulence, constipation, and a thickly-furred, moist, brown tongue. The attack yielded to ordinary remedies, and by May 24th, the tongue was clean, the appetite much improved and the bowels acting better, although the stools were still very clay-coloured and offensive. The flatulence continued, although not so distressing, and the belly remained considerably distended. There was no pain on pressure over the distended bowels at any time or at any point. From this time (24th) his symptoms became aggravated ; that is, the flatulence was more distressing and the bowels became loose, with yeasty, clay-coloured, very offensive motions. He now began to lose flesh very rapidly. Symptoms continued much the same up to morning of the 9th of June, when, about 8 o'clock, he passed a large quantity of blood in bed ; it was florid, mixed with dark clots, and loose fiecal matter. He com- plained of pain in lower part of belly. At 12.30 he lost again a still larger quantity and sank rapidly, dying at 4 p.m. the same day. Autopsy, 24 hours after death. Body that of a large, well-nourished man; no signs of post-mortem decomposi- tion; belly greatly distended. In making preliminary incision a coil of intestine was accidentally wounded, and a quantity of very foetid gas escaped. Small intestine is enormously distended and very dark-coloured; the coils are as large as the thick part of an average sized forearm. This condition exists in all parts, with the exception of the first few inches of the 6 62 PATHOLOGICAL REPORT. jejunum, and the terminal part of the ileum. There is no fluid in peritoneum, nor is the membrane inflamed. On tracing down the coils of bowel, they can be followed for four or five feet, and then the lower ones, in the neighbourhood of upper part of pelvis, become matted together, so that it is impossible to separate them without tearing. Lying upon the promontory of the sacrum, and extending towards the right side, is a flattened purulent sac, the size of the palm of the hand, and to this the coils of the ileum and the mesentery are closely adherent. On dissection the following condition was discovered:— Coecum and large bowel normal. Appendix vermiformis is long, passes horizontally out and is firmly attached to the purulent sac, with which it communicates by two openings. When slit open, the mucous membrane of the outer third is rough and in places denuded, while at the extreme apex are the two round perforations. This part of the appendix is very closely united to the wall of the sac. Several coils of the ileum are in close union with the sac, and when slit open two perforations are seen. In the neighbourhood of these are several ulcers on the mucosa. The intestinal wall is so softened that the dis- section without tearing was impossible. The mesentery is also firmly united on the upper wall of the sac, and one of the vessels in it is plugged, with a firm thrombus. The origin of the fatal haemorrhage was not discovered. (b.) Liver. 7.—Hydatid Cyst. The specimen was found in the liver of a subject in the Class of Operative Surgery during the Summer Session Patient, a tramp, had been admitted to the Hospital with Pneumonia, of which he died. No information could be obtained from him as to his past history ; so that it is not BY WILLIAM OSLER, M.D. 63 known how long he had been a resident in the country. The cyst occupies the posterior part of the right lobe of the organ, and is in dose contact wTith the diaphragm. On removal, it measures 10 by 8 cm., and is about the size of a large orange. The following parts appear on dissec- tion :— (1.) The external cyst-wall, intimately adherent to the liver substance. It is firm, dense and fibrous, in some places of cartilaginous consistence, and here and there covered with soft cretaceous matter. (2.) Lining this is the internal capsule or proper sac; a translucent membrane, 1*5 m. in diameter, easily torn, in places bile-tinged, and on the inner surface presenting a finely granular appearance. (3.) Within this are four or five secondary or daughter cysts with exceedingly delicate membranes, so that they burst on being turned out, and gave exit to a quantity of jelly-like fluid; and numerous smaller grand-daughter cysts of all sizes, from a pea to a large walnut. In colour they are opaque white or perfectly translucent. All are partially collapsed. On examination some of the cysts contain only granular matter; others, the majority, con- tain innumerable hydatid heads. These are free in the fluid of the cysts. No brood-capsules met with. In some of the larger cysts, a fourth generation is seen in the form of small bead-like projections from the lining membrane, ranging in size from a pin's head to a pea; some are pedunculated, others free. They consist of a laminated sheath, enclosing a dark granular mass. Remarks.—Hydatid disease is very uncommon in this country. I believe one case occurred in the General Hos- pital some years ago; and Mr. Mignault read a paper, at a recent meeting of the McGill Medical Society, on a case of hydatids of the liver, which he met with last summer in the Eastern Townships. These are the only examples of the disease in this country with which I am acquainted. 64 PATHOLOGIC A L REPORT. I do not think that any case has been recorded in the Journals. In my helminthological studies, I have examined some scores of dogs, and have not yet found a specimen of the Taenia ecchinoeoccus. 8.—Primary Cancer. A. II., aet. 54. Patient of Dr. Drake's. A temperate man, of spare habits. History of dyspepsia for over two years. Up to eight weeks before his death was able to attend to his work as usual. Since this time he has been laid up—the chief symptoms being pain, enlargement of the liver, gastric disturbance, and rapid emaciation. During the last week of life, jaundice supervened. Autopsy.—Liver could be felt as a firm, hard structure, nearly a hand's breadth below the costal margin. On opening Abdomen, nothing special observed beyond the enlargement of this organ. In Thorax, moderate effusion in right pleura. Heart, •small. Lungs—Cheesy masses and small cavities at apices, together with much fibroid tissue. Firm miliary granu- lations in neighbouring lung tissue. Liver much enlarged; weight 3,000 grams. ; normal shape retained. Adhesions, recent and old, to diaphragm. Upper surface smooth, but presents many flattened and rounded eminences of a yellowish-white colour or mottled with red. They project but slightly, and only two of them present shallow depressions. The masses range in size from a pea to a large walnut. On the under surface the masses are not so numerous. On making a section through the organ the greater part of the substance appears occupied by the cancerous masses, the limits of which are often ill-defined, blending with the bile-stained liver tissue. In addition to the usual areas of an opaque white colour, with vascular BY WILLIAM OSLER, M.D. 65 borders, there are others of a pale-brown hue, particularly numerous on the under surface of the organ. There is no single large mass, but all parts of the organ appear equally involved. Tissues in hepatico-duodenal ligament thickened. Giands a little enlarged. Vein in its primary branches com- pressed ; right branch only admits the top of the little finger. Stomach—Mucous membrane much mammillated, espe- cially at the pylorus, where the little fissures separating the mammillae are unusually deep. The membrane is tough, tearing with difficulty. Spleen, pancreas, and kidneys, normal. Nothing of note in large or small intestine. No other cancer found, after careful search in all organs of the body, except the brain, an examination of which was not allowed. 9.—Cirrhosis of Licer—Collateral Circulation by Means of an Enlarged Umbilical Vein — Death from Pneu- monia. Body that of a small, but well-nourished woman. So far as could be ascertained, she had never suffered from ascites or any symptoms of cirrhosis. On opening abdomen a large tortuous vein is seen, passing from the liver in the round ligament to the umbilicus, where it is continuous with the deep epigastric veins of the left side. It does not communicate with the superficial epigastric vessels, but unites at once with the deep, the two main branches of which, on the left side, are greatlv enlarged and can be traced down beneath the peritoneum to the internal iliac, where they open by a single vessel, which also receives branches from the wall of the pelvis and the bladder. Veins of left ovary and in broad ligament of this side are much enlarged ; right, not to the same extent. Inferior 66 PATHOLOGICAL REPORT. cava is increased in size, and measures 5*5 cm. across, just above the renals. Liver weighs 1,755 grams., and is very irregular in shape. Capsule is smooth but opaque. There are no superficial granulations as in the " hob-nailed " organ, but the surface is mapped out into large hemispherical areas, separated by shallow grooves. On the under side there is consider- able deformity from the projection of a large mass, half the size of the left lobe, and apparently formed by the lobus Spigelii and lobus caudatus. On section the increase of the fibroid tissue is chiefly in the sheath of Grlisson, large areas of the liver substance being compressed, and but very little excess of connective tissue between small groups of lobules, as in the ordinary form of cirrhosis. In the hepatico-duodenal ligament, bile duct is pervious ; hepatic artery is natural. Portal vein admits index finger; when slit open its branches in the liver are found considerably contracted, the largest going to the right lobe only admits an ordinary sized lead- pencil. Passing off from the portal, towards the anterior border, is the large vein described above, as running in the round ligament to the umbilicus. At its origin it admits the tip of the little finger. Inferior cava, where it passes through the liver, admits three fingers. Upper and middle lobes of right lung in state of puru- lent infiltration. Kidneys moderately fibroid. Left ventricle hypertro- phied. 10.—Pylephlebitis. J. P., aet. 26, a commercial traveller, patient of Dr. F. W. Campbell, who has kindly furnished the following notes :—Had been ill for several weeks in July with an attack of inflammation of the caecum, and in August, BY WILLIAM OSLER. M.D. 67 when he returned to Montreal, he was weak and much emaciated. On August 9th, tongue white, abdomen much distended, with clear percussion note over every part except transverse and upper part of descending colon. Complains of shooting pains, which are relieved by passing wind. Has no appetite, feels sick at stomach, and occasionally vomits. Under nitro-muriatic acid and pepsin mixture, with poultices to belly, he improved somewhat, but early in September the symptoms returned, the pain became more severe, and there were acid eructations. Continued to get weaker and more emaciated in spite of very active supporting treatment. In the end of September he appeared somewhat better, and was able to sit up each day for an hour or so. On the morning of the 10th of October he was found dead in bed. Autopsy.—Body much emaciated. No jaundice. Exter- nal abdominal veins not enlarged. On opening abdomen, entire peritoneum of a deep slate-colour, and covered in spots with soft, easily removable flakes of lymph. About 6 oz. of turbid serum in pelvis, and at bottom of this cavity a little more than an ounce of pus. On carefully inspecting the coils of intestines from the duodenum downwards, the central part of jejunum appears specially dark, and the portion of mesentery corresponding to this is much swollen and fluctuates. All the coils are relaxed and of a very peculiar colour. Signs of past peritonitis in the form of old bridles in neighbourhood of ascending colon. On pelvic peritoneum, a little to the right of the centre of the lower third of rectum, is a small superficial slough, the size of a sixpenny bit; the base grey and stringy, the tissue about it discoloured and a little haemorr- hagic. It is situated in the part of the pelvis where the pus had lodged. No inflamed veins can be traced in connection with it. Stomach, liver, mesentery and portion of jejunum removed together. Mucous membrane of 68 PATHOLOGICAL REPORT. stomach pale, and presents on anterior wall two or three round swellings, the largest the size of a small walnut; and from this one, on pressure, pus oozes at .1 small orifice. In duodenum, bile flows from the duct on pressing the gall-bladder. Throughout the small intestine the mucosa is sodden, dark in colour, blood vessels not distinct ; no ulceration. In c-ecum, orifice of appendix is obliterated. It is firmly adherent and presents on its upper surface a small superficial slough involving the peritoneal and muscular coats. Tissue in neighbourhood injected, but no great amount of lymph. On slitting up the tube, mucous membrane dark, not ulcerated ; no perforation at the slough. Caecal end obliterated for 6 m. No suppur- ating vein could be traced in connection with the slough. The mesentery in its whole extent is thickened and infiltrated, and in the central part has a boggy, fluctuating feel. In places it is covered writh flakes of lymph. When cut into a large quantity of creamy, inodorous pus escaped, and was thought to come from a mesenteric abscess. On squeezing the membrane, however, the pus is seen to ooze from several points, and on inserting the probe-pointed scissors and slitting in the direction indi- cated, distinct channels are found, wThich can be followed towards the root and also towards the intestinal border. ',' In the former direction they" connect with the mesenteric vein; in the later it was not possible to determine accurately how they ended, most of them apparently by blind extremities at the intestinal border. They commu- j.' nicate freely with each other, forming a series of elongated j cavities filled with pus. No mesenteric vessels filled with .1 blood can be seen. A few lymphatic glands noticed; none suppurating. On tracing up the mesenteric vein, 4 the suppuration extends into the portal and gastric veins. The splenic vein is closed at its junction with the gastric, f The trunk of the latter contained pus, and its branches passing from the greater curvature along the anterior ) BY WILLIAM OSLER, M.D. 69 wall are much dilated and tortuous—the swelling on the mucosa being in connection with them. The walls of the portal vein are thickened and matted with the sur- rounding tissues. It contains a quantity of creamy pus, and the internal lining when washed has a rough, shreddy appearance. It is somewhat narrowed at the commencement, but widens as it passes up. On slitting open the main branches in the liver they are found dilated, full of pus, walls greyish-yellow in colour, and presenting here and there bits of sloughing membrane. On every section of the organ suppurating veins are seen, from which pus flows freely ; they often look like local abscesses, but in every instance they could be traced in connection with branches of the portal vein. The vessels of the right lobe were more dilated than those of the left. Hepatic artery and its branches are normal. Hepatic duct pervious; its branches in the liver contain bile. Liver itself not much, if at all, enlarged ; substance of a deep brown colour, in places almost black. The tissue in immediate contact with the suppurating veins, for from 1 to 2 m., is of a yellowish-grey colour, and sharply limited from the rest of the substance. URIXARY SYSTEM. Kidneys. 1.—Extensive Scald of Thorax — Pneumonia — Numerous Sjnds of Fatty Degeneration in Kidneys. A. B. Severely scalded in upper half of front of the chest and in front of shoulders and arms. Death from m pneumonia of right lung. Kidneys, enlarged; capsules detach easily. Surface mottled. On section they present a very peculiar appearance. Scattered through cortices and medullse are 70 PATHOLOGICAL REPORT. numerous small isolated areas, yellowish-white in colour, and contrasting strongly with the tissue about them. They are about 2 m. in diameter and are solitary, not running in lines. They are equally abundant in both organs. On examination they appear to be localized spots of fatty degeneration affecting limited areas in the tubules ; the epithelium is in places distinct, in others obscured by the amount of molecular fat and oil drops. The tissue in immediate neighbourhood is not altered, and nothing abnormal could be detected in the blood vessels. 2.—Small Contracted Kidneys—Left Organ affected lo an unusual degree—Right only involved in the lower part —Hypertrophy of Heart. Ann T., aet. 40 ; a washerwoman. Admitted January 4th, under Dr. Ross. Five years ago suffered with pains in limbs and severe headache, with a pemphigoid eruption, probably syphilitic.* Has enjoyed fair health until last September, when, after exposure to cold, she had a febrile attack, followed by general dropsy, headache, pains in back, bloody urine with casts. Remained in Hospital six Weeks, and was discharged much improved. When re-admitted, at above date, had general dropsy, anaemia, cough, dyspncea, headache, and pa.in over cardia. Urine scanty, 16 to 20 oz.; low sp. gr., 1,003; contains 40 per cent of albumen. A few granular casts. Heart enlarged ; systolic murmur at apex. Patient improved rapidly under digitalis. Jan. 21st.—Worse again. Urine diminished in amount. Condition varied from day to day, severity of the symptoms being in inverse ratio to amount of urine and of urea elimi- nated. Variations in 10 days, 24th to February 4th :— Urine, 24 to 64 oz.; urea, 94 to 167 grains. Towards end of February effusion took place into both pleurae. Cough BY WILLIAM OSLER, M.D. 71 and dyspnoea increased. Patient gradually lost conscious- ness, and died on the 2nd of March. Autopsy.—Body that of an average sized, moderately well-nourished woman. (Edema of legs ; slight puffiness of face. In thorax, about a pint of clear serum in each pleural cavity. Kidneys.—Right much mis-shapen, consisting of a large, natural looking, upper segment, still lobulated, and a diminutive, greatly shrunken lower portion. Capsule peels off easily ; surface of upper part is smooth and natural looking ; that of the atrophied portion is darker in colour, finely granular, and in places puckered. Limit between these two regions very sharply defined, extend- ing farther up on the anterior than the posterior side. Organ cuts firmly; tissue of upper part normal, but pale, vasae rectae alone visible. Vessels at bases of pyramids distinct. In the lower atrophied region there is only a narrow zone of cortex, very granular and coarse looking; pyramids small, flattened, in places scarcely distinguishable. The small arteries have very thick walls and stand out prominently between the two areas. Renal artery, firm; walls thick. Pelvis and ureters normal. Weight of organ, 75 grams. Left Kidney, not so large as a testicle ; weight, 20 grams. It is composed almost entirely of a thin cortical region 2-4 m. in thickness, and scarcely distinguishable as kidney substance. Pyramids very much flattened, in spots not recognizable. Pelvis and ureter small and |[.. shrunken, but pervious. Capsule thick and dense ; peels off readily, leaving an excessively granular surface. v Heart enlarged, due chiefly to hypertrophy of left ventricle. Valves healthy. Left ventricle, 10 cm. from | aortic ring to apex ; circumference, 14 cm. Anterior wall, middle part, 2 cm. in thickness. Aorta presents numerous atheromatous patches. Small 72 PATHOLOGICAL REPORT. arteries of the body—mesenteric, splenic, gastric and radial, moderately still. Lungs oedematous in posterior parts. 3.—Large Cirrhotic Kidneys [Congested)—Hypertrophy of Heart—Apojilextj. ^ * Susan G.,aet. 40. Admitted under Dr. Ross. March 10th, with right facial paralysis of three weeks duration. Complains of weakness, short breath, and violent action of the heart. Is anaemic; superficial arteries firm and tortu- < ous. Heart large ; impulse strong. Apex beat indistinct; no murmur. First sound distant; second strong, sharp, and loud. Urine about 40 oz. per diem ; contains 20 to 30 per cent, of albumen. BowTels loose. Symptoms did not vary until the 15th, 2 A.M., when she was suddenly seized with right hemiplegia, became comatose and died in two hours. There was constant tossing of the left arm and leg during the attack. Autopsy.—Body that of a well-nourished woman ; no dropsy. Nothing of note on inspection of thorax or abdomen. Kidneys.—Left, organ of full volume, but long and narrow. Capsule detaches without difficulty, exposing an irregular, coarsely granular surface of a deep red colour. | On close inspection, small white areas are seen on the projecting portions of the surface. On section, organ firm ; \ substance deeply congested. Pyramids somewhat darker than the cortex, which in places is thin, but for the most J part looks of normal thickness. At bases of pyramids are numerous prominent arteries, large and small. Tissue of I cortex is coarse, and on examination with a lens the J medullary rays can be faintly seen as opaque lines in the ] deep red back-ground, running up from the cones. Mal- pighian bodies not visible. Calices and infundibula are f large ; ureter normal. Right kidney a little smaller, and BY WILLIAM OSLER, M.D. 73 presents precisely the same appearance. No cysts in either. Renal arteries stiff and large ; left measures, at its central part, 10 by 7 m. Heart much enlarged. Considerable amount of blood in right chambers. Right ventricle large; columnae carneae much developed, causing great increase in the thickness of the walls (7-8 m). Tricuspid orifice dilated; heart cone 15 cm. in circumference passes freely through. Septum bulges a good deal towards this side. Left ventricle dilated; measures 9*5 cm. from aortic ring to , apex, circumference 16 cm.. Contains only one small clot. Walls very thick; anterior, close to septum, 3 cm.; septum, 2 cm. ; near apex, 1*8 cm. Muscle substance of good colour, but coarse looking. Valves normal. Coronary arteries a little stiff; no degeneration of intima. Arch of aorta healthy looking; button-like masses of atheroma in thoracic and abdominal portions, and some opaque white areas of fatty degeneration. Smaller arteries moderately firm. Brain presents a large extravasation in the left hemis- phere outside the ventricle, involving the anterior limit of the internal capsule, the anterior part of lenticular nucleus, and the white substance between these parts and the con- volutions of the central lobe. The caudate nucleus is not much affected, but is pushed forward and to the right. 4.—Sarcoma of Left Kidney. A. B., aet. 47. Had suffered for over two years with symptoms of renal disease, the haemorrhage being one of the most marked. In May, 1877, he passed a remarkably long blood cast of the ureter. About a year after the appearance of the first symptoms a tumour developed in the left side, and grew slowly and painlessly, while his strength and flesh progressively decreased. A remarkable feature of the case was the entire absence of pain, and up 7 74 PATHOLOGICAL REPORT. to within ten days of his death the digestion remained good. Autopsy.—Body that of an average sized, greatly emaci- ated man. On inspection, left side of abdomen presents a considerable enlargement, firm, immovable, and resist- ant to the touch. On opening the cavity, peritoneum smooth, no exudation ; A'iscera are pushed aside by a large tumour which occupies the hypochondriac and lumbar regions of the left side, and extends to the left beyond the middle line. The diaphragm is pushed up by the tumour to a level with the 4th rib on the left side, while below, the mass is in contact with the spine of the ilium. Smooth, glistening peritoneum covers it in front, the transverse colon crosses it obliquely about the upper third, and near the middle the pancreas is stretched across it to the duodenum. At the upper end the spleen is closely adherent. The tumour readily turns out, not having any very firm attachments. It is oval in shape, measuring 71 cm. in length, 60 in transverse circumference. Weight, 5400 grms. (12 lbs). Lower end is pointed; upper end more obtuse. Numerous superficial veins cross it in all direc- tions beneath the peritoneum. Anteriorly it is smooth and round, mapped out by superficial furrows into irregular masses of a greyish-white colour. Posteriorly, and a little to the right, there is a deep groove correspond- < ing to the point of attachment to the spine. At the lower * end of the mass the tissue looks of a reddish-brown ■■ colour ; here, on section, there is a thin layer of renal substance, nowhere more than 2 to 4 m. in thickness, and _' in immediate continuity with the soft medullary tissue of the tumour. At the inner border, close to the groove, for the spine, are the aorta and inferior cava. The former is closely connected with the growth, and gives off a slightly enlarged renal artery, and two smaller branches, all of which penetrate the mass. The inferior vena cava is of BY WILLIAM OSLER, M.D. 10 normal size up to the point where the renal vein enters About 4 cm. above the iliacs, a vein, the size of the little finger, enters from the kidney and is distended with a greyish-white thrombus which projects half way across the lumen of the cava. The renal vein is of enormous size, measuring 10*5 cm. in circumference, and can be traced for 12 cm. along the inner border of the tumour, receiving three branches in its course. All of these veins, with the exception of one entering from the adrenal, are distended with thrombi, greyish-white in colour; in the renal vein the thrombus is not adherent to the walls, but in close apposition. In the branches they are adherent. The thrombus projects from the vein into the inferior cava, up which it passes for a distance of 8 cm., nearly to the entrance of the hepatic veins. Here, also, it is loosely adherent, and a space exists along which the blood could readily pass ; the cava is in this part a good deal dilated, measuring 8*5 cm. in circumference. The thrombus ends in a tapering, rough, bifid extremity, attached to which are some shreds of fibrin. Passing down from the tumour along the side of the left iliac vein for some distance, is a distended tube filled with soft material; this, probably, represents the ureter, but, unfortunately, its prolongation towards the bladder was not traced. On the posterior surface of the mass, there is a large convoluted vein filled with a soft, greyish thrombus, and several smaller ones are to be seen at the left border, in the same condition. At the upper and anterior part of the tumour is the supra- renal capsule, greatly stretched and flattened, measuring ' 12 by 3 cm. It is easily separated ; its vein is free and empties into the renal. One retro-peritoneal gland in the neighbourhood of the aorta is enlarged and soft, but none of the other abdominal lymph glands are affected. On microscopical examination, the softer portions of the tumour are found to be made up of large irregular cells, with distinct nuclei. Many of these are exceptionally 76 PATHOLOGICAL REPORT. large, somewhat flattened, and with one or two central nuclei. In sections, the softer parts appear made up entirely of closely packed cells with very little stroma; but in the peripheral firmer parts a fibro-nucleated stroma occurs, in which the cells are imbedded, but there is no constant alveolar arrangement. The Pancreas is elongated and flattened. Right Kidney of full size; tissue a little coarse looking. Bladder normal. Lungs present posteriorly numerous small secondary nodules, ranging in size from a pea to a marble, chiefly in lower lobes. Spleen natural looking. Liver has one secondary nodule the size of a walnut at the posterior border. GENERATIVE SYSTEM. 1.—Dermoid of Ovary—Ulcerative Colitis. B. F., tet. 44. Admitted November 11th with profuse diarrhoea, and died on the following day. Autopsy.—Body that of an average sized, moderately well-nourished woman. On opening abdomen a conical shaped tumour is seen projecting from, and entirely filling, the pelvis, reaching nearly to the navel. The apex of the tumour projects to the left. No adhesions; no fluid in peritoneal sac. Uterus, ovaries, and tumour removed together, when it is seen that the latter is connected with uterus by a narrow, somewhat twisted stalk, 4 cm. long, representing the Fallopian tube of this side, while the tumour corresponds to the ovary. It is about the size of an infant's head, ovoid in shape, smooth externally, and free from adhesions. To the touch it is soft and doughy, but on firm pressure a harder mass can be felt in the centre. On section a quantity of dirty-looking, semi- diffluent matter escaped, mixed with long hairs. In the BY WILLIAM OSLER. M.D. 77 centre there is a firm mass the size of the fist, greyish- white in colour, of the consistence of putty, and consist- ing of inspissated sebum, intermingled with hairs. On removal of this and after washing out the cyst, the lining wall appears rough and covered with scales, looking like a bit of ichthvotic skin. The part near the attachment of the tumour is thicker and more fleshy, and here numerous long dark-brown hairs are attached, some 35 cm. in length. Where the long hairs are absent, there are numerous small pubescent ones. Corresponding to the insertion of the stalk there is a strawberry-like projection of the cyst wall, indentated with orifices of sebaceous follicles; immediately above this a bicuspid tooth is inserted, with well developed crown, neck, and fang, the latter inserted into the cyst wall for 5 m. Close to it, beneath the lining membrane, there is a flattened piece of bone, irregular in shape, notched, and dentated, measuring about 10 m. in each direction. Fallopian tube can be traced up to the base of the tumour, at which part it is coiled. Uterus and opposite ovary normal. Ccecum and Colon present innumerable small ulcers. 2.—Cancer of Neck of Uterus—Constriction of Right Ureter —Pyoneph ros is. Mary B., ret. 40, ill for more than a year with well- marked symptoms of cancer at neck of uterus. For more than four years had suffered on and off with haemorrhage from the uterus; and this has been a prominent symptom through her illness. No special symptoms referable to kidneys. Autopsy.—Body much emaciated. In abdomen, small quantity of sero-purulent fluid. On drawing the small intestines aside, the right kidney is seen to be enormously enlarged, extending from high up beneath the liver to below the crest of the ilium. In 7£ 78 PATHOLOGICAL REPORT. pelvis, uterus is in position ; there is thickening about the broad ligament of the right side. Right kidney, uterus, bladder, and rectum removed together. On dissection, rectum is closely adherent to vagina and neck of uterus; mucosa normal. On slitting up vagina, the upper zone is rough and ulcerated, the posterior wall being deficient in one spot. The lips of the uterus are gone and the walls of the cervix are puckered, dense, and roughened. A narrow orifice com- municates with the cavity of the uterus, the mucous membrane of which is dark-coloured but intact. The disease is entirely confined to the cervical region and upper part of the vagina, and consists chiefly of fibroid induration, the softer portions having disappeared in the ulceration. Behind and to the left side of the uterus is a sac filled with pus, about the size of a small apple. It occupies the broad ligament and extends almost to the vagina. The Fallopian tube and ovary of this side cannot be seen, having apparently been involved in the formation of this sac. When laid open the walls are rough, sloughy, and crossed here and there by fibrous trabeculae. There is no communication with the uterus or with the disease at the neck. Right Kidney forms a large fluctuating tumour, irre- gularly sacculated, and when cut into nearly 30 oz. of thick pus escaped. The whole organ is composed of a number of sacculi, communicating with the pelvis ; some of them are as large as an orange. The walls are thin, 1 to 2 m., and covered internally by a rough, greyish mem- brane. The capsule of the organ is thickened, but strips off easily, leaving a dark surface, which still retains some appearance of kidney substance. Pelvis is moderately dilated, in proportion to the kidney; the ureter communi- cates with it by a narrow orifice, 10 m. in circumference, beyond which the tube is dilated, and in the body was BY WILLIAM OSLER, M.D. 79 as large as the thumb. Walls are thick, mucosa pale; not ulcerated. On tracing it down it retains its large size to within 12 m. of the bladder, where it appears to terminate in a blind extremity; but at the bottom of this apparent cul-de-sac there is a small orifice through which a bristle can be passed into the bladder, the narrow canal being about 16 m. in length. The constriction of the ureter at this part has resulted from its involvement in the contraction of the fibroid tissues about the neck of the womb. Left Kidney is normal; its pelvis and infundibula are slightly enlarged. Ureter is a little narrowed near the uterus. 3.—Ruptured Follicle in Rigth Ovary—Peritonitis. E. L., aet. 28. Admitted March 11th, with general peritonitis. Illness began on Saturday, the 8th, with a chill and pain in the abdomen. Continued at work, but on Sunday was much worse ; pain very severe, particularly on right side. She had menstruated three weeks before the commencement of the attack. When sent to Hospital on Tuesday, there were all the symptoms of general peri- tonitis, to which she succumbed early on the morning of the 13th. Autopsy.—Body that of a well-nourished, healthy look- ing woman. Abdomen distended, and when opened, intestines found matted together with recent lymph and peritoneum moderately injected. Inflammation most intense about the pelvic organs and specially in region of right ovary. More than a pint of sero-purulent fluid removed. Right Ovary 4*5 cm. in length, almost entirely covered with a layer of greenish lymph, which can be peeled off as a continuous membrane, exposing a discoloured, in- ilamed-looking surface. Close to the outer end, on the 80 PATHOLOGICAL REPORT. anterior surface, is a ruptured follicle with a blood clot hanging from it. The orifice is round, 2 m. across with thin, dark-coloured edges. The follicle is about the size of a large pea, lining membrane distinct, somewhat dark- coloured, but in one or two spots has a decidedly yellow tinge. A reddish-black clot, 7 by 5 m.. projects from it, being attached to the upper edge of the margin. The surface of the ovary surrounding the orifice is dark- coloured and a little roughened, and the same condition is seen upon the convex border of the organ. On section numerous Graafian follicles are seen in all stages of development, together with small cicatrices of corpora lutea, Left Ovary smaller, 4 cm. long ; surface discoloured but smooth, not covered with lymph. On section two corpora lutea seen ; largest 5 by 7 m. Wall slightly convoluted and pigmented ; centre, fibroid. Uterus—Length, 65 cm.; of cavity, 5 cm Peritoneal surface of a dirty-green colour, and covered with flakes of lymph. Organ soft; muscular walls of normal thick- ness. In cavity, mucous membrane of upper three-fourths covered with a bloody mucus, after the removal of which a thin deep-red mucosa is exposed. This exudation on the surface is composed of innumerable cylindrical epithe- lial cells—cilia ill-defined—leucocytes and a moderate number of red corpuscles. With these are fibrin fibrils and molecular fat, and occasional shreds of tissue made up of elongated cells. Teased bits of the mucosa show uterine glands, presenting nothing abnormal, and numer- ous blood corpuscles. Broad ligament and Fallopian tube on right side, covered with lymph ; not so much on left side. • Viscera of thorax present nothing abnormal. Abdominal viscera carefully inspected with a view of finding cause for the peritoneal inflammation. Stomach and intestines healthy. BY WILLIAM OSLER, M.D 81 Remarks.—Reference is made in obstetrical works to the possibility of the occurrence of peritonitis after rupture of a Graafian follicle, but I have not been able to find any- thing definite on the subject. The connection in this case would seem clear—in the absence of any of the well recognized causes of peritonitis, and considering the fact that the intensity of the inflammation was about the right ovary. It appears, moreover, to have been an ordinary ripe follicle which had ruptured, but somewhat prematurely, as she had menstruated three weeks before the attack. The blood in the uterine cavity was probably not men- strual in the true sense. The history of the beginning of the attack and of the antecedent circumstances are imper- fect, and there may have been constitutional or sexual disturbances of which we know nothing, but which may have had considerable influence in bringing about the inflammation. 4.—Extra Uterine (Abdominal) Pregnancy. S. A., ret. 35, patient of Dr. Kennedy's, was admitted under Dr. Ross on November 18th. Had expected her confinement (second child) about the middle of October. On July 24th foetal movements were distinctly lelt. Early in August she stated that she thought the child must be dead, as its movements had ceased, and on exami- nation they could not be felt. From the beginning of September she began to fail in health, got thin, and had chills followed by fever. The uterus was examined, and found to be healthyr. When admitted, she was pale. emaciated, and febrile. Abdomen is smooth, prominent, and somewhat tense ; the lower zone projects, but no definite tumour can be felt. On the right side, low down, there is fulness and hardness and great tenderness. She has severe rigors, followed by profuse sweating. On the 82 PATHOLOGICAL REPORT. 12th she had two greyish, very foetid stools, containing some macerated foetal bones, a tibia and three ribs. The next day she passed a temporal bone. No aperture could be felt on digital examination of the rectum. The condition of the woman precluded any idea of operative interference. She remained in this state until the 30th, when death occurred. Autopsy.—Body greatly emaciated. On opening the abdomen, peritoneal layers below the navel closelv matted together. After separation a tumour is seen, extending from the pelvis as high as the transverse colon, to which it is attached ; while latterally it encroaches on the ingui- nal regions. The tumour is about the size of a child's head; anterior walls flaccid, and when cut into a large quantity of material, looking like a mixture of ashes and water, escaped. In this are the bones of a fcetus, completely denuded of soft parts, and much blackened. All are dis- articulated and those of the head separated. The walls of the sac are from 2 to 4 m. in thickness ; the lining mem- brane is dark-grey in colour, in some places quite black. Behind the uterus the cavity extends as low7 as the neck, and on the right side are several sinuses passing into the tissues between the sac and the rectum. On the right side the sac is firmly adherent to the coils of the ileum; and in one or two places ulceration has almost caused perforation of the thin wall between them. A little to the left of the upper part of the sac is an oval orifice of communication with the sigmoid flexure, about 2 cm. in length ; edges rounded and dark in colour. In broad ligament of right side there is a cyst, the size of an apple, filled with material similar to that in the main sac, with which it is in communication by a valvular orifice. The Fallopian tube on this side terminates in the upper part ■] of the cyst wall in a blind, somewhat dilated, extremity. f Ovary of this side was not found. Tissues of broad ligament in both sides thickened and indurated; and in BY WILLIAM OSLER, M.D. 83 the right, below7 the smaller sac mentioned above, there are lines of suppuration running towards the os uteri, and some of the veins in this situation contain thrombi. Uterus is enlarged, 12 cm. in length. Mucous membrane soft, not hypertrophied. 5.—Cryptorch idismus. R. M., aet. 38 ; a strongly-built machinist. Admitted with strangulated inguinal hernia of right side, which was operated upon, death'following in a few hours. On opening abdomen, omentum is injected and attached in right inguinal canal. A few ounces of dirty semi- feculent fluid in peritoneal cavity. A few flakes of lymph are seen on coils of ileum. The bowel has been nipped, just three feet from the valve, and immediately above the constriction there is a tiny perforation. Right inguinal canal is large, admitting two fingers, and leads to a large scrotal sac. On examination it is seen that the patient has been the subject of undescended testes ; the right organ lies just at the internal ring, the left high up on the postero-lateral wall of the pelvis. Both organs are very small, not larger than good-sized almonds. They were removed with the vasa defferentia, prostrate, and bladder. On dissection the epididymis of each organ is small and separated by a con- siderable interval from the body of the testis, the vasa eflerentia being very distinct. On section the substance of the organs is soft, yellowish in colour, and teased pre- k parations show that there is an entire absence of secreting structures; the seminal tubules can be uncoiled, but they are filled with granular debris and fat. No trace of seminal vesicles or epithelium. The vasa defferentia are small and cord-like ; the lu- mina very fine. Vesiculre seminales are of a normal size, and from some of the tubes a fluid resembling semen can 84 PATHOLOGICAL REPORT. be squeezed ; but when examined it is found to be com- . posed of epithelial cells. No spermatozoa. In some of the larger coils there is a firm inspissated matter, like wax. Prostate is normal. Left inguinal canal admits the index finger, and leads down to the upper part of the scrotum, forming a short peritoneal pouch. Nothing abnormal about the other organs. LYMPHATIC SYSTEM. 1.— Medullary Sarcoma of Axillary Glands — Secondary i Masses in Heart, Lungs, Stomach, Intestines, Liver, Spleen, Kidneys, Supra-Renal Capsules, and Pancreas. P. B., ret. 45 ; for two and a half months had noticed the rapid growth of a tumour in right axillary region. Had lost 30 lbs. in weight. Great oedema of right arm. Liver enlarged and tender. Left upper eyelid paralysed and left pupil dilated. All the ocular muscles of this side are paralysed. Optic disc and retina normal. Autopsy.—Body that of a medium-sized, tolerably well- nourished man. Right arm and hand much swollen and oedematous, fully double the size of the limb on the left side. In the right axillary region is a large tumour, involving also the shoulder and all parts about the head of the humerus. The largest mass fills up the axilla, being , moulded upon the chest, convex externally ; above it reaches the clavicle, below the level of the 7th rib. f Anteriorly it extends below the clavicle to within two i inches of the sternum, while lower down it reaches the mammary line, almost touching the nipple ; posteriorly ■ it fills the subscapular fossa, infiltrating and destroying 1 the muscles in this region. The axillary vessels pass I directly through the mass ; the artery is narrowed, but 1 the probe passes freely. The vein pursues a sinuous 1 BY WILLIAM OSLER, M.D. 85 course, and in places is almost obliterated by the projec- tion into its lumen of nodular masses. It is not ulcerated at any part. The cords of the brachial plexus are com- pressed, but not infiltrated.' The deltoid muscle, where it passes over the head of the humerus, is much thinned ; its low7er part is infiltrated and destroyed. Immediately beneath the acromion process, and to the outer and back part of the head of the humerus, is a large rounded pro- jection, which elevates and involves the terminal portions of the infra-spinatus and teres minor. The neck of the scapula is eroded and the articular surface almost separ- ated from the body of the bone. The coracoid process and upper border are involved, the growth passing through the bone and infiltrating the supra-spinatus. The articular surface of the humerus is covered by peculiarly dry, leathery tissue, not unlike the fibrinous laminae of an old aneurism. The ligaments are all involved and the bone eroded at the margin of the articular surface, which is itself intact. On section of the large mass beneath the pectoral muscles and in the axilla, it presents an indistinctly lobular appearance ; the surface tolerably firm, greyish- white in colour, interspersed with blood-red areas of either extravasation or congestion. Heart presents nothing unusual beyond a secondary mass, the size of a cherry, in the anterior wall of the left ventricle. Lungs.—Throughout both organs are numerous firm nodules, ranging in size from a pea to a marble. On section, whitish in colour not very vascular. Bronchial glands very large, and on the left side a mass the size of a billiard ball exists at the root of the lung. Spleen enlarged. 320 grams. Four masses, the size of large walnuts, project from the convex border. One, the smallest, is cupped On section they are reddish-white in colour, haemorrhagic in centre. 8 86 PATHOLOGICAL REPORT. Kidneys enlarged, lobulated. Substance thickly stud- ded with secondary masses, some as large as marbles. The majority of them have an opaque-white appearance; others are dark-red, or even black. Supra-renal bodies enlarged and extensively infiltrated. Pancreas presents several secondary masses Liver weighs 3,970 grams., and is uniformly enlarged ; surface smooth, no nodular masses, but on section there is seen a diffuse infiltration of extensive areas, not sharply defined, but blending with normal looking substance. Stomach.—On the mucous membrane of fundus there is a flat elevated mass, beginning to ulcerate on the surface. Intestines.—About twenty small ulcers are seen through- out jejunum and ileum, nearly half of them being in the upper part of the bowel. They range in size from a three- penny bit to a sixpence, or a little larger; edges much elevated, bases cupped and covered with a greyish-yellow material, beneath which is a firm translucent matrix involving the coats of the bowel to the depth of 3-4 m. In the caecum are eight or ten ulcers presenting similar characters. The Brain itself presents nothing abnormal, but the pituitary body in the sella turcica is enlarged and soft, and a tolerably firm extension from it passes into the left cavernous sinus, surrounding all the parts in this situa- tion, the whole forming a firm immovable mass. The 3rd nerve runs along the top of the mass and was dis- < sected off without much difficulty, appearing somewhat \ compressed. The 4th is imbedded in the upper part; the j 5th passes to the outer side, and is not involved ; the 6th \ is on the under surface, and in part of its extent is surrounded by the tissue of the mass. The artery is not compressed. The histological notes of this case have unfortunately been mislaid. Both primary and secondary masses pre- BY WILLIAM OSLER, M.D. 87 sen ted the characters of medullary sarcoma, the cells being large and round, the stroma variable in amount in differ- ent localities and not presenting a distinctly alveolar arrangement. The occurrence of secondary ulcerating masses in the stomach and intestines is a point of interest in the case, on account of the rarity with which these organs are attacked in secondary disease. 2.—Sarcoma of Retro-Peritoneal Glands—Lobstein Cancer. J. S. Male child (patient of Dr. Gardner), ret. 3; the subject of an abdominal tumour, which had been growing rapidly for about three months. Position central. Rapid emaciation. Belly greatly distended. On opening the abdomen a large tumour is seen to occupy almost the entire cavity, the intestines being pushed into the pelvis. At the upper end it is closely adherent to the under surface of the liver. It lies entirely behind the peritoneum. In front the ascending colon crosses diagonally; the caecum is pushed up to the level of the navel, and the ileum runs along the lower third to join it. A little to the left of the median line is the inferior cava, pervious in its whole length, but empty ; the aorta lay a little further to the left at the side of the mass. The tumour is easily turned, having no adhesions except to the right kidney, which is partially imbedded in it. Weight estimated at about 12 lbs. It is soft, and with an elastic, semi-fluctuating feel. It is enclosed in a thin capsule, and in front and at the sides by the peritoneum; pos- teriorly it is in immediate contact with the vertebral column and lower ribs, the 11th on the right side being slightly eroded. A section made through the mass revealed a soft cerebriform tissue, white in colour, interspersed here and there with vascular and hremorrhagic spots. At the posterior part extensive hremorrhage has taken place into the growth, and the tissue here is blood-stained and 88 PATHOLOGICAL REPORT. mingled with clots. The mass is uniform throughout; not lobulated, and does not present signs of degeneration. The Right Kidney is much flattened, and the upper and anterior part is involved in the growth. The ureter passed through the mass and was partially compressed, the upper part and the pelvis of the kidney being dilated in consequence. No secondary masses. Microscopic appearances are those of a rapidly grow- ing lymphoma, composed of small, closely packed lymph corpuscles. 3.—Lymphosarcoma of Deep Cervical Glands, involving the Thyroid and simulating Goitre. M. D., ret. 16 ; an average sized, but feebly-developed girl. Had been under treatment for three weeks for what appeared to be an ordinary bronchocele. She stated that she had not noticed it before, and it had grown rapidly while under observation. On the evening of the 14th of October she became restless and had considerable difficulty in breathing, so much so that a consultation was held as to the propriety of performing tracheotomy. She became easier and the operation was deferred. Later on in the evening she got up and walked about, and, according to the statements of the attendants, died suddenly. Autopsy, 18 hours after death. Lips a little bluish ; face pale ; no lividity. A large round mass occupies the front of the neck in the situation of the thyroid body, extending to the left and projecting to a level with the chin. Skin over it is tense andtne surface has a leaden hue. Heart.—Right chambers moderately full, not distended. Tricuspid orifice large for the size of the organ. Left chambers contain small amount of fluid blood and clots'; BY WILLIAM OSLER, M.D. 89 ventricle not flaccid. Valves normal. About 10 oz. of blood and clots escaped from the heart and vessels in the preliminary incisions, and in the removal of the organ. Lungs crepitant throughout, and contain a good deal of blood in dependent parts. Arch of aorta, vessels, and nerves of the neck, wTith the tumour, larynx, trachea, and pharynx removed together. The mass turns out easily, but extends deeply into the neck beneath the muscles on the left side, which are stretched over it. Tonsils and glands at base of tongue swollen and of an opaque white colour. (Esophagus considerably compressed, the little finger just passes at the narrowest portion. On slitting it open, mucous membrane normal. Glottis natural looking. Trachea pushed to the right and considerably flattened in the antero-posterior direction by the pressure of the enlarged left lobe of the thyroid. It admits the little finger, so that there is no very great stenosis ; but it may have been greater before the tension on the skin was relieved. On examining the tumour from the front, the growth is seen to involve almost exclusively the left lobe of the thyroid, in the situation of which there is a large round mass 20 cm. in circumference, which extends above to the level of the thyro-hyoid ligament, and below passes down beside the trachea to the bifurcation. In a groove on the outer side of the mass, the left carotid artery and pneu- mogastric nerve are deeply imbedded ; both are stretched, but not otherwise affected. From behind, the mass is elongated and of a somewhat oval shape. It lies along the whole length of the left side of the trachea, the lowrer end resting on the left bronchus. Along this surface it measures 12 cm. in length, 5 cm. in breadth. The oesophagus lies between this somewhat flattened posterior surface and the spine. The right lobe of the thyroid is of normal size and 90 PATHOLOGICAL REPORT. appearance. At the upper and right angle of the mass in front, there is a small thin remnant of the left lobe, capping the tumour in the situation; the tissues of the two blending together, not separated by a capsule. The mass is of a greyish-white colour externally, and on section .the external parts are moderately firm ; centre soft, like softening brain matter. The whole is interspersed with vascular spots. Left pneumogastric nerve is stretched, but not otherwise involved. Teased bits from any portion of the tumour show numerous small lymphoid corpuscles, which, with a small amount of delicate connective tissue, make up the chief histological elements of the growth. In the part corres- ponding to the left lobe of the thyroid there are strands of fibrous tissue, but, except at the extreme upper part of the lobe, there is no trace of the proper gland sub- stance. 5o ON THE SYSTOLIC BRAIN MURMUR CHILDREN. BY AVILLIAM OSLER, jtf. D., M. R. C. P. Lond., PROFESSOR OF THE INSTITUTES OF MEDICINE, MCGILL UNIVERSITY, MONTREAL. [Reprinted from the Boston Medical and Surgical Journal] CAMBRIDGE: $rinte& at tfie ftite^ifce |te££. 1880. ON THE SYSTOLIC BRAIN MURMUR OF CHILDREN. BY WILLIAM OSLEK, M. D., M. R. C. P. LOND., Professor of the Institutes of Medicine, McGill University, Montreal. I desire in the following communication to call attention to this interesting clinical phenomenon, first described by Dr. J. Fisher, of Boston, in the Medical Magazine for 1833. Like many other observations, this one has suffered from the lapse of time, and has been, to a great extent, forgotten and neglected. In conversation with many physicians, some of them spe- cially connected with pediatrics, I have been surprised to find how few were even aware of the existence of such a murmur. Very cursory mention is made of it in works on auscultation and, with a few exceptions, those on diseases of children. Up to 1863 the Ger- man and French physicians had written many papers on the subject, and within the past few years interest has been re-aroused in it by the publication of impor- tant memoirs by Jurasz 1 and Epstein.2 English and American physicians have not given it much attention, and in the literature as collected by Jurasz the only references are Whitney, the American Journal Medical Sciences, 1843, and J. "W. Smith, the Lancet, 1839. In the autumn of 1876, I was asked by a medical friend to see a child, aged three years, with a remark- able murmur in the head, about which the parents 1 Das systolische Hirngerausch der Kinder. Heidelberg. 1877. 2 Beitrag zur Kenntniss des systolischen Schadelgerausches der Kinder. Prag. 1878. 4 The Systolic Brain Murmur of Children. were very anxious. The child was a well-nourished little girl, with a ruddy complexion, well-formed head, fontanelles closed ; no evidences of rickets. On plac- ing the ear upon any part of the head a loud, high- pitched systolic murmur could be heard, variable in intensity, loudest in the temporal regions, also audible in the carotids, and disappearing entirely on compres- sion of these vessels. There was no heart disease. The mother had noticed the noise in the head, she thought, from the time the child was a year old, and the child also appeared conscious of its presence, but said she only heard it; at intervals. The medical at- tendant had suggested the possibility of aneurism, but there did not seem to me to be any evidence in favor of such a view. I had a distinct recollection of the fact that a murmur was described as occurring in the brains of children, but I thought it was always audible over an open fontanelle, and partaking of the nature of a venous hum, originating in the longitudinal sinus. As the child was in good health, and the murmur had persisted for nearly two years, I gave a favorable prognosis. The mother did not appear satisfied, but I heard nothing further of the case for some months, when I recognized it in the description of a Case of Supposed Gummy Tumor of the Brain, in which the murmur was attributed to the possible existence of a syphilitic growth pressing upon the vessels at the base of the brain. About the same time Jurasz's memoir came to hand, and renewed my interest in the case, which has proved to be one of unusual value from the length of time which the murmur has continued. The history of the child from the spring of 1877 to the present is as follows: she has thriven, and is now a bright, intelligent little girl of seven, perfectly healthy, head not enlarged, and no trace of swollen lymphatic glands in the neck. I have examined her on four oc- casions, and found the murmur persistent, with the same characteristics. On the 15th of May of the pres- ent year I examined her again, and found it still very The Systolic Brain Murmur of Children. 5 distinct, loudest in the temporal regions, rather more variable in intensity than hitherto, and sometimes dis- appearing entirely for a few moments. It was with difficulty heard in the carotids. I have examined about sixty children for this mur- mur, and have discovered it in eight cases, all un- der three years of age: one, a case of chronic hydro- cephalus ; one, chronic intestinal catarrh with rickets ; the others appeared healthy. Among the sick chil- dren examined in whom no murmur existed were sev- eral cases of rickets, two of tuberculous meningitis, and one of chronic hydrocephalus. Dr. James Bell, late house surgeon of the Mo»treal General Hospital, ex- amined one hundred children, and found only six in- stances of the " brain murmur ;" but, as he remarked, the difficulty of detecting a soft, low-pitched bruit in the head of a struggling child in a busy, "out-door" room makes it probable that in many instances it was overlooked. No special, note was kept in these cases of the condition of the children. Observers differ very much in their estimation of the import of this murmur, some regarding it as patholog- ical, others as physiological. Dr. Fisher thought it to be the former, and described variations of the murmur in such diseases as whooping-cough, congestion of the brain, acute and chronic hydrocephalus, and apoplexy. Barthez and Rilliet (1853) thought that it afforded a diagnostic sign between rachitic hypertrophy of the brain and chronic hydrocephalus. Roger (1859) and Henoch (1861) regarded it as specially connected with rickets. Wirthgen (1855), on the other hand, believed it to be physiological, and states that it is heard most frequently over the heads of robust children. The views of these and other writers are given very fully in Jurasz's monograph, and the discordance of opinion is amply illustrated. This author concludes that it is not pathological, but occurs in both healthy and dis- eased children, and does not stand in direct connection with any particular disease. In reading over the rec- 6 The Systolic Brain Murmur of Children. ords of cases it is certainly noteworthy how frequent the subject of the murmur is described as rickety. There is remarkable unanimity among all the writers as to the age at which the murmur prevails, the ex- tremes in the recorded cases being the third month and the sixth year, the majority of instances occurring dur- ing the second year. The case of the little girl above given is of interest, therefore, in this connection, as she is now over seven years of age, and further from the fact of the persistence of the murmur since infancy. I have not found any recorded instance of the murmur persisting for such a length of time. The seat of the production of the murmur is placed by most authors in the arteries at the base of the brain and in the carotid canal. Hennig believed it to be venous, and produced in the longitudinal sinus. It is worthy of note that in the majority of the cases a mur- mur is also heard in the carotid arteries. Jurasz has brought forward evidence to prove that the murmur originates in the carotid canal, and as his ex- planation of it has not, so far as I know, been published in any English or American journal, it may be worth while to give a summary of his views : He measured the width of the upper and lower orifices of the carotid canal in twenty-five adults and twenty-five new-born infants. In the former the inferior aperture varied from 6.4 m. to 1 cm. in the long, and 5.4 to 7.6 m. in the short diameter; the superior aperture from 5.4 to 8 m. in the longest, and 5.3 to 7.4 m. in the shortest diameter. Measurements in the mature fcetus and new- born when compared with these show a difference of from 4.1 to 6.2 m. for the long, and 3.7 to 4.6 m. for the short diameter of the inferior aperture, and 3.1 to 4.3 m. for the long, and 3.3 to 3.9 m. for the short di- ameter of the superior aperture. The carotid canal must therefore enlarge considerably in the course of development. Does this take place gradually, or does it occur more rapidly at one period than another ? His observations and measurements go to show that up Tlie Systolic Brain Murmur of Children. 7 to the sixth month the canal does not enlarge, remain- ing unchanged ; but from this date it widens rapidly, so that from the third to the sixth year the' dimensions of the adult canal are attained. The enlargement is held to be due to the increase in volume of the carotid artery, and not to an independent growth, that is, expansion, of the bone; and this being the case it is not impossible that a temporary local disproportion ensues between the rapidly enlarging carotid artery and the surround- ing bony wall, or, " in other words, a temporary steno- sis of the carotid takes place in the carotid canal." This physiological stenosis is held to be the cause of the systolic brain murmur, which is to be regarded as a normal occurrence. It is the expression of a struggle between the artery and its bony investment, which per- sists until by the pressure of the pulsations the canal has been widened to a suitable degree. Epstein1 criticises this theory and the anatomical data on which it is based, denying the rapid expansion of the carotid canal after the sixth month and its en- largement by the pulsation of the artery. Taking the following circumstances as favoring the production of vascular murmurs, namely, wide vessels, rapid blood flow, diminished peripheral resistance, elasticity, and thinness of the walls, he proceeds to show that these prevail to an unusual degree in infancy, particularly in the vessels of the head, which, according to Beneke, are relatively larger than the others of the body. In children, also, the arterial walls are thinner, the capillaries wider, the blood flow more rapid, and consequently the blood pressure is low. The existence of such conditions, es- pecially in anaemic children, is regarded as the predis- posing, if not the exciting, cause of the brain murmur. He calls attention to a fact of great importance in this connection : in two cases there were found, post mortem, enlarged and hard lymph glands in the course of the carotid arteries, and in all children examined subsequent- ly, in whom the murmur was heard, the presence of en- 1 Loc. cit. 8 The Systolic Brain Murmur of Children. larged glands in this situation was determined. He suggests that the murmur may be due to this cause. So far as my limited experience goes, I am not in- clined to regard the murmur as of any special patho- logical significance. There can be no doubt, however, from the numerous observations of French and Ger- man physicians, that it occurs most frequently in weak, rickety children, but its presence and persistence in per- fectly healthy infants are sufficient to disprove the pe- culiar connection which some have supposed it to have with this disease. Thus I have had a strong, well- developed child under observation since birth ; the mur- mur appeared at the fourth month, and has now con- tinued for twenty-two months, with little or no change. Though not prepared to criticise Jurasz's ingenious view, not having entered into the anatomical question, I think that the cases of the little girl above mentioned, in whom the murmur has lasted for six years, and the infant in which I have followed it for twenty-two months, are strongly opposed, if not fatal, to any such theory. If the carotid canal is widened by the pulsa- tion of the artery, it is scarcely conceivable that a physiological stenosis could persist for six years. I have not been able to detect any special enlarge- ment in the cervical glands along the carotids in the cases which have come under observation since receiving Epstein's pamphlet. In one case there were two en- larged and firm glands behind the sterno-mastoid mus- cle on the right side. Unless the enlargement is con- siderable, it is difficult to feel the deep glands along the carotids, particularly if the child is well nourished. Epstein's suggestion is, however, worthy of further in- vestigation. Re-printer] from the " Cu-nnih, M-~? ON HEREDITY IN PROGRESSIVE MUSCULAR ATROPHY A.s ILLUSTATED IN THE FARR FAMILY OF VERMONT. Bv WILLIAM OSLER, M. D., M. R. C. P., Lond. PROFESSOR OF THE INSTITUTES OF MEDICINE IN MC GILL UNIVERSITY, MONTREAL. The accompanying genealogical chart of the Farr family illus- trates well the hereditary nature of progressive muscular atrophy. I will first give a brief account of the member of the family who has been under my care : Erastus Farr, aged 47, a farmer, from Vermont State, admitted to General Hospital September 16, 1880, complaining of weakness in the left leg and peculiar twitchings in the muscles of various parts of the body. He is a tall, large- boned man of medium muscular development. History.—Has been a hard worker, very temperate, never had any serious illness. Is married, has seven children, all of whom are well. About fourteen months ago began to notice twitchings of the muscles of the left buttock and thigh, which gradually in- creased in frequency, and within six months after their onset he felt the left leg weaker than the right. Has had no pain, only the uneasy sensations caused by the muscular tremors, which he de- scribes as occasionally accompanied by a feeling of nausea. Dur- ing this year the left leg has got steadily weaker and has dimin- ished considerably in size. The twitchings have also become general and occur irregularly in different muscles. Present condition.—When stripped, the left leg is seen to he smaller than the right, owing to uniform wasting of the muscles. Measurement gives a difference of 2.5 cent, in the circumference of the calves, and 7 cent, in that of the thighs in the middle third. The atrophy is best marked in the hamstring and gluteal muscles, Reprinted from the Archives of Medicine, Vol. iv, No. 3, December, 1880. 2 ORIGINAL OBSERVATIONS. and extends slightly to those of the lumbar region of the same side. Fibrillar twitchings are of frequent occurrence in the muscles of the affected leg, and also in those of the trunk and other extremi- ties. The strength of the left leg is greatly reduced. Sensation is less acute than normal in the legs ; the points of the aesthesi- ometer have to be separated over 7 cent, before two impressions are perceived, and there is scarcely any difference in this respect be- tween the legs or different parts of them. The electro-contrac- tility of the muscles is preserved. In walking, patient requires the aid of a stick, and drags the left leg very much. He remained in hospital about a month, and was treated with the galvanic and faradic currents without evident benefit, though he thought him- self somewhat improved. Family history.—Thirteen individuals in two generations have been affected, nine of whom have died. The following is a brief record of the cases : Samuel Farr, father of patient, died at age of 61 ; ill over two years. Patient cannot say what his paternal grandfather died of ; never heard that it existed in that generation. Samuel Farr bad five brothers and sisters, two of whom were affected. One brother, Erastus, who died at the age of 40. This was the first case heard of in the family. One sister, Mrs. Streeter, who died at the age of 54. It is probable also that another sister, Mrs. Stoddart, had the disease. She died of paralysis, but whether this form or not is doubtful. Ten members of the second generation have been affected. Two of the patient's brothers and one sister : Samuel, who died at the age of 45 ; ill over two years. Had six children. Wesley, aged 41, at present affected. Has no evident wasting, but the fibrillar twitchings have begun, and he has rheumatic pains. Has two children. Ellen, died at the age of 27. Had four children. Six of the patient's cousins, as follows : Alinira (daughter of Mrs. Stoddart), aged 45, still living, has been ill over two years. Has two children, one a cripple with legs undeveloped. Hiram, son of Erastus, died at the age of 45. Two children living, one 30 years old. Four children of Mrs. Streeter : ARCHIVES OE MEDICINE. 3 Mrs. Alexander, died at age of 55. Four children living. Mrs. Robinson, died at age of 46. Three children. Mrs. Alexander, aged 48, still living, arms much affected ; can- not lift them. Hiram, died at age of 24 ; ill several years ; disease began in the legs. Thus, of the 13 members of the family affected, 6 were females and 7 males, a larger proportion of the former than is common in this disease. With the exception of two, all of the cases occurred, or proved fatal, above the age of 40. Of the 10 instances in the second generation, 5 are the offspring of males (Erastus and Samuel), and 5 the offspring of females (Mrs. Streeter and Mrs. Stoddart). The disease has not yet appeared in the third generation, which promises between 40 and 50 individuals, several of whom are over 30 years of age. I append a genealogical table of this family, in order to show its liability to progressive muscular atrophy, and also repro- duce Prof. Naunyn's table of the Bessel family. {Berliner Med. Wochenschrift, Nos. 42 and 43, 1873.) 4 ORIGINAL OB SERVAJ JO AS. GENEALOGY OF THE FARR FAMILY. Rossin Farr. . . Died at 50. 5 Children No disease Russell Farr..... Died at 60. Drinker. S Children. No disease. Samuel Farr..... Died at 61. ill two years. Erastus Farr..... Died at 40. First case heard of in Family. Mrs. Stoddart. ? Died at 40. Mrs. Streeter. Died at 54. Samuel. 45.....6 Children. Ellen. 27......4 Children. Maria........ Rossil........ Wesley. 41.....2 Children. EraStUS. 47.....8 Children. Edwin........ [ Matilda........ f 3 Children died of scarlet fever. ! Hiram. 55......2 Children. Orary. f Altina. 35......3 Children. William, died 24. . . , Adaline.......1 Child. Almira. 55.....2 Children, i child legs undeveloped. L Almond. 60......3 Children. Joil......... Hiram. 24...... Mrs. Alexander. 55- 4 Children. Mrs. Robinson. 46. 3 Children. Mrs. Alexander. 48. Mrs. Smith. 38..... Mrs. Cleveland. 60. . . 3 Children. All well. 1. All well. All well The individuals whose names are printed in heavy face type were the sub- jects of the disease—the others escaped. ARCHIVES OF MEDICINE. 5 GENEALOGY OF THE BESSEL FAMILY (NAUNYN). f DQ ' . "3 CO CO DQ----- in CO Z ■'.c/^K'^ ' V' F.Huth,LitlTEdiii* •*- &?faj* - J ---------L------^h >& INFECTIOUS (SO-CALLED ULCERATIVE) ENDOCARDITIS V WILLIAM OSLER, M. D., M.R.C.P., Lond. PROFESSOR OF THE INSTITUTES OF MEDICINE, MCGILL UNIVERSITY ; PHYSICIAN AND PATHOLOGIST TO THE GENERAL HOSPITAL, MONTREAL [Reprinted from the Archives of Medicine, February, 18S1] NEW YORK PUTNAM'S SONS 182 Fifth Avenue 1881 INFECTIOUS (SO-CALLED ULCERATIVE) ENDOCARDITIS. By WILLIAM OSLER, M. D., M. R. C. P.. Lond., PROFESSOR OF THE INSTITUTES OF MEDICINE, MCGILL UNIVERSITY ; PHYSICIAN AND PATHOLOGIST TO THE GENERAL HOSPITAL, MONTREAL. UNDER the terms diphtheritic, ulcerative, malig- nant, septic, or infectious endocarditis, arterial py- cemia, mycosis endocardii, physicians now recognize one of the most formidable of cardiac affections, characterized by a peculiar morbid process on the valves, blood con- taminations, constitutional symptoms of the typhoid or pyaemic types, and usually associated with multiple em- boli. It is only within the past few years that the sub- ject has received due attention in the text-books ; indeed, in some it is barely touched upon, and even in recent manuals on heart disease the account is not very satisfac- tory. From the number of reported cases in French and German journals, and from the interest which the disease has excited in these countries, we might suppose it to be more common there than in England or America. A considerable number of reports, however, occur in the "Transactions of the Pathological Society of London" and in the British journals. In the leading American periodicals there are very few references, but cases have Reprinted from the Archives of Medicine, Vol. v, No. i, February, 1881. 2 INFECTIOUS ENDOCARDITIS. been reported by Ellis,* Lomax,f Pepper,*]: Keating,§ and Peabody.f With regard to the nomenclature, I think the terms in- fectious and septic, as given by Jaccoud,"T[ better than the others. Against the name ulcerative is the fact that there may be no actual ulceration on the valves, and there may be, on the other hand, endocardial losses of substance with- out the special constitutional disturbances by which the disease is characterized. The term diphtheritic is good, in so far as it expresses a resemblance in the histological feat- ures of the valvular disease to that of true diphtheritic ex- udation, but this is scarcely sufficient ground for its use; and it is, in a way, misleading, indicating a relation be- tween diphtheria and the disease, which is not known to exist. The name mycosis endocardii certainly expresses a striking feature of the local process, but with our present imperfect knowledge of the relation of the micrococci colo- nies to the disease, such a designation is, to say the least, premature. On the other hand, the term infectious presup- poses no special view as to the nature of the local process, and at the same time indicates, as Jaccoud says, a constant and exclusive character of the disease. It would appear that, clinically, three classes of cases are included in the disease known as ulcerative endocarditis, and I think it important that a distinction should be made between them. We have : I. Those cases in which the disease appears without any obvious cause, either spontaneously or in connection with rheumatism or some other affection. The term infectious * Boston Med. and Surg. Journal, Nov. 15, 1877. \ Philadelphia Medical and Surgical Reporter, 1874. \ American Journal of Medical Sciences, 1871. § " Transactions of the College of Physicians of Philadelphia," 1879. fl New York Med. Record, 1880. ■ft* Pathologie Interne, tome i, and Nouveau Dictionnaire, tome iii. WILLIAM OSLER. 3 might be applied to this class. It is the arterial pyamia of Wilks, the primary ulcerative endocarditis of some au- thors. 2. Those in which the endocardial disease is secondary to some inflammatory focus—acute necrosis, puerperal en- dometritis, etc. To these the term septic might be applied. 3. In certain cases of chronic valvular disease an acute en- docardial process may be engrafted (recurrent endocarditis), presenting anatomical features similar to the infectious form, but not characterized by the same clinical picture, the patients dying with the symptoms of chronic heart disease. The following paper embodies my experience of this dis- ease. The chief points to which I wish to call attention, and which are illustrated by the cases, are: 1. That the majority of cases of infectious endocarditis occur independently of rheumatism. 2. To the frequency with which infectious endocarditis is associated with pneumonia. 3. The production of acute multiple aneurisms of the aorta in the disease. 4. To certain histological features in the endocardial vegetations, and particularly to a remarkable fungoid growth met with in one of the cases. Case i.—In January, 1878, I received from Mr. McEachran, of the Montreal Veterinary College, the heart and part of the aorta of a cow which had died with symptoms of urgent dysp- noea. He saw it only a short time before death, and no satisfac- tory history of the case could be obtained. The weather was very cold, and the heart was frozen immediately after its removal, and in this state I received it. The organ was large, particularly the ventricular portion ; the chambers had been cut open, and the blood had escaped. On ex- posing the tricuspid orifice, from the auricle it appeared to be al- most closed with irregular vegetations attached to the valves. From 4 INFECTIOUS ENDOCARDITIS. the ventricle the following condition was presented : The seg- ment next the septum was completely covered on its under surface with a grayish-white outgrowth, which was prolonged at the apex and extended about half way over the auricular surface. The chordae tendineae were entirely covered, and similar masses ex- tended down the septum, forming irregular warty projections, some of which were the size of large cherries. The other seg- ments were not so much involved, but in both the growth was most extensive on the ventricular surface, and irregular masses projected from the tips of the cusps, which resembled somewhat the comb of a cock. The chordae tendineae were uninvolved. Pulmonary semilunar valves healthy ; mitral valves unaffected. Aortic orifice blocked with vegetations similar to those in the tricuspid. On slitting up the vessel the segments of the valve were found much crumpled and covered on the ventricular sur- faces with warty outgrowths, some of which were over a centi- metre in length. In the ascending portion of the arch there were several small outgrowths on the endocardium, and near the terminal portion of the arch there was a much larger, irregular mass. All of these structures presented a similar appearance—grayish-white in color, of moderate consistence, but on firm pressure somewhat friable. They were very closely adherent to the parts from which they grew. An outer cortical and an inner parenchymatous part could be distinguished. It appeared a typical example of a verrucose endocarditis. The other organs were examined, but I could get no information as to the presence of infarcts. Case 2.—Lnfections endocarditis; pneumonia; menin- gitis. Mary D., aged 29, admitted to hospital October 22, 1878, in an unconscious state. She is a married woman, and has two chil- dren. Has been a hard drinker for several years. History of the onset of the attack could not be satisfactorily obtained. On the 23d, when examined, she was still unconscious ; pupils moderately dilated ; no twitchings or paralysis ; slight dulness at right apex, with blowing breathing and rales ; systolic murmur at apex. T. 1040 ; P. no; R. 40. On the 24th, she was partially conscious for a short time, and complained of great pain in the head and back of the neck. Morning, T. ioo° ; Evening, 1040. WILLIAM OSLER. 5 Throughout the 25th she lay in an unconscious state ; passed faeces and urine in bed. Evening, T. 1040. On 26th, temperature rose to 1070 at 4 a.m ; was 1050 at 2 p.m. There was a slight divergent strabismus of left eye, and commenc- ing superficial ulceration of left cornea. Right pupil dilated widely. Death took place at 4 p.m. Autopsy.—In the heart, ventricular surface of anterior segment of mitral valve was covered with grayish vegetations ; toward the right side of the valve they were larger, and extended to the chordae tendineae, passing down the entire length of several of them. On the auricular surface of the valve there was a soft, grayish-white patch, 1 by 1.2 cm., covered in part by a thin mem- brane, but in the rest of its extent rough and divided into a num- ber of irregular projections, which were friable and readily de- tached. The other valves were healthy. In the right lung the upper lobe was in a state of red hepatization ; toward the anterior border the process was more advanced, and a sero-purulent fluid bathed the surface. The upper third of the lower lobe was also inflamed. In the brain, meninges at the base were matted and oedematous, but there was no exudation. On the hemispheres there were numerous patches of lymph beneath the arachnoid, situated chiefly in the anterior regions. The posterior margin of corpus callosum and contiguous surface of cerebellum were cov- ered with a thick, creamy exudation. Spleen presented a single infarct. Organ a good deal en- larged. Kidneys healthy. Nothing special in other organs. CASE 3.—Lnfectious endocarditis ; pneumonia. J. B., aged 38, admitted January 7, 1880. Has been a healthy man. Ten years ago had a severe attack of pneumonia. On the night of the 4th he felt uneasy, and did not rest well; got feverish, and in the morning had pain in the side, with cough. These symp- toms continued, and he came to the hospital on the 7th. On ad- mission, T. 103.8° ; P. 128 ; R. 40. Signs of pneumonic consoli- dation in right lung ; dulness from second rib in front, and extend- ing into the lower axillary region and the base posteriorly. There were blowing breathing, rales, and increased tactile fremitus. The expectoration was viscid and rusty. During the first week in hospital nervous symptoms appeared ; he became delirious, rest- 6 INFECTIOUS ENDOCARDITIS. less at night, and passed urine and faeces in bed. Tongue dry, and on the 9th and 10th there was troublesome vomiting. The temperature was irregular, ranging from ioo° to 1040 ; the even- ing record was usually a little higher, but twice it was lower than in the morning. Pulse range 120 to 148 ; respiration 32 to 50. During the second week the intensity of the symptoms abated somewhat; the temperature kept lower, not once reaching 1010. Respiration diminished in frequency, and the pulse range was from 112 to 120. The nervous prostration continued, with tremor of the whole body ; the muscles of the face and hands twitched constantly. Delirium persisted, and discharges were passed in- voluntarily. A very disgusting fetor emanated from his body. The cough improved, and the dulness diminished somewhat in front. Tongue dry ; took food and stimulants freely. On the 19th, a painful swelling appeared in left parotid region. In the third week he began to have chills, and sweated a great deal each day. The swelling in left parotid diminished, and the lung cleared. The prostration continued and the delirium per- sisted, but the twitching moderated. The temperature was very irregular, usually below ioo°, but on two occasions it went up to 1030 after chills. Pulse range from ir6 to 130. During the fourth week the swelling of left parotid increased, and on February ist an abscess was opened in this region. Severe chills on the 30th, blueness of face and finger-tips. T. 1020. Still sweats. Became somewhat brighter after the abscess was opened. Tongue dry ; nervous symptoms less marked. No cough. Pulse feeble, range 108 to 120. Temperature 980 to ioo° ; on three days after chills it rose about 102°. In the fifth week he remained in this typhoid condition, with very little change ; an occasional chill and profuse sweats. During the sixth week the prostration increased, and he lay in a heavy, unconscious state. Tongue dry and cracked ; no chills, but profuse sweats. On the 13th and 14th, T. began to rise, and reached 1040. Mus- cular tremors again set in, and death took place on the 15th, after an illness of 42 days. Autopsy.—Body wasted ; in preliminary incision thoracic and abdominal muscles pale Heart of average size ; not apparently hypertrophied. Coagula in all the chambers. Valves on right side normal. In left ven- tricle a large mass filled the outer angle of the mitral orifice, look- ing like a fibrinous clot between the valves, but on closer inspec- WILLIAM OSLER. 7 tinn it proved to be a large endocardial vegetation. Viewed from the ventricle, the outer half of the aortic or anterior segment was involved, and the disease had penetrated the entire thickness of the valve, projecting in grayish-white, flattened masses between the points of attachment of the chordae tendineae. On this surface it extended to within 1.5 cm. of the semilunar valve. The poste- rior mitral segment was not so much involved on this surface, but at the outer angle between the two flaps, the mass was very thick, and extensions from it passed along the chordae tendineae to the top of the posterior papillary muscle. The full extent of the dis- ease was seen when the mitral ring was laid open—a thick grayish mass encrusted the auricular surfaces of the outer halves of both segments, filled the angle between them, and extended up the wall of the auricle. On this aspect it measured 3 by 2 cm. The sur- face of the mass was nodular, in great part of its extent unbroken, and covered with a thin membrane, which could be lifted up. In places there was extravasated blood beneath this thin coating. The portions upon the wall of the auricle and on the contiguous part of the valves were roughened and granular. The anterior curtain was most affected, but the vegetations on the posterior projected much more. Section through the mass on this segment gave a thickness of 12 mm. ; no proper tissue of the valve could be seen, but only a uniform, finely-granular, grayish-white tissue. Aortic semilunar valves healthy. Aorta not atheromatous. Lungs crepitant in upper and anterior parts, heavy and oedem- atous posteriorly ; the tissue of the right lung at the base was firmer than that of the left, but the section was not granular. Spleen large, weighed nearly 400 grammes ; pulp very soft; one wedge-shaped infarct of grayish-yellow color. Kidneys pale ; no infarcts. Liver soft, and of a muddy-brown color. There was nothing of special note in the stomach or intestines. Peyer's patches not swollen. The brain presented nothing abnormal. . In the left parotid the abscess had nearly healed. CASE 4.—Lnfectious endocarditis ; pneumonia ; meningitis. M. W., aged 43, a tall, well-built man, was admitted to hospi- tal under Dr. Ross, Feb. 26, 1880. Served his time (21 years) in the British Army. Has had syphilis, and only a month ago was under treatment in ward 11, for syphilitic ulcers in right 8 INFECTIOUS ENDOCARDITIS. gluteal region. On Oct. 27, 1879, he was admitted with pneu- monia of lower three-fourths of right lung and had severe cerebral symptoms. He has been a very hard drinker. On evening of Feb. 23d had a severe rigor followed by fever, headache, cough, and pain in the left side. On admission T. ioo°, R. 38, P. 120. Cough with viscid expectoration. Has spells of vomiting and feels very weak. Examination of chest revealed dulness, blowing breathing, and crepitant rales at left base as high as angle of scapula. 27th. T. M.1010, E. 101.40, P. 128, R. 34. A friction sound is heard just above the angle of the scapula on the left side. 28th. T. M. 99.40, E. ioo°, R. 36, P. 114. Patient became delirious through the night, expectoration profuse and blood- tinged. March 3d. For the past three days patient has been improving slowly ; cough not so troublesome ; no special change in the physical signs. Temperature has fallen and has been only 980 for the past three mornings. Is free from delirium. 4th. Patient had a chill at one o'clock P. M. accompanied by vomiting, and the temperature rose to 1010. 5th. Had a restless night, delirious again, no extension of the disease in the lung; at two o'clock P. M. had a chill, and the temperature went up to 103.50, P. 104, R. 40. Has had five stools. 6th. Morning T. 980. Patient is very prostrate, passed a rest- less night, there is a low wandering delirium. 7th. T. rose to 103.50 from 980 during the morning ; very profuse diarrhoea, 10 stools. 8th. Morning T. ioo°, E. 104.30. Dulness persists at left base, rales more liquid in character; diarrhoea is better. 9th. Patient is in a low typhoid state, tongue coated and dry. T. went up to 105.30 in the evening, R. 36, P. 126, and feeble. 10th. Profuse diarrhoea, nine stools ; is very prostrate. P. 124, R. 36, T. morning 1010, evening 1020. From this time until his death on the 14th he gradually sank, remaining unconscious. The temperature range was from 1010 to 1040, the evening exacerbation being usually about three degrees. On the 12th there were signs of oedema at right base. The amount of urine passed ranged from 40 to 50 oz., acid in reaction ; there was albumen on the first three days after admis- sion. Chlorides were diminished ; on the 2d of March they were absent. WILLIAM OSLER. 9 Autopsy. Nothing special on superficial inspection. Brain ; at base membranes a little oedematous, no lymph. An aneurism the size of a pea projected from the central part of the basilar artery and has formed a bed for itself in the pons. There was consider- able meningeal inflammation on the left hemisphere ; the posterior part of the ist frontal and the ascending frontal convolutions were covered with a thick creamy lymph, and a similar condition existed along the outer part of the Sylvian fissure and over part of the ascending parietal convolution and the superior parietal lobule. On the right side there were a few patches of lymph along certain of the vessels, but none on the convolutions. Nothing special noticed in the substance of the organ. Heart. All the chambers contained blood and partially decolorized clots. Left ventricle looked a little large. Mitral orifice not enlarged, valves thin and healthy-looking; on auricular surface of the edges numerous small bead-like vegetations. Aortic orifice obstructed with large irregular vegetations, which, on slitting up the vessel, were seen to spring from the right posterior segment. The ventricular sur- face of this valve was almost covered with a grayish-yellow out- growth irregularly divided into two portions, the pointed ends of which were covered with closely adherent blood-clot. The sur- face of these masses was smooth, though nodular ; it was only in the cleft between them that the granular substance of the vegeta- tion was exposed. From the arterial side it was seen that one- half of the valve was completely destroyed and the gray-green tint of the substance of the growth was here very marked. There was one small patch on the ventricular face of the anterior seg- ment. Lungs. Lower three-fourths of the left lung heavy, airless, reddish in color, except at anterior border where it is more anaemic. Granular condition of section not very distinct. Pleura of this part covered with a thin exudation. Other parts of the lungs crepitant. Spleen is large and very soft ; no infarc- tions. Kidneys. Left presented one small infarct the size of a pea. Organs are soft and cortices a little swollen. Liver pale and soft. Intestines pale, no ulceration. Cases 3 and 4 offer typical examples of this disease ; —the chills, irregular temperature, sweats, and diarrhoea were very characteristic. Case 3. conformed more to the typhoid form, Case 4 to the pyaemic variety. IO INFECTIOUS ENDOCARDITIS. CASE 5.—Chro7iic valvular endocarditis ; recent endocar- ditis and endarteritis; multiple aneurisms of aorta ; rupture into pericardium. Robert I., aged 29, a hospital orderly. When seven years old had a severe burn in right axilla and front of chest, which has left a large scar. Has been troubled with palpitation since a lad, and during the past few years this has become'worse, particularly on exertion. Has been a sailor. In 1876 was treated in the hospital for syphilis, and was told he had aneurism. He had a sharp attack of quinsy in February, 1879, and in the clinical report it was then noted " that the heart was somewhat hypertrophied, double murmur at base, and a distinct systolic thrill could be felt in the aortic area." Unfortunately the notes of his final illness are very scanty. I have been furnished with the following by Dr. Imrie, the House Surgeon : Patient was readmitted on June 4, 1880, with a history of diarrhoea of several days' standing, chills, headache, dyspnoea, cough and fever. On examining the lungs there were signs of pneumonic consolidation at left base, dulness, blowing breathing, rales and exaggerated fremitus ; temperature- 1040, and he became delirious the same evening. Heart embar- rassed ; distinct double aortic murmur, and basic thrill. The inflammation of the lung extended and involved nearly the entire organ. There was great nervous prostration, a low delirium, and distinct chills at intervals. The temperature ranged from 990 to 1050 ; death took place on July ist. Autopsy.—Body somewhat emaciated. In thorax there was a rounded tumor beneath the first piece of the sternum, and which passed to the right beneath the first two ribs and the clavicle. It was quite soft and had no superficial adhesions. Pericardial sac looked large, and when opened, 18 ounces of blood and clots were removed. The source of the hemorrhage was discovered to be a laceration in an aneurismal pouch which projected into the pericardium from the ascending aorta. Heart.—Auricles contained blood and thick clots ; there were numerous small ecchymoses beneath endocardium of the right side. Right ventricle small in comparison with the left; tricuspid and pulmonary semilunar valves healthy. Left ventricle dila- ted and hypertrophied, the walls unusually thick. Mitral orifice measured n cm. in circumference; valves opaque ; chordae ten- dineae thick ; aortic valves incompetent ; segments thick and curled at the edges ; the anterior and left posterior segments have WILLIAM OSLER. I I fused together, and from the ventricle, presented the appearance of a single curtain, but on the arterial side, a median raphe passed half way up the segment and divided the sinuses incom- pletely. Attached to the thickened border were four grayish veg- etations, the size of small peas ; and on the right posterior seg- ment, a large flat one covered nearly one half of the ventricular face of the valve. On the endocardium of the ventricle, just be- low the aortic ring, there was an elevated flattened mass the size of a five-cent piece. Immediately above the right posterior seg- ment, two large grayish-yellow vegetations projected from a slight depression in the wall of the aorta and were in contact with the edge of the valve. A sort of cleft separated the two masses, and when probed, was found to lead into a saccular pouch the size of a large marble, from the edges of which the outgrowths arose. The walls of the small aneurism were thin, composed chiefly of the adventitia, and had lost the appearance of an arterial coat. The interior of the arch was smooth, with the exception of two small patches of superficial atheroma. Two and a half centime- tres above the valves the arch measured 8.5 cm. in circumference. At the junction of the ascending and transverse portions, about 1.5 cm. from orifice of innominate, there was a circular opening the size of a fifty-cent piece, leading into a saccular aneurism, the size of a small apple, which projected to the right side and was partially enclosed in the pericardium. The edges of the opening presented large fungoid vegetations, attached to the margin of the intima, and projecting in some places as much as 1 cm. The sac contained blood and recent clots, but no laminated fibrin ; the walls were exceedingly thin, in places quite translucent. The veg- etations at the edge of the orifice extended upon the inner sur- face of the sac, covering it in at least half its extent, and in places infiltrated the entire thickness of the wall, so that the peculiar greenish-yellow color of the growth could be observed from the outside. In the wall of the aneurism, just within the line of at- tachment of the pericardium, there was an irregular laceration 1.3 cm. in length. On the intima of the ascending portion, just be- low the margin of the aneurism, were two small warty outgrowths which, when carefully examined, were found to spring from the edges of small lacerations or losses of substance, behind which were two aneurismal pouches, about the size of large peas, the walls thin and formed chiefly of the adventitia, which appeared dissected away for a short distance around the narrow break in the internal and middle coats. In one the vegetation extended 12 INFECTIOUS ENDOCARDITIS. round the edge of the orifice upon the outer surface of middle coat, and into the angle between it and the adventitia. Lungs crepitant in anterior parts ; bases heavy and sodden ; on section much blood and serum escaped. The left lower lobe was firm, almost airless, but had not a granular appearance on the cut surface. Spleen weighed 560 grammes ; pulp very soft ; two small yel- lowish-white infarcts, tolerably firm and surrounded by deeply congested tissue. Kidneys not enlarged ; the right organ contained one small yel- lowish infarct. Stomach and Intestines presented nothing of note ; no ulcer- ation in small bowel, or enlargement of Peyer's glands. Brain. Meningeal hemorrhage beneath arachnoid, chiefly on the right side, upon the sphenoidal convolutions and along the fis- sure of Rolando ; it was thick enough to obliterate the outlines of the convolutions. On the left side there was a thin extravasation over the second and third frontal and upper half of the ascending parietal convolutions. No lesions of the vessels were found ; substance healthy.. CASE 6.—Fractured legs; pneumonia ; ulcerative endo- carditis ; meningitis. Unfortunately, the notes of this case have been mislaid, and I am only able to give a brief summary. The patient, a young woman aged 19, jumped from the third story window of a hotel, during a fire, and sustained a double Pott's fracture, and fracture of lumbar vertebrae. She seemed to be doing very well for about a week, when the temperature rose and she complained of pain about the heart and shortness of breath. A systolic murmur in the mitral area was detected. She became exceedingly weak and prostrated, blood appeared in the urine, and she died sixteen days after admission. At the autopsy, there was no suppuration about the fracture. The lungs were engorged with blood posteriorly, and the lower part of right upper lobe and contiguous parts of middle and lower lobes were hepatized. The heart was not enlarged ; on the anterior curtain of the mitral valve was a large endocardial outgrowth, in- volving the anterior part of the valve and extending on to some of the chordae tendineae ; a blood clot was adherent to it, but its surface did not seem broken. A small infarct in spleen, and two WILLIAM OSLER. 13 in kidneys. There was purulent infiltration in the sulci, beneath the arachnoid on the cortex of the brain, chiefly on the parietal and frontal lobes ; none at the base. In the ccecum and ascending colon, were eight or ten superficial patches of membranous colitis, the exudation grayish-yellow, thin, and situated upon injected mucosa. This case comes, doubtless, under the second class, in which the endocarditis appears to follow some injury or wound. In go- ing over the literature of the subject, I noticed the reports of a considerable number of cases of this kind. Dr. Peabody's case, the autopsy of which I witnessed, resembled this in all its essen- tial features. I should like to remark here that the endocarditis in many cases of this class is a secondary and subsidiary phe- nomenon in septic infection. Thus, in acute necrosis and in puerperal septicaemia, it is sometimes present, sometimes absent, and the fatal effect and malignancy of the affection does not ap- pear dependent upon it. CASE 7.—Sclerotic endocarditis of aortic valves, with incompetency ; recent vegetations {ulcerative endocarditis}. Annie M. L., aged 40, admitted Nov. 23d under Dr. Ross. No history of acute rheumatism. For five or six years has suf- fered with shortness of breath on exertion. For the past year health has been failing, and she has had a troublesome cough. For three months has been confined to bed ; dropsy has gradually come on, and for three weeks past spitting of blood. Her condi- tion on admission was that of a patient in the advanced stage of obstructive heart disease,—great dropsy of legs, right hydrothorax, dyspnoea, lividity, cough, and bloody expectoration. A double aortic murmur was determined. She only lived for a little over two days after entering the hospital. The temperature was normal. At autopsy heart was large, chambers full of dark clots. Mitral valves healthy. Left ventricle dilated and hypertrophied. The aortic orifice was blocked with vegetations, and when slit open the valves were found much diseased ; all the curtains were thickened, curled at the edges and foreshortened. On the ventric- ular faces were large grayish-yellow vegetations, closely adherent, but friable and roughened on the surface. In one mass the de- position of salts of lime had taken place on the outer part. Large patches of apoplexy in the lungs. No infarcts in spleen or kid- neys, which were large and indurated. 14 INFECTIOUS ENDOCARDITIS. This is an illustration of the third class, and perhaps such instances furnish the large proportion of the cases which go under the heading of ulcerative endocarditis. General and microscopical characters of the vegeta- tions : With the exception of the specimens from Case I, the outgrowths on the valves presented the well-known appear- ance of the so-called diphtheritic endocarditis. There are one or two points in connection with their general character to which I wish to refer. The term tilcerative, as I re- marked before, is in certain instances a misnomer. The vegetations on the valves in Case 6 presented a smooth sur- face, neither granular nor broken, and there were no signs of separation at the attached border. One or two writers have remarked upon this, especially Gray, of Oxford.* Usually, however, the surface of the vegetations is rough- ened in places, and the friable stroma exposed ; and of course if the entire mass were removed there would be an ulceration or even perforation of the valve. We do not know much about the beginning of the process, but it may be that the ulceration comes first, and the thick vegetations represent subsequent formations in the exposed surface. About the vegetations in Cases 2, 3, and 4, there was a peculiar greenish-gray color, especially marked when they were broken. It was common to meet with a blood clot adherent to the masses, and frequently a thin superficial ex- travasation beneath the outermost layer of the vegetation. In Case 1 the vegetations were firmer, not so friable, and had rather the characters described as verrucose. In Case 5 the outgrowths on the aorta and at the margin of the larger aneurism were soft, of a light grayish-yellow color, and the term "fungoid " best expresses their general appearance. The valvular outgrowths in Case 7 presented * Med. Times and Gazette, 1874. A/ y. ;-;.y. z 1 *^ <> T ^ -/#'r ,.(, 7J! -r *^ /, ■j. wmmm T'-'ijL -r*f. WILLIAM OSLER. 15 the same general characters as in the other specimens, ex- cept in the slight calcification at one part. The microscopical characters of the vegetations in Case I offer many interesting features. In the study of this speci- men we will begin with the description of small outgrowths. Fig. I represents the section of a small wart-like excres- cence on the wall of the right ventricle. It is mushroom- shaped, measures 3 mm. across, and springs from the endo- cardium by a small pedicle. There is no special change in the heart muscle immediately below it (a). At the site of attachment the subendothelial tissue is thickened, and con- tains in the deeper part many nucleated corpuscles imbed- ded in an indifferent matrix, while in the more superficial part it is distinctly fibrillated, and large elongated corpuscles occur. The vegetation is attached directly upon the fibril- lar layer, with the intervention of a thin stratum of round and elongated cells. At b in the figure there appears to be an additional base or stalk, and here the proliferation of the subendothelial elements was very marked. The pedicle itself is composed of closely aggregated corpuscles of the size and general appearance of white blood corpuscles. The material in which they are imbedded is granular; fibrils can- not be detected. An irregular break, probably the result of manipulation, occurs about halfway across the mass. At the edges of this (c) the colorless cells are thickly set and are stained deeply. The stroma of the mass is made up of a dense fibrin meshwork, only seen with a high power and in a thin section. It is variously interspersed with- cells ; from some places they are entirely absent. Toward the surface the fibrin assumes a stratified disposition, and the corpuscles are less numerous (Fig. 2). A short distance from the pedicle, ball-like masses are seen imbedded in the fibrinous stroma, and at the super- ficial part of the mass similar bodies are very numerous and 16 INFECTIO US ENDOCARDITIS. constitute the most remarkable feature in the entire tex- ture, Fig. I, d; Fig. 2. Many of the tendinous chords passing from the tricuspid curtains were thickly encrusted, and sections afforded a good view of the general arrangement of the parts. In a section of such an encrusted tendon, 6 mm. across, there can be seen the tendon in the centre, 1.5 mm. in diameter. Under the microscope it does not appear much altered, and it is only at the periphery that there is any nuclear in- crease; outside of this is a layer devoid of cell elements, finely granular, and in places laminated. In logwood this part does not stain so deeply. In it are remarkable micro- coccus balls, some of large size and isolated, others smaller and closely aggregated together (Figs. 4 and 5). External to this layer and separated from it by a small amount of granular matter is a narrow zone of fibrinous tissue, in which elongated corpuscles are very abundant. It looks as if this was the outer part of the tendinous chord, and as if the layer just described had developed beneath the suben- docardial tissue. The external part, comprising the greater portion of the section, is made up of a fibrinous matrix, con- taining leucocytes scattered through it; most abundant in certain areas. The outermost part of the encrusting mass is distinctly laminated, and contains very few corpuscles, but is thickly set with micrococcus balls, and the tissue has a darkly granular appearance. Fig. 3 shows the stratified appearance and the spherical bodies which here form a nipple-like projection, and appear as if passing toward the surface. This appearance is by no means infrequent. In the larger outgrowths the chief mass is composed of a nucleated fibrillar tissue, while in the superficial parts there are fibrinous lamination and numerous micrococci colonies. Capillary blood-vessels penetrate the deeper parts of the large masses, and along many there is a deposition of WILLIAM OSLER. IJ brown-red pigment. In some sections large micrococcus balls were met with 4 or 5 mm. from the surface. The most remarkable structures in this specimen are the rounded bodies represented in Figs 1 to 6, and which have been spoken of above as micrococcus balls. They vary very greatly in size ; the majority of those in the specimen from which Fig. 1 was taken measured from 0.15 to 0.375 mm. Many are not more than .0075 mm., while at Fig. 6 one is shown which measured .1500 by.1125 mm. In places they occur in hundreds, closely set together, and often very small, as at Fig. 4. The outlines are sharply defined, but it is not certain whether they possess a definite membranous investment. They contain minute refractile granular spher- ules, which behave with reagents like micrococci. In some of the larger balls, as shown in Fig. 6, secondary ones carc be seen. I am not prepared at present to discuss the nature and affinities of these structures, but hope to do so on another occasion, when I shall enter more fully into the histology of the primary and secondary lesions of this disease. The vegetations in the other cases may be finally spoken of together, as, histologically, they presented the same features, with a few slight variations. A section through the grayish-yellow material composing the outgrowth has an appearance as represented at Fig. 7,—groups of granular bodies separated by an indifferent tissue. These colonies are usually closely compressed, and form rounded or tubu- lar structures. In the specimen from which Fig. 7 was taken, the groups measured from .050 to .125 mm. in diameter. In the out- growths from the aorta in Case 5 this arrangement in colo- nies was particularly marked, and there were sharply-defined bodies, which bore a close resemblance to the micrococcus balls of Case 1, even to the occurrence of secondary spheres 18 INFECTIOUS ENDOCARDITIS. within them. In a section through the entire thickness of an outgrowth from the mitral valve, 7 mm. in diameter, the following appearances were presented: At the site of at- tachment there was moderate proliferation of the endocar- dial tissue, as shown by numerous round and elongated cor- puscles, which stained deeply in logwood. The greater part of the thickness of the mass is made up of irregular groups of dark granules, separated by indistinct fibrinous bands. The arrangement is not so uniform as that repre- sented at Fig. 7. In the superficial parts the texture is lower, the fibrinous laminae more distinct, and the corpuscles much more abundant. A collection of red blood corpuscles exists just beneath the outermost layer of this fibrin. I do not propose to make any further remarks upon the special clinical features of these cases, none of which came under my care. My attention, however, has been directed to several circumstances in connection with the disease, which have not, so far as I know, received attention at the hands of writers on the subject. First.—The fact that primary infectious endocarditis in the majority of cases does not occur in connection with acute rheumatism, as is almost universally stated to be the case. I have gone over the reports of 57 cases of this kind, and in only 15 is there any mention either of acute rheuma- tism or of previous rheumatic attacks, i. e., in 26.3 per cent. I have not been able to make an exhaustive review of the literature of the subject, but have gathered the cases from the British and American journals, transactions, hospital re- ports, and from some of the recent French and German journals. I have excluded those due apparently to septic infection, as from whitlow, urethral laceration, acute necro- sis, and the puerperal condition. Nor have I included those instances described as ulcerative endocarditis in chronic valvular affections (with dropsy, etc.), class 3 of above WILLIAM OSLER. 19 division, often accompanied with aneurisms of the valves; but it may be mentioned in this connection that Dr. Ogle, in the ninth volume of the " Transactions of the Patho- logical Society of London," gives 21 cases of aneurism of the valves from ulcerative endocarditis, and of 18 of these cases in which a history is given, 15 are distinctly stated not to have had rheumatism. Kirkes,* the pioneer in this depart- ment of pathology, noticed the fact of its independent oc- currence. I confess to having been considerably surprised at the result of this investigation, as I was previously of the opinion, expressed so strongly by Rosenstein f and others, that the great majority of the cases were met with in con- nection with acute rheumatism. The second point to which I wish to direct attention is the frequency with which this disease occurs with pneu- monia. Naturally, I regarded it as not a little remarkable that in five cases in succession I should meet with this com- bination. Cases 2, 3, 4 and 5 appear to have set in with the symptoms of ordinary pneumonia. In Case 6 it did not de- velop until after the patient had been in hospital for some days. In all, the disease appeared to be of the primary lobar form. In Cases 3, 4 and 5, at the time of the autopsy, the stage of hepatization had passed and resolution had be- gun. Of 21 cases of primary infectious endocarditis re- corded in the " Transactions of the Pathological Society of London," hepatization of the lung is mentioned in 10 as a concomitant pathological condition. Of the 57 cases which I have analyzed, 22 were complicated with or occurred in pneumonia, i.e., 38.5 per cent. What is the nature of this connection? Is the inflammation of the lung a complica- tion of the endocarditis, or vice versa ? In most of the cases it is distinctly stated that the lung was hepatized, and in * British Medical Journal, 1863. f Ziemssens Cyclopedia, vol. vi. 20 INFECTIOUS ENDOCARDITIS. the majority of the instances the disease appears to have begun, as in Cases 3, 4 and 5, with the symptoms of ordinary pneumonia, so that the conclusion naturally suggests itself that the endocarditis was either secondary to the pneu- monia or excited by the same cause, which latter I think the more probable supposition. Endocarditis is scarcely mentioned as a complication of inflammation of the lungs. In Huss' statistics * there are only 4 cases mentioned out of 959. Still, I was not altogether unprepared for the occurrence of the so-called diphtheritic inflammation in other organs in pneumonia. Bristowe f was, I believe, the first to point out that diphtheritic colitis was by no means infrequent in this disease, having met with it in 2 out of 30 cases of secondary "and 4 out of 16 cases of primary inflam- mation of the lungs. I have also had my attention directed to this complication, though I have not met with it so fre- quently as Dr. Bristowe; still of some 40 autopsies in lobar pneumonia, of which I have notes, diphtheritic colitis occurred in 4, usually in the form of thin grayish-white patches, but in one case %' there were large, thick, rupia-like masses involving the entire thickness of the mucosa, It is exceedingly interesting to note that in Case 6 this condi- tion of the colon occurred with the pneumonia and endocar- ditis. Litten § gives a case of ulcerative endocarditis accompanying diphtheritic colitis. The condition of the inflamed part of the lung in these cases did not present any coarse or microscopical differences from ordinary cases. There were no micrococci in the air-cells, nor any appear- ances resembling the remarkable bacteritic pneumonia de- scribed by Delafield.|| It is not very evident wherein the * Quoted by Wilson Fox in Reynolds' System of Medicine. f Path. Society Transactions, Vol. viii. % Pathological Reports, Montreal General Hospital, No.i, 1878. § Quoted in Brit. Med. Jourtial, Sept. 7, 1878. [Studies in Pathological Anatomy, Page 65, PI. XXXV. WILLIAM OSLER. 21 connection lies between these affections, but the very con- siderable number of instances in which they occur together is against a simple accidental complication. A third point of clinical interest is the occurrence of meningitis in these Cases as in 2, 3, and 6. In the 57 cases which I have analysed this is mentioned as present in 13; i.e., 22.8 per cent. In 7 it occurred with pneumonia. Meningeal hemorrhage, as in Case 5, is mentioned several times. It is probable that the meningitis is embolic, though I have not found micrococci in the exudation. Meningitis is a very rare complication of pneumonia and may occur apart from endocarditis; but in a case of inflammation of the lungs, particularly if the apex is involved (in 3 out of 4 such instances I found the upper part of the lung affected), the development of an irregular temperature with cerebral symptoms should suggest the possibility of endocardial mischief, with secondary meningeal inflammation. The exudation in the meninges in these cases is lympho-puru- lent, not very extensive, and generally on the surface of the hemispheres, not basic. The presence of multiple aneurisms of the aorta in Case 5 is deserving of comment, as I have not been able to find any similar observation in the literature of either ulcerative endocarditis or of aneurism. The man had evidently been the subject of that peculiar congenital malformation of the aortic semilunar valves which results in the fusion of two segments. In this condi- tion they are very liable to be the seat of a sclerotic endo- carditis which terminates in incompetency; and I have met with two other cases in which the united curtains, when in this state, were the seat of extensive ulcerative endocarditis.* The cardiac affection was evidently of old standing, and in * On fusion of two segments of the aortic valves. Mont. Gen. Hosp. Re- ports, Vol. I, 1880. 22 INFECTIOUS ENDOCARDITIS. February, 1879, a year and four months before his death, hypertrophy, a double murmur and a thrill were noted. The interest of the case centres in the four aneurisms of the arch, their age, and method of production. There can be no question of the recent character of the three small dila- tations, but in the case of the large one there is room for doubt. Could it have been formed during the five weeks of his last illness, or was it of old standing, and was the thrill heard in February indicative of its presence? I incline to the belief that it was of recent origin for the following reasons:—ist. The character of the sac-wall, which was thin, in places translucent, looking like the stretched adven- titia. In a very considerable number of aortic aneurisms of all sizes which have come under my observation, I have never seen one of this size with such a thin sac-wall and without any attempt at condensation. The internal and middle coats were not prolonged into the aneurism. 2d. The absence of laminated fibrin in the sac. Such a narrow- necked aneurism, if it had lasted for many months, would certainly have showed signs of the deposition of fibrin, which takes place in aneurisms quite as small and less saccu- lated. 3d. The condition of the intima of the arch. Apart from these aneurismal dilatations the lining membrane was remarkably free from degeneration, particularly when we consider the hypertrophy of the left ventricle which must have existed for some time. There was an entire absence of that e?idarteri'itis deformans which has, in my experience, been invariably associated with multiple aneurisms of the arch. 4th. A study of the four aneurisms shows that they have essentially the same characters and differ only in size. There is loss of substance involving the intima and media, the edges are covered with fungoid vegetations, and there is saccular distension of the adventitia, the only difference being that in the smaller aneurisms the breach of continuity WILLIAM OSLER 2} is slight, and the vegetations so luxuriant that they com- pletely cover it. Whatever the essential nature of the so- called ulcerative endocarditis may be, I think there can be no doubt that in this instance we have to deal with an identical process in the arterial tube, which has caused loss of substance and subsequent dilatation, just as it does on the mitral or aortic valve with the production of valvular aneurism. If this be granted, Case 5 adds an interesting section to the etiology of aortic aneurism. With regard to the intimate pathology of this disease, it is assumed by most recent writers to be a mycosis, i.e., to be dependent upon the growth and propagation of lowly fungi on the valves with a consequent blood contamina- tion. Certainly the minute bodies found in the endocar- dial vegetations correspond in their chemical and micro- scopical relations to micrococci. They are motionless, highly retractile spherules, less than a micro-millimetre in diameter, arranged in groups or colonies without any per- ceptible stroma. Acids, alkalies, ether and chloroform have no effect upon them. These characters are supposed to afford satisfactory means for distinguishing them from granular detritus of an albuminous or fatty nature. Most writers have accepted the view that these bodies are fun- goid in nature. Heller,* however, criticizes strongly the prevailing conceptions with regard to micrococci, and thinks that there are scarcely any micro-chemical agents or physical signs by which they can be distinguished from fatty detritus. He recommends soaking the tissue in 10 per-cent. potash solution and then in iodine solution, 1 in 10 of spirit, which tints monads yellowish-brown, but is inert on fat granules. Sections of the vegetations in these cases, treated in this way, show the colonies stained of a brownish-yellow color. * Virchow's Archiv. lxii, 1875. 24 INFECTIOUS ENDOCARDITIS. Apart from any micro-chemical tests there are peculiari- ties about these masses which we do not see in any form of fatty degeneration, as the uniformity in size of the gran- ules and their collection into large groups. The question of the relation of the micrococci to the dis- ease presents many dfficulties, and we are probably not yet in a position to give a final answer to the problem. Klebs, and most German writers on the subject, give an unhesitating assent to the parasitic theory and suppose the micrococci to gain access either through the gastrointesti- nal or respiratory systems, and they believe them to con- stitute the actual materies morbi. According to Koster* and Klebsf not only are these fungi present in the so- called ulcerative form, but they also exist in, and cause the development of, the ordinary warty or bead-like vegeta- tions so frequently met with in the valves. Within the past few months I have examined four specimens of this variety of endocardial vegetation, and have been able to determine in each instance the presence of micrococci, not, it is true, in the same luxuriance, or arranged in defi- nite colonies, but still sufficiently distinctive. In one case of mitral stenosis a fresh vegetation, when teased, showed many closely-packed spherules, some of which were, as Klebs has remarked with reference to the micrococci in this variety, larger than those met with in the ulcerative form. I was greatly struck with the resemblance which certain of these bodies, in this instance, bore to the indi- vidual elements of Schultze's granule-masses—those pe- culiar granular clumps common in blood of some animals and of impoverished persons. These structures are usu- ally regarded as the debris of colorless blood corpuscles, but I have shown*}; that they are aggregations of discoid bodies, * Virchow's Archiv., Bd. lxxii. \ Archiv fur Exper. Pathol, u. Pharmacol., Bd., ix, \ Proceedings of the Royal Society, 1873. WILLIAM OSLER. 25 probably living organisms of the nature of which we are still ignorant. They do not exist in the form of masses in the blood, but as isolated particles which might readily be- come adherent to the fresh endocardial outgrowths. I merely mention this as a point worthy of future investiga- tion. It matters little how the micrococci get to the valves, whether by embolism of the small vessels, as Koster sup- poses, or by deposition on the surface, as Klebs thinks; the question is: Are they responsible by their growth for the peculiar course and malignancy of cases of infectious endocarditis, primary or secondary? The facts of their oc- currence in the verrucose form, which may not be accom-: panied by any symptoms, and of their abundance in the recurrent endocarditis, which attacks old sclerotic valves, are, I think, opposed to this view, for if they act as a septic poison in the one case, why should they not do so in the other ? The micrococci do not appear to infest the blood in any numbers, so that they must be supposed to distil some subtle poison, " such soon-speeding gear as will dis- perse itself through all the veins " and profoundly disturb nutrition. The occurrence, however, of fatal septic cases, closely allied to, or identical with those in which a bacteric endocarditis is found, but in which no micrococci can be detected, either in the local process or in the blood, teaches us that the same poison may exist without the interven- tion of bacteria, the presence of which in any case may be only a partial phenomenon in a general infective process. Tle-},ri,ifed from the " Canadian Journal of Medical Science," May, 1S81. *1 CLINICAL LECTURE ON IDIOPATHIC OR PERNICIOUS AXUMIA.' By WILLIAM OSLER, M.D., M.R.C.P., Lond., Professor of the Institutes of Medicine, McGill College, {Delivered at the Montreal General Hospital in the Slimmer Session Course, April Uth.) Gentlemen,—The patient before you offers an example of that interesting disease described by Addison, in 1855, as "Idiopathic" Anaemia. Biermer, in 1872, thought he had discovered a new affection, and gave it the title of " Progressive Pernicious Anaemia." Lebert gave to it the name of " Essential," and you will find it described under one of these three terms. Here, in Montreal, we have been made familiar with it by the labours of Dr. Howard, your Professor of Medicine, whose paper, before the International Medical Congress, held at Phila- delphia in 1876, was one of the earliest and most important of the recent contributions to the subject. Owing to his kindness, and that of several of my colleagues, I have had opportunities of investigating certain points in connection with the pathology of the disease, particularly with reference to the state of the blood and the bone marrow, t * Reported by Mr. T. W. Duncan, and revised by Dr. Osier. t Canada Medical and Surgical Journal, March, 1877 ; Transactions of the Canada Medical Association, 1877 ; Centralblatt f. d. Medicin. Wissenschaften. Nos. 15 and 28, 1877, Berlin ; Centralblatt f. d. Medicin. Wissenschajtcn. No. 26, 1878. \/ 0 The history of the case is as follows :— Thomas W---, aged 47, a well-built ErglishmaD, was ad- mitted under the care of Dr. Ross, on January 19th, transferred to my charge ou the 1st of April. He was a bricklayer by trade, but served for twelve years in the army, and was through the Crimean War. For the past two years he has been a baggage-man at the Railway station. He has always enjoyed good health, has never had ague, though he resided for some time in a malarial district. He is a married man, has four children; has not had any special domestic or mental trouble. Up to August, 1877, he enjoyed good health ; but about this time he began to feel weak and lost colour. He fainted on several occasions, and had attacks of bleeding at the nose. In January, 1878, he entered the hospital, and remained three months—his symptoms being anaemia, without any recognizable cause, weakness, swelling of the ankles and retinal haemorrhages. He improved very much, and in a couple of months after leaving the Hospital, was able to work, though pale and weak. Through the years 1879 and 80, he followed his occupation, but never regained his former strength or colour. There appear to have been slight digestive troubles as he has not been able to eat meat. In August last his wife was confined and was very ill after- wards. Attendance upon her and anxiety brought on the old symptoms, and when he entered the hospital, on January 19tl), he was exceedingly weak and pale; had headaches, bleeding at the nose and dizziness when standing. These symptoms have continued with occasional intermission up to the present date. On several occasions the bleedings were severe, lasting once for nearly twelve hours ; the blood coming drop by drop from the right nostril. The temperature was usually normal, but at times went up to 101° or 102°. For the past three weeks there has been no haemorrhage, and his general health has improved, the headaches have disappeared and he takes nourish- ment better. His present condition is as follows :—You notice, in the first place, the extreme bloodlessness of the exposed regions, particularly marked in the face * but I would call your attention to a peculiarity in the colour of the skin, which is 3 well marked in this case, and has been so in all of the cases which I have seen in this city. It is not blanched from simple bloodlessness as in the pallor of fear or haemorrhage; but there is a peculiar sallow, dirty yellow or lemon tint, not the hue of jaundice, and, moreover, the conjunctivae are not stained. It is also quite distinct from the greenish yellow tinge of the skin in chlorosis. The patient still has a fair amount of sub- cutaneous fat, though he has lost a good deal of flesh in the past three years. He is weak, easily tired, and it has been as much as he could do to get from the ward to the lecture room. His breath is short on exertion, and he feels faint and dizzy, when he stands for any time. The appetite is poor and the digestion weak, but he has never had vomiting. The bowels are regular, no diarrhoea. Pulse is 84 per minute, soft and weak. On listening to heart sounds, which are very distinct, there is a blowing systolic murmur at the base, evidently haemic in character, and the venous hum is loud in the neck. There is no evidence of any pulmonary trouble. The examination of abdomen is negative ; liver dulness, normal. Spleen dulness, about four inches in vertical diameter, edge cannot be felt under the ribs. Urine clear, reaction acid, sp. gr. 1015. There are no cerebral symptoms; he has suffered from headaches, but not latterly. On examination of the eyes, retinal haemorrhages are seen, and also pigmented spots, the result of old extra- vasations. The examination of the blood yields the following results : With Grower's Haemacytometer, red corpuscles per cubic milli- metre, 970,000, 19*4 per haemic unit, instead of about 5,000,000 in the c. m. The haemoglobin, as estimated by Grower's Hsema- chroniometer, is only 20% of the normal, and about the same pereentage is obtained by Quincke's apparatus. The blood drop, when expressed, has not the full rich colour and consistency of normal blood, but is paler, thinner and watery. Under the microscope, the corpuscles show a great inequality in size, some are larger than normal, others very much smaller. Many are very irregular in outline. The colour of individual cor- puscles is pretty good, a few nucleated red corpuscles exist. The white corpuscles are not materially increased, the proportion, when counted, 1 to 230 red. There is an entire absence of 4 Bohultze't* granule masses, so common in tht< blood of debilitated individuals. I have put, for purposes of comparison, the blood of an anaemic girl under another microscope and you will be able to perceive a marked difference. Summing up the chief symptoms, we have,— 1. Profound anaemia without any obvious cause. 2. Cardiac and vascular murmurs. 3. Repeated attacks of epistaxis, which began originally after the anaemia was established. 4. Retinal haemorrhage. 5. Peculiar alterations in the histological character of the blood. The clinical picture which Addison has left of the disease is unequalled, as you may gather from the following extract:— " It makes its approach in so slow and insidious a manner, that the patient can hardly fix a date to his earliest feeling of that languor which is soon to become so extreme. The countenance gets pale, the whites of the eyes become pearly, the general frame flabby rather than wasted ; the pulse, perhaps, large but remarkably soft and compressible . . ; there is an increasing indisposition to exertion with an uncomfortable feeling of faintness, or breathlessness on attempting it; the heart is readily made to palpitate ; the whole surface of the body presents a blanched, smooth, and waxy appearance; the lips, gums and tongue, seem bloodless; the flabbiness of the solids increases; the appetite fails; extreme languor and faintness supervene, breathlessness and palpitations being produced by the most trifling exertion or emotion; some slight oedema is probably perceived about the ankles ; the debility becomes extreme."* He says that these were " cases in which there had been. no previous loss of blood, no exhausting diarrhoea, no chlorosis, no purpura, no renal, splenic, miasmatic, glandular, strumous, or malignant disease." Of the individual symptoms of the affection, I shall not speak fully, as most of them are common to all forms of anaemia, but one or two demand special attention. I have already told you of the state of the blood in this patient, and of the remarkable diminution in the red corpuscles. Instead of 5,000,000 to the * Addison's Works, New Sydenham Society, p. 212. cubic millimetre, the number is reduced to 970,000. Tn over fifty cases of diseases, accompanied with wasting, in which I have carefully counted the corpuscles, pernicious anaemia is the only one in which I have met with a reduction in the red corpuscles below 1,000,000 to the cubic millimetre. Even in an instance of severe haemorrhage—haemoptysis extending over a week—and during which time the man lost nearly ten pounds (by measurement) of blood, the number of corpuscles was 1,390,000 per cubic millimetre. The reduction may be much more marked than in this case ; the most striking instances which I have found recorded are given by Quincke,* in one, 330,000 per c. m. ; and in another, 143,000 per c. m. ! Strange to say, this patient recovered after transfusion, and the number of corpuscles rose from 143,000 on the 22nd of May, to 1,234,000 per c. m. on the 5th of August. The colour of phe blood is much altered ; the drop, as expressed from the linger tip, has not the rich red tint of health, but is lake coloured or like claret and water. In some forms of anaemia, particularly chlorosis, the haemoglobin is greatly reduced, even when the number of red corpuscles maintains a fair standard. Thus, in two cases of chlorosis, while the globular richness was 87*8 and 92 per haemic unit,+ respectively, the haemoglobin, as estimated by the haema-chromometers of Quincke and Gower was 64, and 66 per cent.; that is to say, the individual corpuscles were poor in colouring ingredients. In pernicious anaemia, the loss in colour is usually proportional to the corpuscular poverty as in this case, in which the red corpuscles are only 19*4 per haemic unit, and the haemoglobin 20%. The microscopical characters of the blood in this disease are worthy of your closest attention, as I know ot no disease in which that remarkably constant histological element, the red blood corpuscle, undergoes such important modifications. I have * Archiv. f. Klin. Mcdicin. Bd. xx., 1877. t " With normal blood the average number of corpuscles in two squares of the Hemacytometer (containing '00002 cubic millemetres of blood is 100). I propose, therefore, to take this volume of blood, -00002 c. m., as the standard volume, and to term it "hsemic unit." Thus the number of red corpuscles per hsemic unit is the percentage proportion to health." (Gowrs ) 6 studied carefully the blood in six instances of ihe disease, and in all there has been a striking uniformity in the microscopic features, which are as follows :— 1. Remarkable variations in the size of the red corpuscles, three sorts being distinguishable; (a) Giant forms; usually not very abundant. I have measured some of these as much as rfjyj; and yj1^ of an inch in diameter, (b) Medium-sized cells, such as ordinarily met with ; they constitute the larger pro- portion, (c) Very small corpuscles — raicrocytes — tolerably numerous; they are globular, and of a deep colour ; they range in diameter from ^Vo" *° "o 0V0 °f an inCD- Quincke has coined a term to express this great discrepancy in size, Poikilocytosis.* It is certainly a remai'kable feature in the blood of this disease, and though not absolutely peculiar to it, yet, is much more marked, in my experience, than in leukaemia, splenic anaemia and Hodgkin's disease. 2. Great irregularity in the form of the corpuscle. The disc shape of the red blood cell is rarely departed from in health or disease, but in this affection, the margin of the corpuscles are indented and irregular, or there are various extensions of the stroma, giving to the corpuscles a balloon or hammer shape—alterations which cannot be mistaken for crenation. 3. The colourless corpuscles do not present any special characters, and are not actually, though they may be relatively, increased. The amaeboid movements are active. In one or two instances they were reduced in size, and in a few cases in number. 4. Schultze's granules, so common in cachectic conditions, are absent. 5. In one case, nucleated red-blood corpuscles, such as occur normally in red marrow, were found. In a large number of cases, haemorrhages constitute an important symptom. Epistaxis is common, and this patient, as you heard, has had severe attacks. Retinal haemorrhages fre- quently occur, and have been thought to be peculiar to the disease ; but Littent has shown that they develop in the anaemia * motxiXm. variously formed. t Btrliner Klin. Wochenschrift, 1877. ( of cancer, and after severe loss of blood. In several of the cases which have occurred in this city, there were small cutaneous extravasations. The etiology of the disease is, in many cases, obscure; but in others, well recognized predisposing causes may be traced. Of the recorded cases, the large proportion appear to have been in women, particularly in Switzer and, where the disease appears to prevail extensively* owing, doubtless, to local con- ditions. Thus, of ninety-three cases reported from the clinics of Berne and Zurich,* sixty-seven were females and twenty-six males. In England, the majority of cases have been males. Of eleven cases which I know of as occurring in this city, eight were males. Among the more important causes which have been assigned, are: 1. Pregnancy and Parturition. Many of the cases on record have developed during pregnancy or shortly after delivery. It may be doubted whether such cases can be classed under the heading Idiopathic or Essential. 2. Defective food. A considerable proportion of the Berne and Zurich cases resulted from this cause, and were more correctly examples of inanition anaemia. It is quite striking, in reading over the records of continental cases, to note how frequently this circumstance is mentioned, and the majority of the patients appear to have been derived from the lower classes; while here, and in England, many of the cases have been among the well-to-do. 3. Gastro- intestinal troubles, atonic dyspepsia or diarrhoea, have preceded the onset of the anaemia in a large group of cases. 4. Grief, mental shock or worry, have been mentioned by writers as probable causes. In one of the cases which occurred here (Dr. Gardner) the failure in health began after the death of two sons. In the present case none of these causes can be assigned. The diagnosis is arrived at only by the exclusion of all possible affections which might cause, or be accompanied by, great poverty of blood. You must carefully inquire into the history and mode of onset, interrogate the various systems * Midler Die pro. per. Anamie, Zurich, 1877; Quincke, Volkmann's Sammlung, no. 100 ; and Zinns*en's Archiv. Bck. xx. and xxv. 8 and organs in a searching and methodical manner, when, if no definite disease can be detected the diagnosis of idiopathic or pernicious anaemia will probably be correct. The affections with which it would be most liable to bo confounded, are : 1. Cancer of the stomach, some instances of which run a very latent course. In the case you have here, the gastric symptoms have not been marked, there is no tumour, nor tenderness, nor marked emaciation, and the disease has lasted a much longer time than cancer would. 2. The appearance of the patient and the retinal haemorrhages suggest Bright's disease —and would still more if th? ankles were swollen, as formerly —but examination of the urine is negative. No casts, no albumen. 3. From certain other blood diseases the diagnosis might be difficult, but scarcely in this instance. In leukaemia there might be the same pallor, the poverty of red blood corpuscles, the vascular murmurs, and the irregular, slight pyrexia, but we would have in addition, splenic enlargement, and a great increase in the colourless elements. Hodgkin's disease and splenic anaemia, while presenting a blood condition, closely resembling that of pernicious anaemia, would be dis tinguishable by the glandular enlargements. It is not im- probable, however, that there is a relationship between these affections, which resemble each other so closely in certain clinical features. Litten* gives a remarkable instance of anaemia follow- ing parturition, in which three days before death leukaemia of a high grade developed. In the morbid anatomy of this affection there are three points of interest, the extreme bloodiessness of the organs and the small quantity of blood in the heart and vessels, the advanced fatty degeneration of the heart and other organs, and the condition of the bone marrow. [In certain cases, having a close resemblance to pernicious anaemia, Dr. Fen wick, of the London Hospital, has described an atrophy of the gland structures of the stomach; but what con- nection that has with the anaemia—whether as cause or effect —appears doubtful. In future, the stomach should be carefully examined in these cases.] The bloodiessness of the organs is extreme, and the heart * Loc. cit. 0 and arteries almost empty; in one instance 1 could collect only Vj of blood from the chambers of the heart and the aorta. The fatty degeneration is secondary to the anaemia, and is a very constant change. Formerly, cases of this disease were described by some writers as, "idiopathic fatty degeneration." The alteration in the bone marrow has attracted considerable attention, and is believed by certain pathologists to have an important connection with the disease. The long bones have been found to contain a rich red marrow, which has replaced the normal fatty tissue of the medullary canals of bones of adults. This consists of granular marrow cells, small lymphoid corpuscles, myeloplaques, red blood corpuscles, and large nucle- ated red corpuscles. The latter have been spoken of by many writers as if they were not a usual constituent of adult marrow ; according to my observations they can always be found in the red marrow of the ribs and short bones, often in considerable number. [I am surprised that so good an observer as Prof. Rutherford, of Edinburgh, should state, in the little work on Practical Histology, which many of you use, that he has never been able to see these bodies in the marrow.] This change in the medulla of the bones, in pernicious anaemia, was first studied by Pepper, Cohnheim and myself, and we were inclined to attribute to it a somewhat important role in the pathology of the disease. The position which I took in the matter may be gathered from the following remarks in a paper before the Canada Medical Association in 1877 : " Clinically, these cases present certain similarities to those of leukaemia and Hodgkin's disease, or pseudo-leukaemia. Now these latter diseases differ chiefly in this, viz., that in leukaemia the colourless blood corpuscles are in excess ; in pseudo-leukaemia they are not. Both present three varieties: 1st, the splenic, in which the chief lesion is the great enlargement of the spleen ; 2nd, the lymphatic, in which the lymph glands throughout the body are mainly affected; and 3rd, the researches of Neumann, Mosler.. and others have made us acquainted with a variety known as the myelogenous or medullary, in which the marrow of the bones is the seat of disease. This tissue is now generally regarded as sharing, in the young animal at any rate, with the spleen and lymph glands, in the formation of blood cor 10 puscles. In the long bones of the adult it is in a state of atrophy, and its place, in great part, supplied by fat. In many cases of leukaemia and pseudo-leukaemia, it increases, becomes more vascular, its cellular elements multiply, nucleated red blood corpuscles, such as occur in the embryo, are formed, and the whole tissue passes into a condition of hyperplasia, strictly analogous to that affecting the spleen and lymphatic glands. This may be, as in a case recently reported by Mosler, the primary lesion in leukaemia, and the development of the marrow may produce definite symptoms, such as swelling and tenderness of certain parts of the bones; so that the myelogenous forms of these affections are now well recognized. Clinically, the myelo- genous form of pseudo-leukaemia, though rarely uncomplicated, presents such a similarity to pernicious anaemia that Jaccoud and Immerman suggested the identity of the two affections, while Prof. Pepper, declared distinctly that pernicious anaemia was ' merely the simple medullary form of pseudo-leukaemia.' "In the present state of our knowledge it may, I think, be reasonably affirmed that certain cases of idiopathic anaemia may be placed in the category of myelogenous affections. To many it may appear far-fetched to spek, in the altered condition of the bone marrow, an explanation of the extreme anaemia of this disease, but the reports of numerous cases leave no room for doubt that a serious alteration in its structure, and a return in adult life to its embryonic state, may profoundly influence the composition of the blood, producing anaemia and death. It must be borne in mind that the red marrow in the short bones of an adult probably equals in bulk the constituents of the spleen, and structurally is very similar to that organ and to the lymphatic glands. In the long bones it is largely replaced by fat, but traces of it still remain. Now, granting that the marrow is a tissue which shares in the blood-making functions, it is quite as reasonable to suppose that, if hyperplasia of the elements of the spleen can lead to serious disturbance in the composition of the blood, producing the splenic form of leukaemia or pseudo-leukaemia, according as the colourless corpuscles of the blood are increased or not, so a general increase of the consti- tuents of the marrow may induce similar conditions. For it is to be remembered that, in a general hyperplasia of the 11 marrow, the actual amount of lymphoid tissue in the osseous system equals or perhaps exceeds, that of an enlarged spleen. Why a simple hyperplasia of this tissue should interfere with the elaboration of the blood, altering in the one case the mutual proportion of the corpuscles, and in the other simply reducing the total number, we do not know; but we are just as ignorant why an enlarged spleen and lymphatic glands should produce in the one case leukaemia, and in the other not." When the paper was published, from which I have read you these extracts, a systematic investigation into the condition of the bone marrow, in various diseases, had not been made; but since then a number of observers have found this hyper- plasia of the medulla in many chronic diseases, particularly in phthisis and cancer. In a considerable number of examinations, I have also met instances of red marrow in the long bones in chronic wasting disease, but not so frequently as Litten and Orth,* or Blechrnann.T In only two instances have I found such intense and universal hyperplasia of this tissue as in the three instances of pernicious anaemia, which I have had an opportunity of examining. On the other hand, in eight cases of phthisis, and in two of cancer, (oesophageal and pyloric) I have found the marrow of the long bones fatty. I think that we have still a good deal to learn with reference to the bone marrow. I am not quite disposed to give up the view that some instances of pernicious anaemia may be of myelogenous or igin. The similarity of the clinical features to leukaemia and pseudo-leukaemia, and the transition in Litten's case, from pernicious anaemia to leukaamia, suggest a close relationship. Such a profound anaemia, as in the case before you, might result from one of two causes: 1st. A faulty formation of blood corpuscles—anhaematosis, or loss of blood, either by haemorrhage, chronic discharges or excessive destruction of the coloured eel Is—haemophthisis. Yery many of the reported cases of this disease do not come strictly under the definition as given by Addison ; but there have been various causes at work, productive of hcemo-piithisis. Dr. Howard holds that " all the various forms of anaemia, * Berliner Klin. Wochenschrift, 1878. t Archiv. der. Heilkunde, 1878. 12 i.e., forms, deteimined by the conditions, under which they occur, may occasionally take on progressive and pernicious characters." And this is the view taken by Quincke. Dr. Howard further maintains that there is not a distinct variety of anaemia having an etiology and pathology peculiar to itself, and it is upon this point, particularly, that more light is wanted. The cases require sifting ; and, for my own part, I would insist, with Immerman, " that no case should be accepted as belonging to this disease, unless, besides being an instance of extreme and fatal anaemia, it is also impossible to account. either rationally or empirically, for the progressive course of the anaemic symptoms."* The prognosis is most unfavourable ; all of our Montreal cases have died. Of the sixty-four Zurich cases, given in Midler's monograph, only seven recovered. Of Quincke's thirty-one cases, eleven are stated to have recovered; hut you must remember, with reference to many of these Switzerland cases, that they come more properly under the head of inanition anaemia. The duration of the disease is from three months to a year. This case is remarkable as lasting for over three years. One of Biermer's patients lived for five years after the first onset of the symptoms. The most rapid course in his cases was seven weeks. The treatment is not very satisfactory. Special attention must be given to the weak digestion which almost invariably accompanies the disease. Iron, in some form, should be em- ployed ; this patient has been taking Blaud's pills for some weeks, but without any apparent benefit. Arsenic should be given, as several successful cases have been reported under its use; it may be given in combination with the iron. Our patient has not been taking it long enough for us to say whether it is doing any good. Transfusion of blood has been employed in many cases, but without very encouraging results. Quincke, however, has had several successful cases. He transfuses into the radial artery. The transfusion of milk, as first employed by my old preceptors, the late Drs. Hodder and Bovell, of Toronto, is stated to have cured, even after blood transfusion had failed. * Quoted by Hartshorne in his article on "Prog. Pernicious Anaemia," in the American edition of Keynolds's System, Vol. III. >7 CASES OF HODGKIN'S DISEASE. By WM. OSLER, M.D., M.R.C.P., Lond. Professor of the Institutes of Medicine in McGill University, and Physician to the Montreal General Hospital. 'e-printed/rom the " Canada Mediml & Surgical Journal, Montreal, February, 1881.) CASES OF HODGKIN'S DISEASE. By Wm. OSLER, M.D., M.E.C.P., Lond. Professor of the Institutes of Medicine in McGill University, and Physician to the Montreal General Hospital. There is at present a tendency among certain writers to the belief that the various diseased conditions of the lymphatic glands are so related as to form a pathological series, the members of which may pass the one into the other. Thus Dr. Goodhart, of Guy's Hospital, says : " We find the following conditions of the lymphatic glands all closely related to each other : First there is a local chronic inflammation (the so-called scrofulous gland); next a local simple tumour, called by some hypertrophy; lastly a local malignant tumour, some varieties of which are called by some lymphatic cancer. These are all local. But there is also a parallel series of generalized affections, a diffused chronic in- flammation or scrofulous state, a diffused or general simple tumour, a generalized malignant tumour, and with the exception of the scrofulous or caseous group .... and perhaps of the generalized malignant tumour, these various conditions can be shown upon very good clinical, if not pathological evidence, to lead the one into the other." However this may be, the cases characterized by a certain set of clinical features have been con- venientlv grouped together, and are described under the various names of Hbth/Jcin's Disease, Anccmia lymphatica, Adenie, Pseudo-leukcemia, §c. The distinctive features of this affection are : gradual enlargement of groups of lymphatic glands, gene- 4 rally also of the spleen, disseminated lymphatic growths in the viscera, and anaemia with more or less cachexia. To the morbid process in the glands, the names of Lymphadenoma, Lympho- sarcoma, Malignant Lymphoma, Desmoid Cancer, &c, have been given, and they indicate the diversity of opinion that prevails with regard to the nature of the growth. In the majority of instances, perhaps the term lymphadenoma is applicable, as the enlargement is due to an increase in the normal tissues of the gland, though the relation between the constituent elements is scarcely maintained so closely as in simple hypertrophy from irritation. In other cases the growth resembles an actively- growing sarcoma, and may involve contiguous tissues, or even infect distant organs. The following cases illustrate many of the chief features in the clinical history and morbid anatomy of the disease :— Case I.—Lymphadenoma of the Retro-peritoneal glands— Enlargement of the Spleen—External Glands not affected.— C. C, an immensely stout man, aged 40 years, first complained in May, 1876, of severe pain in the lumbar region. It evidently followed the course of the lumbar nerves, and there was tender- ness over the same parts. This was called and treated as lumbar neuralgia, which it certainly was. There was at this time no alteration in the general condition of the patient, who maintained his usual appetite and strength. Some months later, and after the lumbar pain had continued with varying intensity, other symptoms occurred. Pains were felt down both legs, but more especially the left, and occupying mainly the anterior aspects. He began to feel weak and to lose flesh, and the pulse became soft and habitually rapid. The loss of weight was neither rapid nor excessive, but his muscles became soft and flabby, and he kept throughout an enormous corpulency of abdominal fat. After this a new direction of pain was experienced, viz., along the left spermatic cord, sometimes very severe. Then chills appeared ; these occurred at irregular intervals, sometimes slight, but at other times amounting to well-marked rigors. After these, the temperature would be quite high, 100°F. to 104°F, and during the interval, though much lower, it was nearly always a degree 5 or more above the norme. Diarrhoea set in, and obstinately resisted the use of astringents and other remedies Exhausted by the very severe pain, which constantly required hypodermic injections of morphia for its relief, by the diarrhoea, which was generally copious, by the fever and by c uMiquative sweating, he gradually sank and died, 1st March, lgjSfc The case was cer- tainly one in which it was extremely difficult to arrive at a posi- tive diagnosis. The opinion held during life was that there was either deep-seated abscess in the abdomen (peri-nephritis ?) or that malignant disease occupied the deep abdominal glands and pressed on the lumbar nerves. The former seemed the more probable explanation, being favored by the rigors, fever, sweat- ings and diarrhoea in the later stages. The autopsy alone re- vealed the true nature of the case—lymphadenoma of the retro- peritoneal glands, there being also a large spleen. This condition was not suspected during life, which will not be wondered at when the extreme rarity of such an occurrence is considered, and the fact that there were no enlargements whatever in the external parts which might have led to a suspicion of similar trouble in the corresponding internal lymphatics. It should be said that the extreme corpulency of the patient quite precluded the possibility of recognizing a moderate enlargement of the spleen. The blood was not examined. It is doubtful if, even had this been done, any material assistance would have been rendered in the diagnosis. Autofxi/, 24 hours after death.—Body that of a large-framed, somewhat corpulent man. Abdomen large ; no oedema of legs. Skin very pale. External lymph glands not enlarged. In peritoneum, about 30 ozs. of turbid serum ; intestines of a dark slate-grey colour. In thorax, a few ounces of turbid serum in pleurae. Heart soft, and the sub-pericardial fat is in ex- cess ; chambers contain dark blood and clots ; valves are healthy; muscle substance very pale, of a yellowish-brown colour. Lungs are crepitant throughout. No enlargement of bronchial or mediastinal glands. Spleen is much enlarged, measures 35 cm. in length by 15 6 cm. in breadth ; capsule is thin ; pulp soft, of a dark purple-red colour ; trabeculge not much developed. Kidneys: fatty, capsules thick and more fibrous than usual; organs are large and flabby, cortices swollen ; vessels of pyramids injected ; many of the straight tubules are filled with urinary salts. Liver not enlarged ; substance pale and looks fatty. Stomach&nd intestines present nothing of special note. Peyer's glands not enlarged. When the intestines were turned out, the chain of lymphatic glands about the aorta and iliac vessels were seen to be greatly enlarged. Beginning immediately below the diaphragm, they extended in a continuous series to the femoral rings, involving the lumbar, sacral and internal iliac groups. They were entirely retro-peritoneal, and the affection was limited to the glands above mentioned, not involving the mesenteric or external iliac. Though in contact, the individual tumours were distinct, and could be isolated. Along the aorta to its bifurcation they were about the size of large walnuts ; close to the lower end of the left kidney there was one the size of a small apple. Four or five large ones were situated on either side of the external iliac arteries. One on the left side lay directly upon the genito-crural nerve ; an- other on the same side plugged the femoral ring. In the course of the internal iliacs the tumours were not so large. The larger tumours were soft, conveying to the touch the sensation of in- distinct fluctuation. The smaller ones were firmer and more resistant. On section, the substance was soft, greyish-white in colour, interspersed with reddish streaks. In the smaller growths the cut surface was consistent, and looked more like the natural gland tissue. Histological Examination.—Blood taken from the splenic and jugular veins did not show such a marked increase in the number of colourless corpuscles as to constitute leukaemia. Spleen : The only points of special note were the number of small lymphoid, colourless corpuscles, and the abundance of large round bodies containing either red blood corpuscles, diffused colouring matter or yellowish granular pigment. I have never seen these struc- 7 tures so numerous as in this specimen—from four to six could be seen in each field of the No. 9, im*. (Hartnack). The enlarged retro-peritoneal glands consisted of the following elements : (1) Lymphoid corpuscles, very abundant; (2) colourless cells, like white blood corpuscles, about double the size of the lymph cells and with a more granular protoplasm ; (3) giant cells ; (4) fibre cells of connective tissue. Heart muscle was very fatty. Only the marrow of a rib could be secured for examination, and it presented the usual characters of this tissue, but the corpuscles containing red-blood were very numerous. Case II.—Lymphadenoma of the Cervical, Axillary and Thoracic Grlands—Large 3Iediastinal Tumour—Right Hydrothorax —Progressive Anccmia. James K., aet. 20, a patient of Dr. Sherman's of Morrisburg, Ont.,who brought him to Montreal for examination on June 30th, 1880. Family history—Parents alive ; has brothers and sisters ; he is himself a twin ; no history of scrofula or other hereditary disease in the family, the members of which appear healthy and well nourished. Father and sons are very hard-working fanners. Previous history—Has been a healthy lad ; never any special illness. Has been a very hard worker. Present illness—In November, 1879, he caught cold, had a severe chill, and pain in the right side. Did not lay up or have a doctor, but felt unwell for several weeks. About Christmas he noticed the glands on the left side of the neck to be enlarged. There was at the same time swelling of the thyroid. A slight prominence of the upper part of the sternum was noticed in January, and shortly after the glands in the right axilla began to enlarge. About a month ago the left axillary glands became swollen. Under treatment (iron and cod liver oil) the cervical glands diminished in size, and the enlargement of the thyroid disappeared. He has lost flesh, not much since March, and has become pale and short of breath. Present condition.—Patient is an average-sized young man, fairly well nourished ; eyes blue ; complexion muddy, particularly 8 on lower part of the face ; is anaemic, and complains of muscular weakness. Appetite is good ; bowels regular ; tongue moist, indented with the teeth. Pulse 128 ; respirations 55. On inspection, left cervical glands greatly enlarged, forming a continuous tumour from behind the ear to the clavicle, occu- pying both anterior and posterior triangles. The individual glands in the collection can be felt, are moveable beneath the skin, of elastic feel, and not painful. On the right side there is no evi- dent enlargement, but the glands can be felt with unusual dis- tinctness, and just above the clavicle they are decidedly enlarged. Iri right axilla, just within the axillary fold, there is a tumour the size of a couple of billiard balls, and in the left axilla a smaller one ; both are freely moveable, of moderate consistence, and not painful. The inguinal glands are not enlarged. In front of the chest there is marked bulging of the upper two-thirds of the sternum and corresponding costal cartilages, forming a somewhat flattened tumour, extending from root of neck to level with the nipples, and about six inches in breadth. Its point of greatest prominence is opposite the 2nd rib. The skin over it is natural looking ; there are a few dilated venules. There is no pulsation ; it is painful on pressure, and pits slightly. The glands are enlarged in the epi-sternal pit, and just over the right sterno-clavicular joint are two glands, to which the skin is firmly adherent. In respiration the left side of chest moves more freely than the right, and the intercostal spaces are obliter- ated in the latter. On mensuration, right, 18 inches ; left, 17| inches. Apex beat visible If inches below and 1 inch to the outer side of the left nipple. On percussion, absolute dulness over swelling in front of the chest, extending on the left side as far as the nipple line. Outer part of left infra-clavicular and mammary regions presents a clear note; same on posterior regions of this side. Right side is uniformly dull, except a finger's- breadth beneath the clavicle and in the supra-spinous and upper part of outer scapular regions behind. Tactile fremitus absent over dull areas. On auscultation, breath sounds exaggerated and harsh on left side ; tubular at upper part of right lung in front and behind, abolished at base on this side. 9 Heart is depressed, dulness merges with that of the sternal tumour ; impulse forcible ; sounds clear. Abdomen looks full ; superficial veins distended ; when he stands up they become very marked, are coiled, and in places varicose. Sense of increased resistance in region of navel, but no definite tumour can be felt. Liver extends two fingers-breadth below costal border, and in sternal line reaches to the navel. It is depressed, not enlarged. Spleen not increased in size. Urine is amber-coloured; sp. gr. 1023. No albumen. There is no tenderness over any of the bones. Blood thin, claret-coloured. Red corpuscles tolerably uniform in size, with regular outlines ; a few small ones noticed. White corpuscles appear a little more numerous than normal; no special alteration in size or appearance. No nucleated red corpuscles. With Gowers' hemacytometer, number of red per cubic milli- metre about 2.100,000,=42 per cent. Proportion of white to red corpuscles, 1 to 180. Percentage of haemoglobin with Gowers' haemachrometer, 46. Diagnosis—Hodgkin's disease (lymphadenoma),with pleuritic effusion on right side. The young man returned home, and the further history of the case, as gathered from Dr. Sherman, is as follows:—About the middle of July the fluid was drawn off from the right side, 14 pints, straw coloured. This relieved him considerably, and he was able to breathe quite freely. The sternal tumour had in- creased in size and became inflamed. On July 26th Dr. Sherman opened it at the lower part, and about half a pint of ill-conditioned, bloody, pus escaped. Appetite keeps good. On Aug. 9th the lad's father reported that the breathing had again become diffi- cult, and dropsy was beginning in the legs. Death took place on Aug. 20th, rather suddenly, as he had been walking about the barn-yard the same day. Autopsy, about 40 hours after death, in the presence of, and assisted by, Drs. Sherman and C. E. Hickey of Morrisburg, Dr. Wagner of Dickinson's Landing, Dr. S. Hickey of Aultsville, and Dr. Blackstock of Chesterville.—Decomposition had set 10 in ; face swollen, skin discoloured and crepitant to the touch. Swelling in front of the chest had increased in size, and at the lower part, the incision above referred to was seen. Cervical and axillary tumours about the same size. On making the preliminary incision, a quantity of soft greyish material escaped from the tumour over the sternum. When cut into, substance soft and pulpy, with harder masses scattered through it. To a level with the 4th rib the sternum was destroyed, only a small bit uniting the clavicles above. The cartilages of the 2nd and 3rd ribs were also eaten away, and on the right side there was erosion of the bony parts as well. There was slight infiltration beneath the pectoral muscles, but the growth was not continuous with that in the axillae. On fully exposing the cavity of the thorax, the entire anterior mediastinum was filled up with soft greyish white masses, lying upon the aorta and pericardium, and extending into the neck. A large rounded mass, firmer than the rest, occupied the position of the right auricle and pushed the heart to the left. Several isolated tumours were attached to the diaphragm. The antero-lateral part of right lung was closely united to the tumour ; on the left side the lung was free, but the growth projected in nodular masses into the pleural cavity beyond the costal cartilages. About four pints of blood-stained serum in right pleura. Entire mass removed with lungs and heart. On dissection from behind, aorta not compressed, though the arch was surrounded by irregular masses. CEsophagus presented one or two enlarged glands attached to its lower third. On slitting up the trachea and bronchi, former not compressed, right bronchus free, left somewhat narrowed, a conglomerate mass of enlarged glands surrounded the trachea from the root of the neck to the bifurcation, and passed out the bronchi, particularly the left, and were imbedded in the lung substance. Immediately below the fork of the bronchi was a group of large glands, some- what firmer than the others. Heart transversely placed and pushed down ; chambers and valves normal; arch of aorta crossed at level of 3rd intercostal space. Lungs—Right collapsed, only the extreme apex crepitated. 11 Throughout the lower and middle lobes were numerous greyish- white masses, varying in size from a cherry to a walnut. They were very abundant in the fissure between the lower and middle lobes. The left lung was oedematous, otherwise healthy. The enlarged glands at the root penetrated into the substance, but not to the same extent as in the other lung. Spleen 15 cm. in length, pulp soft, uniform; no nodular masses. Kidneys presented nothing abnormal. Liver pale, not enlarged. Nothing special was noticed in stomach or intestines. Peyer's glands not enlarged. Lymphatic Glands.—The cervical, on the left side, formed a large tumour made up of a chain of glands extending from the sternum to the back of the ear. They occupied both triangles of the neck, and the sterno-mastoid muscle was stretched over them. The enlarged glands were closely adherent, about the size of walnuts, and tolerably firm. Many of the smaller ones could be enucleated. On the right side, only the lower cervical glands, just above the clavicle, were affected. The axillary glands were much enlarged, forming large bunches, composed of closely packed glandular masses, the individual elements of which were with difficulty separated. Mesenteric glands of normal size. Retro-peritoneal glands enlarged to the size of horse beans, and firm. One or two in the hilus of liver, also enlarged. Inguinal glands not affected. Owing to decomposition, the glands were doubtless softer than during life. On section, they had a greyish colour and a soft cerebriform appearance ; a con- siderable quantity of juice was obtained on scraping the cut sur face. Some of the glands were firmer, and had strands of firmer tissue passing through the substance. One or two of the masses in anterior mediastinum presented in spots a caseous appearance. The decomposed state of the glands did not allow of a very satisfactory microscopical examination of theii*jtissue,when recent, but hardened specimens showed, on section, closely packed lymphoid cells with a variable amount of fibrous stroma. In several portions of the mediastinal mass the crowded elements had undergone caseous degeneration. 12 Case III.—Lymphadenoma of the Cervical, Axillary and Mediastinal Glands—Progressive Anosmia. T. B., aged 20, a machinist, was admitted to Hospital Nov. 20th, 1880. Parents living and healthy. Has four brothers and sisters. He is a twin. There is no consumption in the family, nor have any of the members suffered from glandular enlargements. Had typhoid fever three years ago ; does not think he has ever been so strong since. About the middle of last February the glands on the left side of the neck became enlarged, and shortly after those of the left axilla ; the latter increased rapidly in size, and got painful. He has lost flesh, and has become pale and weak. Has had a cough for some time. Oct. 25th.—At this date the patient was sent for examina- tion by Dr. Rodger, of Point St. Charles, under whose care he has been. Appearance that of a pale, thin young man ; long face, eyes blue ; head elongated in anterior and posterior dia- meter ; forehead narrow, but very prominent. In left cervical region glands in anterior and posterior triangles enlarged, the size of large almonds, and forming a conspicuous swelling. There is an enlarged gland placed directly over middle of left sterno-mastoid muscle. On the right side there is a single large gland in subclavian triangle ; the others are scarcely perceptible. In left axilla there is a bunch the size of a small fist, situated anteriorly, beneath the pectoral fold. The separate glands can be distinctly felt, and they are elastic, moveable, and not painful. Right axillary glands were sore at one time, and a little swollen, but are now of normal size. Inguinal glands not enlarged. On inspection of chest, a decided prominence is noticed on left side, over cardiac area, extending beneath third, fourth and fifth ribs, as far out as the nipple line to the left, and to the middle of sternum on the other side. The swelling occupies an area about the size of the palm of the hand. Per- cussion gives a dull note over the swelling, as high as the second space above, and merging below with the cardiacand hepatic dulness. To the right its limit is about the mid-sternal line ; to the left, the nipple line. Over the rest of the chest the per- cussion is normal. No special alterations in breath sounds. 13 Splenic dulness not apparently increased. Liver normal. Appetite good. Blood not leukaemic ; proportion of colourless corpuscles not ascertained. Weight, 131 lbs.; in May was 141. Nov. '21st.—Present condition. Has been at home since last note, in much the same condition, but is now somewhat weaker, and has lost five pounds in weight. Glands in left cervical region have diminished much in size, the enlargement being now hardly visible on cursory examination. On palpation, however, they can be felt, slightly enlarged, hard, and freely moveable. There is one the size of a small walnut, lying directly upon the centre of the sterno-mastoid muscle ; on the right side, there is one in the anterior cervical region, and a couple of small glands over the mastoid process of the temporal bone. The right lobe of the thyroid seems a little larger than the left. In left axilla the bunch of glands formerly described maintains about the same size. He thinks they have been larger, and they have been painful (since last examination.) The individual glands are not distinctly perceptible. The skin over them is not adherent, the whole bunch being freely move- able. Inguinal glands just perceptible. Thorax and Abdomen.—Inspection.—There is a promi- nence, as formerly noted, in the left mammary region, extending from about the second to the sixth rib, and laterally from the left border of the sternum to the left border of the nipple, and is most prominent in the transverse nipple line. Percussion.—On the left side there is dulness, from the second rib in the para-sternal line, which is continuous with that of the heart. To the left, the dulness extends for half an inch outside the nipple line. To the right, it extends nearly to the right border of the sternum. Over the upper bone of the sternum, the note, though not absolutely dull, is deficient in clearness. A clear note is obtained over the clavicle, the infra-clavicular, axillary, and posterior regions of the left side, and over the entire right chest. Apex beat can neither be seen nor felt. Auscultation.—At apices, in front breath sounds appear somewhat weaker on the left side; behind, scarcely any notice- 14 able difference. No special difference in breath sounds else- where behind. Liver.—Dulness from lower border of sixth rib, and does not extend below costal margin. Spleen.—Cannot be felt on palpation. Vertical line of splenic dulness is about three inches. Nothing special on palpation of abdomen. Heart sounds clear. Region of greatest intensity, just below and a little to the left of the nipple. Appetite very fair. Bowels regular. Urine, no albumen, no sugar. About three weeks ago his voice suddenly became harsh and husky. Nov. 25th.—Blood examined to-day. Drop of a good colour, not hydraemic. Red corpuscles run together into irregular clumps, and do not form natural rouleaux. They appear of tolerably uniform size, no very small ones are seen. One or two have an irregular outline. Colourless corpuscles are in- creased to a moderate degree, and many appear smaller than usual, otherwise they have a natural appearance. Schultze's granule masses very abundant. Fibrin fibrids form an unusually dense and clearly defined network. Haemoglobin (with Gower's apparatus), 48 per cent. Nov. 21th.—Complains of an aching pain in chest, with a focus in mid-sternum, which came on last evening. It is easier to-day. Nov. 29th.—For three nights the pain has recurred with in- creasing severity, and last night interfered with sleep. No change otherwise. Dec. 2nd.—For three days his evening temperature has been up to 102°. Morning temperature, nearly 101°. Is looking considerably paler than when he came in. No change in neck. Tumor in anterior thoracic region looks fuller, slightly flushed, and oedematous. To-day pain is less over the sternum. No change in axillary tumours. Blood drop of a good colour. White corpuscles seem in greater abundance. Granule masses large and plentiful. Red cor- 15 puscles per cubic millemetre, 3,550,000. The ratio of white to red is 1 : 185*2. Allowed to go out for exercise. Dec. 1th.—Left the hospital for his home in the country. The treatment advised by Drs. Howard and Rodger, of Liq. Arsenicalis and cod liver oil, with nourishing diet, was continued during his residence. tfO CLINICAL LECTURE ON A CASE OF FIBROID PHTHISIS. By WM. OSLER, MD, M.R.C.P., Lond. Professor of the Institutes of Medicine in McGill University, and Physician to the Montreal General Hospital. Delivered at the Montreal General Hospital in the Summer Session Course, May 10, 1881.; Re-printed from the "Canada Medical & Surgical Journal," Montreal, June, 1881. CLINICAL LECTURE ON A CASE OF FIBROID PHTHISIS. By WM. OSLER, M.D., M.R.C.P., Lond. Professor of the Institutes of Medicine in McGill University, and Physician to the Montreal General Hospital. (Delivered at the Montreal General Hospital in the Summer Session Course, May 10,1881.) Reported Stenographically by S. A. Abbott, Esq., op the Hansard Staff. Gentlemen : There is no disease that you will have greater difficulty in thoroughly understanding than phthisis. I have no doubt that to many of you the difficulties which this subject presents have already become apparent. It is, in fact, at present, the bugbear of medical students, particularly in their last year. This is owing in great part to the inherent complex- ity of the subject, and in part, I am sorry to say, to the exceedingly diverse theories and views which at present prevail upon the pathology of the disease. The simplest classification of phthisis is into pneumonic, tuber- culous and fibroid varieties. It is of the last that I wish to speak to you to-day, and to show you this interesting example of the disease which many of you have already studied in the ward. This form of phthisis is characterized by certain peculiar features. In the first place, it runs an unusually long course. Patients may live for twenty-five or thirty years ; in many instances, indeed, it does not diminish to any great extent their term of existence. I will refer, in a few minutes, to a case of a gentleman who has been under Dr. Howard's observation for the last twenty or twenty-five years, and who only died last week of the affection. Then, in the next place, it lacks certain of those characteristic features which we recognise in ordinary phthisis. The patients have not night sweats ; they rarely have diarrhoea, and the loss of flesh is not very marked. They may have attacks of 4 haemoptysis, occurring usually at long intervals. On examina- tion they present certain peculiarities, so much so, that super- ficial inspection alone may be sufficient to give you a good idea of the nature of the disease from which the patient is suffering. There is generally some contraction of one side the chest, accompanied by deficient expansion and some de- gree of immobility. There is not much fever throughout the disease except towards the close. Most of the patients are able to engage in the ordinary occupations of life and are only troubled with a cough and more or less expectoration. As a rule they enjoy a tolerably quiet existence for a long period of time. They are subject to recurring attacks of bronchitis, par- ticularly in the winter season. The history of this patient is as follows: J. W., aged 44, a native of Sheffield, a saw-maker by trade, admitted April 18th with cough and shortness of breath. Family history is good ; none of his relations have died of consumption. Has worked at his trade from his youth ; the special work which he does is beating the saw blades and is not accompanied by much dust. Has been a pretty steady drinker, though not a drunkard. Was strong and healthy up to about five years ago, when, in the winter of 1875, he spat a small amount of blood and had a cough, but did not leave off work. Had no pain in the side ; does not think that he was feverish. The next spring he returned to Canada and remained well until the autumn, when he entered hospital for bronchitis. He has had a cough ever since, and has been laid up part of each winter, getting better in the summer. He has spat blood on several occasions, but never much at a time. Has not had night sweats or diarrhoea. Has lost flesh, particularly in the last four months. Coughing is chiefly in spells, which are violent and very often accompanied by vomiting. Has never brought up very large quantities at a time ; never noticed the phlegm to be stinking. Has not had palpitation of the heart; feet have never swollen. The fingers are clubbed and the nails incurvated. This man has suffered for the past five or six years from these 5 symptoms, the cough coming chiefly in the winter, during which time he lias had to lay up for a longer or shorter period. (The patient disrobes to the hips and is examined.) Notice in the first place that the left shoulder is a little lower than the right. There is decided flattening of the left half of the chest, and when he draws a full breath there is deficient expansion. The heart is drawn a little to the left and is beating a little outside the nipple line, but it is not displaced nearly to the extent we sometimes find it. Sometimes you may find it beating high up in the mammary region, owing to the drawing up of the heart by the contraction of the lung. On measure- ment of the chest the left side is smaller than the right; the left measures 15J inches and the right side 16h inches, not so great a difference as one might have expected. On percussion you will notice that there is uniform dulness, a hard, flat note, over the whole posterior region of the chest, and a similar note in front. The note is nowhere tubular, as is sometimes found. There is a little resonance high up in the axillary region. The tactile fremitus is not markedly increased, but the vocal reson- ance is greatly exaggerated, approaching to bronchophonic over the greater portion of the dull regions. On auscultation you hear very peculiar and characteristic sounds. The breathing in front is hollow, and of the character known as cavernous. It is accompanied by rales, some of which are whistling and piping, and others, just below the clavicle are more gurgling in character and suggest bubbles passing through a liquid. These cavernous sounds are heard all over the front and in the lateral regions. The breathing at the upper part of the lung behind and in the left inter-scapular region is weak, as those of you who have examined this man will remember. At the outer angle of the scapula the breathing is intensely hollow, approaching to amphoric, and is also accompanied by rales. The voice sounds are heard with much greater intensity— pectoriloquy. These are the chief features on a physical examination of this patient. You find flattening of the left side of the chest, deficient expansion, dulness, increased vocal resonance, and 6 numerous cavernous signs over the greater portion of the dull region. At the apex behind and in the left inter-scapular region, the breath sounds are somewhat diminished, being weaker than in the other regions. Over the right lung the breath sounds are clear except at the extreme apex of the lung. At this part you hear coarse breathing, a prolonged expiratory murmur and rales. These are heard in the right infra-clavicular region and at the apex behind. In the rest of the lung the breathing is loud, distinct and unaccompanied by rales. Now the affections which could produce such a condition as this are very limited. There are only three or four which cause contraction and immobility of one side of the chest, with a dull percussion note. These are fibroid phthisis, or cirrhosis of the lung ; chronic pleurisy with retraction, and malignant disease of the lung, and you have to distinguish between them. The immo- bility of the side of the chest and the dull note might be produced by a general collapse of the lung, or by a chronic pneumonia, but you would scarcely have the flattening and retraction. Now, between fibroid phthisis and a cancer of the lung there can rarely be any difficulty in the diagnosis. In the case of this patient the phthisis has lasted for five years, cancer of the lung seldom lasts over a year. Cancer of the lung almost invariably invades it from the mediastinum, and you have other symptoms of intra-thoracic pressure which we have not in this patient. More- over the cachectic appearance of a patient with cancer is marked. There can be no doubt in such a case as this. The diagnosis between chronic pleurisy with retraction and this condition of fibroid phthisis, presents greater difficulty. In both you have dullness, deficient expansion and retraction of one side of the chest. The shoulder is usually depressed much more on the affected side in chronic pleurisy with retraction than in fibroid phthisis. The chief differences to be met with on auscultation of the chest are these : in chronic pleurisy with re- traction you do not find the cavernous signs, which aie so com- monly heard in fibroid phthisis. The breathing is weak and feeble. Some of you may remember the patient with chronic pleurisy, with retraction, that was in No. 11 Ward two summers 7 ago. That man had lowering of the shoulder, retraction of the side, and dullness over the greater part of his lung. The diagnosis between collapsed lung and chronic pneumonia I need not go into. Now with reference to the morbid anatomy of this disease, the affection is known as fibroid phthisis or cirrhosis of the lung, both terms indicating an increase in the fibrous elements of the organ. The latter term was given by Sir D. Corrigan, and I pass around the Plate illustrating his paper. It is, in fact, a fibroid substitution : the normal, histological elements of the lung are replaced by a fibrous tissue which in time undergoes contrac- tion, as all new growths of fibrous tissue do. On examination of one of these patients after death you will have such a condition as you see in the lung I now exhibit to you. This was from a case of cirrhosis of the lung, which died under Dr. Ross's care in the hospital, in January, 1877. In the first place, the lung is greatly reduced in size. It was firmly connected to the chest wall, the pleura is much thickened, in places nearly an inch in diameter. On feeling the lung it does not crepitate, but is firm, dense and leathery. When cut it has a marbled look, being interspersed with areas of pigmentation. At the upper part of it you see an extensive cavity with thick walls, communicating directly with several bronchi. Certain of the bronchial tubes are much dilated, not so marked in this specimen as in others which I have seen. The characteristics I have given you as pertaining to this special lung may be taken as belonging to the great majority of cases of fibroid diseased lung. In the case from which the specimen was taken, there was a very small cavity in the apex of the other lung, the rest of the organ was healthy. Now in connection with the morbid changes in this disease you usually find that the heart is increased in size. It is hypertro- phied, particularly the right ventricle. That chamber has an increased amount of work to do, because of the reduction in the number of capillaries in the lungs. The one lung is cut off in great part from the circulation, and in consequence the right heart has an increased amount of work. The unaffected lung is usually of large size, as in this specimen from the case to 8 which I referred a short time ago. The patient requested that after his death his lung should be sent to Dr. Howard for exami- nation, as the doctor had watched the case for many years. You see what a large lung it is. It is much hypertrophied ; the other lung was reduced to such an insignificant condition that the medical man who performed the post mortem was not able to find it. He speaks of a mass of jelly-like substance, but no lung. No doubt it was shrivelled to a piece not the size of my hand, and flattened against the vertebral column. In the heart from this case you will see the thickening of the right ventricle, the walls of which are much hypertrophied. In the late stages of the disease, particularly in cases with extensive cavities in the lung, it is not uncommon to meet with amyloid degeneration of the various organs. In a case which was under my care in the summer of 1879, in Ward 23, there was extensive amyloid degeneration of the liver, spleen and kidneys. The kidneys and the liver occasionally present evi- dences of the same disease, namely, sclerosis. Now with regard to the causation or etiology of this disease, there can be no doubt that it is complex. In fact, several different varieties may be recognized. We may speak, indeed, of phthisis as a genus which has several species, and each of these species has several varieties. Phthisis being the genus, it has, as species, the tuberculous, the pneumonic and the fibroid. Now the fibroid species has several well marked varieties, just as the species of animals and plants have different varieties. The first you can call the bronchitic; that is to say, chronic bronchitis precedes the disease and appears to stand in causal relationship with it. The second is pleuritic. The disease is caused by and depends upon a fibroid induration of the pleural membranes. which induration extends to and involves the entire lung. Ac- cording to some writers, a very considerable proportion of the cases of fibroid phthisis belongs to this special variety. Thirdly, there is the pneumonic ; about that there is a great deal of doubt. Certain writers state that one mode of termination of a simple pneumonia is in fibroid induration of the lung. The exudation does not resolve, the dullness persists and ultimately fibroid 9 changes go on in the air cells until the entire organ becomes indurated. I do not know of any instance on record in which the pneumonia has been definitely followed until the case resolved itself into one of fibroid phthisis. The fourth variety is syphi- litic. There can be no doubt that syphilis may induce a fibroid condition of the lungs. Many cases have now been recorded of fibroid induration, occurring chiefly in patches, which are directly due to syphillis. The last and most important variety is that due to the inhalation of dust. This is a variety known as miners' phthisis, stone-cutters' phthisis, axe grinders' and file sharpeners' phthisis. In this variety the inhalation of particles of dust and grit excites a chronic bronchitis; fibroid induration occurs about the bronchi and gradually extends throughout the lung until you have extensive fibroid areas. In the past five years I have had three instances of this variety under my care. I show you here a lung presenting what is known as the car- bonaceous cirrhosis, or miners' phthisis. You see that the greater portion of it is converted into a mass of firm, dark tissue, looking more like a bit of hard coal than a lung. The greater portion is indurated by this growth of fibroid tissue and the deposition of these dark carbonaceous particles. That the dark coloring matter in the lungs is due to the inhalation of coal particles, is proved by the fact that on examination you can see portions of the vegetable tissue of the coal. In this drawing which I made from a case of miners' phthisis which occurred under my care in 1876, you will see portions of the scalariform tissue and of dotted ducts, both taken from the case to which I refer. The workers in the foundries and axe manufactories of Sheffield are very prone to a form of fibroid phthisis, produced by the inhalation of particles arising from the grinding of tools. In the same way the workers in the iron mines are subject to a form of fibroid phthisis which is called siderosis. The coal miners' phthisis is known as anthracosis. These are the chief varieties of fibroid phthisis, divided according to their exciting causes. In most of the cases both lungs are affected. In the common form such as you have before you, due, apparently, to chronic bronchitis, only one lung is involved; why, it is difficult 10 to say. Usually, at least in all the case I have examined, there have been traces of caseous matter, either in the affected lung or in the apex of the sound lung. This does not necessarily indicate that these were tuberculous in their origin, though it is of course possible for the tuberculous form of the disease to undergo fibroid degeneration. The course of the disease, I have already told you, is exceed- in •ly chronic. The patient of Dr. Howard's to which I referred was under his observation for over twenty-five years. Indeed, chronicity is one of the remarkable features in connection with the disease. The patients suffer from attacks of bronchitis, which come on during cold weather. The cough is apt to be spas- modic, the expectoration is usually profuse, very often half a cupful or a cupful is brought up at a time. The phlegm is frequently stinking, having remained lodged for sometime in a cavity or in a dilated bronchial tube. There is not much fever except when the patient takes a fresh cold. Several symptoms come on towards the close when the hypertrophy of the right ventricle of the right side of the heart begins to fail. When there is dilatation of the right ventricle and incompetency of the tricuspid valves, they then begin to have dropsy of the legs, sometimes dropsy of the belly. These symptoms usually pre- cede a fatal issue of the case. That is a very common train of symptoms, and it occurred in the case of a woman who was under my care in Ward 23, in 1879. Other cases die of asthenia or gradual failure of strength. Expectoration becomes more pro- fuse, and they die of gradual wasting. The man who died under my care this time last year of miners' phthisis, and whose lung I now exhibit to you, died of asthenia. He had been under my care for two years, and gradually coughed himself away. Then, again, other cases die of waxy degeneration of the organs. The chronic loss of pus from the cavities in this disease, tends to produce the peculiar degeneration known as waxy or amyloid. The woman I spoke of as dying in Ward 23, had extensive amyloid degeneration. Lastly, some cases die of haemorrhage from the lungs, which is not an uncommon symptom. The bleeding is caused either by rupture of a small aneurism on the walls of one of the cavities, or ulceration of the branch of an artery. 11 The prognosis depends entirely on the condition of your patient. In this man's case the outlook is bad. He has lost a good deal of flesh in the past year, disease is evidently com- mencing in the other lung, in which there is a cavity at the apex, and he very probably has tuberculous disease. Where the one lung is healthy and uninvolved the patient may live for a con- siderable period of time and enjoy comparatively good health. Nothing special need be said with reference to treatment. It is entirely a treatment of symptoms. This man came in with severe cough ; he was put to bed and given a sedative cough mixture, and soon felt improved. The shortness of breath diminished, and he is now feeling pretty comfortable and is ready to go out. During the summer months these patients always improve ; during the winter months their bronchitis is aggravated and they are always more troubled with a cough. One point with reference to the treatment, and it also bears upon the cause of the disease, and that is, the use of alcohol in phthisis. It is believed by many, that the use of alcohol in large quantities in certain forms of phthisis tends to produce a fibroid degeneration of the affected lung, and of course tends to a cure, because this fibroid substitution in a lung is in a measure a healing process. Now it is a peculiar fact in connection with many of these cases of fibroid phthisis, that they occur in persons who have been habitual drinkers. Such has been the experience of Dr. Andrew Clark, who was one of the first to call attention to this affection. It has also been the experience of the physicians at Guy's Hospital, and of many other English physicians. The man we have just examined seems to have been a pretty hard drinker. I merely mention this as an interesting fact in con- nection with this disease. This patient will remain in until to-morrow afternoon, and I would recommend those of you who have not already done so, to examine him thoroughly and try to get the main features of the case impressed upon your minds, as he affords an exception- ally good illustration of the disease. ON SOME OF THE EFFECTS OF THE CHRONIC IMPACTION OF GALL-STONES IN THE BILE-PASSAGES, AND ON THE "FIEVEE INTEEMITTENTE HEPATIQUE" OF CHAECOT. Delivered in the Demonstration Course on Morbid Anatomy, January 15, 1881 BY \/ WILLIAM OSLER, M.D., M.R.C.P. Lond. PEOFESSOB OF THE INSTITUTES OF MEDICINE, McGILL UNIVERSITY, MONTREAL ^Reprinted from " Medical Times and Gazette," July SO, 1881.) LONDON PARDON & SONS, PRINTERS, PATERNOSTER ROW 1881 OK SOME OF THE EFFECTS OF THE CHRONIC IMPACTION OF GALL-STOXES IX THE BILE-PASSAGES, AND ON THE " FIEVRE INTEEMITTENTE HEPATIQUE " OF CHARCOT. Gentlemen,—I propose to call your attention this mornin°- to some of the effects of the impaction of gall-stones in the biliary passages. The specimen before you, obtained from an old woman who died this week of septicaemia (Case 5) after a fracture, illustrates the distension of the gall-bladder and ducts which follows the lodgment of calculi, and it has served to remind me of other cases which have come under my observation. I shall therefore occupy the hour with this subject, and shall, moreover, depart somewhat from my usual custom in this course, and speak of certain clinical features in these cases which have not received much notice at the hands of English writers. I will first speak of the effects of impaction of a gall-stone in the cystic duct. This tube is narrower than the common duct, and its mucous membrane is not uniformly smooth, but presents numerous transverse and oblique folds, so that it is almost impossible to pass a probe up or down its course. These valvular folds (valvula Heisteri) often form definite pockets, and the entire arrangement is certainly not the most favourable for the easy passage of a calculus. The following effects may result from the plugging of this duct:—1. Dilatation of the gall-bladder. 2. Inflamma- tion of its coats—catarrhal, diphtheritic, suppurative, or phlegmonous. 3. Obliteration. 4. The formation of fistulas with contiguous organs. 4 The dilatation may attain a very high grade, and the organ contain several pints of fluid. The following instance is remarkable, as the distended gall-bladder reached to the pelvis, and was diagnosed as an ovarian tumour :— Case 1.—On March 23, 1877, I performed an autopsy on a patient of the late Dr. Bell, a woman aged fifty-eight. In August, 1876, she consulted Dr. Bell for pains in the back and loins. He made a vaginal examination, and determined the presence of a tumour, apparently connected with the right side of the uterus. She became jaundiced on December 25, and gradually began to get emaciated. The tumour was evident anteriorly, but it could not be traced to the costal border, a zone of resonance intervening. On March 3, when it was being examined in the lower part, it was suddenly felt to give way, as if something had ruptured. At the post- mortem the gall-bladder was found enormously distended, reaching to within two inches of the pubes. On the surface of the right broad ligament was a round space covered with fibrin and deeply haemorrhagic. On the apex of the gall- bladder was an irregular surface corresponding in size to that on the broad ligament; it looked as if the tumour had been attached at this point, and had been dislodged at the examination on March 3. There was no uterine or ovarian disease. The gall-bladder contained a quantity of a turbid and bloody fluid, and a large, recent-looking clot of blood. On the posterior wall there was a large ulceration, the base of which was haemorrhagic. Nine or ten gall-stones were found, one being lodged in the duct. An irregular mass of cancer occupied the neck of the gall-bladder, and several nodular masses were found scattered throughout the substance of the liver. More commonly, the dilatation which results from the impaction of a gall-stone in the cystic duct is of very mode- rate dimensions, and may produce no symptoms during life, as in the following examples :— Case 2.—M. G., aged thirty-five. Death from abscess in broad ligament. Liver fatty. Gall-bladder of average size, contained about twenty concretions, the size of small cherries, and an ounce of a turbid, viscid fluid. A gall-stone the size of a large pea was lodged in the upper part of the cystic duct. So far as could be ascertained, this woman had not suffered from any symptoms referable to biliary derangement. Case 3.—J. B., aged thirty-eight, died of heart-disease twenty-two hours after admission to the hospital. Liver congested ; nutmeg. GaU-bladder moderately distended; contained a clear, slightly viscid fluid, with thirty concretions of various sizes, one of which, as large as a cherry, pWeed the mouth of the cystic duct. Case 4.—J. S., woman, aged sixty-five, died of emphy- sema. No history of any biliary disorder. Liver small and soft. Gall-bladder projected two inches below the edge of the organ, and contained about two ounces and a half of a clear, slightly viscid fluid, with two gall-stones; one,the size of a walnut, lay free in the sac, the other, as big as a marble, was firmly wedged in the first part of the cystic duct. The mucous membrane of the bladder looked normal. Case 5.—Mary G., aged seventy-five, died from septicaemia after a fracture. Was not jaundiced. No history of biliary colic. Liver not enlarged; soft and fatty. Common bile- duct dilated to the size of the little finger, and the enlarge- ment extended to the branches in the liver. They contained bile. Mucous membrane looked normal. A small calculus was situated in the terminal portion of the duct, about 8 mm. from the papilla. The gall-bladder was mode- rately dilated, and contained an opalescent, viscid fluid and fifteen calculi, chiefly of small size. Two, the size of peas, were lodged in the fossae of the cystic duct and completely obstructed its lumen. A fortunate termination in a case of distended gall- bladder, which produced symptoms during life, is illus- trated by the following, in which obliteration of the sac took place:— Case 6.—E. B., aged forty, a large, powerfully-built man ; patient of Dr. Finnie's. Death from pneumonia. Eight years before his final illness he had suffered with an ab- dominal tumour, situated in the right hypochondriac region, which caused uneasiness and pain, but no serious trouble. He was seen by a great many medical men, and very diverse opinions appear to have been given as to the nature of the tumour. It lasted for many months, and then gradually disappeared. He left instructions that his body should be examined, in order to find out the cause of the tumour which had given him so much anxiety. Liver of large size, but healthy. Common duct pervious. Cystic duct dilated at its distal end, occluded in its upper part. Gall-bladder was small and shrunken, and its coats tightly embraced two gall-stones, the size of large cherries. A membranous septum separated the stones, and the walls of the bladder 6 were so closely adherent that it was difficult to strip them off from the rough surface of the calculi. I have seen another instance in which this condition of the gall-bladder occurred, but I have no notes of the case. Inflammation of the gall-bladder (cholecystitis) not in- frequently follows obstruction of the duct. More or less catarrh is probably a constant sequence, but the severer affections are rare. Diphtheritic inflammation is met with, leading to ulceration and even perforation. Gangrene is mentioned as occasionally occurring in and about the ulcers. A remarkable instance of primary inflammation passing on to gangrene happened recently in the practice of Dr. Howard, and I had an opportunity of inspecting the body:— Case 7.—J. C, aged forty-eight, an old soldier, temperate and healthy. Taken ill on Tuesday, October 12. Chief symptoms—vomiting, pain in abdomen (particularly on right side). On account of the obesity a satisfactory examination of the abdomen could not be made. Many of the symptoms were those of obstruction of the bowels. No previous history of gall-stones. At the autopsy, localised purulent peritonitis about anterior border of liver, and between it and the trans- verse colon. Gall-bladder moderately distended; walls tense, and of a dark livid aspect; when slit open, a dirty, brownish- red, ill-smelling fluid escaped, and six or eight light coloured gall-stones. A calculus was found in the orifice of the cystic duct. The mucous membrane was not ulcerated, but was dark, and the coats looked sphacelated, particularly towards the fundus. The common and hepatic ducts were free, and there were no other special morbid features. Between a dilated and inflamed gall-bladder and contigu- ous parts adhesions may form and fistulous communications be established by ulceration. Thus it may happen that the dilated sac adheres to the abdominal wall, ulceration at the fundus occurs, and by suppuration the skin is perforated and an external fistula established. Murchison has noted over eighty-seven cases of this kind. It is not uncommon for a fistula to form with the duodenum, more rarely with the colon or stomach. The following cases illustrate these latter varieties:— Case 8.—S. J., a man aged forty-six; death from a low pneumonia after severe fracture. No history of biliary colic. Liver not enlarged j common and hepatic ducts normal. Gall-bladder was of small size; but the pylorus and first part of the duodenum were adherent to it. When opened, a small quantity of purulent fluid escaped, and two 7 large calculi, the size of filberts, occupied the cavity. Two wide fistulae led into the duodenum and stomach; that to the latter did not perforate the mucous membrane directly, but formed a small abscess beneath it, the orifice being about 2 cm. within the ring. The one to the duodenum was shorter, and would have permitted the passage of a pea. Case 9.—R. S., aged forty-eight, a stout, well-nourished person; patient of Dr. Eodger, of Point St. Charles. Fifteen years before her fatal illness she had an attack of what was called inflammation of the liver; there was no jaundice, but ever since she had been troubled with dyspepsia and more or less feeling of discomfort in the region of the stomach. Her last illness extended over about three months, and the chief symptoms were jaundice, epistaxis, and occa- sional melaena. Death took place by haemorrhage from the stomach and bowels. Stomach, duodenum, and transverse colon were closely adherent to the under-surface of the liver near the gall-bladder. Immediately outside the pyloric ring, in the upper and back part of the duodenum, was a large orifice 3-5 x 1-5 cm. partially blocked with clots, and commu- nicating with the gall-bladder and an irregular cavity at the hilus of the organ. The source of the haemorrhage was found to be an ulceration of the right branch of the hepatic artery. The gall-bladder was much ulcerated and commu- nicated freely with the duodenum and with the irregular cavity at the hilus. At its fundus there was a fistulous opening into the colon, 7 mm. in diameter. Whether this represented the perforation of a duodenal ulcer into the gall-bladder, or the orifice caused by the passage of a large gall-stone into the duodenum, it is impossible to say. The extensive ulceration of the gall-bladder and the fistulous communication with the colon rather favour the latter view. The very large calculi, which are sometimes passed per rectum, and which may induce symptoms of obstruction, most^)robably ulcerate into the bowel, and do not pass the common duct. We will turn now, gentlemen, to the consideration of some of the effects of impaction of gall-stones in the common duct. The usual site for the lodgment of the calculus is in the ter- minal portion of the duct, the pars intestinalis, as here he calibre is considerably narrower than elsewhere. You see in this specimen taken from Case 5, above mentioned, how small a stone may find difficulty in getting through. It is impossible to say exactly how large a concretion may pass. 8 Von Schweppel * places the limit at about 1 era. in diameter. It is important for you to bear in mind that a gall-stone may remain permanently lodged in the pars intestmalis, and yet not be impacted. In such instances it may still permit the passage of bile past it, or it may act as a ball-valve and only permit of the flow when the distension behind has reached a certain point. Dilatation of the bile passages is the constant effect of permanent obstruction. At first they contain bile, but subsequently, if the channel is not re-established, this may be absorbed, and a clear mucoid fluid take its place. In obstruction from the pressure of tumours, etc., the enlargement of the ducts and gall-bladder may be excessive, and even the finer branches in the substance of the organ become dilated into tortuous canals which can also be seen beneath the capsule. Inflammation of the bile-ducts (cholangitis) not infre- quently succeeds dilatation, and may go on to suppuration, as in the following instance : — Case 10.—Calculus at Orifice of Common- Duct—Dilatation and Suppuration of Bile Passages and Gall-Bladder. Unfortunately I have no history of the case, but it occurred in an old man who had been ill for nearly a year with symptoms pointing to hepatic disorder. When the duodenum was laid open a dark spot was noticed at the papilla biliaria, which proved to be a gall-stone as large as a marble, lodged just within the orifice. It was freely movable, and could readily be pushed away. Behind it the common duct was much dilated, measuring 4'5 cm. in circumference at the orifice of the cystic duct, and 5*5 cm. at the hilus. The contents were purulent and tinged with bile. The ducts throughout the liver were dilated, and several as large as goose-quills coursed beneath the capsule of the right lobe. They all contained pus, and the walls were thickened. The gall-bladder was greatly dilated, and had formed close adhesions with the anterior abdominal wall, the duodenum, and the colon. When slit open, nearly a pint of pus escaped, and two small calculi. The walls were extensively ulcerated, and the contiguous part of the liver was rough and suppurating. I wish more particularly to direct your attention to some remarkable symptoms, which occur in patients the subject of chronic obstruction of the common duct, and which are described at length by Charcot in his " Lecons sur les Maladies du Foie et des Reins." Under the name " fievre * " Ziemssen's Encydopsedia," art. "Bile Passages." 9 intermittente hepatique " he has given an account of attacks resembling closely paroxysms of ague, characterised by severe rigors, fever, and sweating. He states that these must not be confounded with the rigors and fever which sometimes accompany an attack of hepatic colic. The following cases, which have been lately under my care, illustrate this symptom in a most admirable manner :— Case 11.—Obstruction of the Common Bile-Duct by a Large Calculus for over Nine Months—Repeated Ague-like Paroxysms—Jaundice—Passage of Gall-Stone—Recovery. N. K., aged thirty, a dark-complexioned, slightly-built woman, was admitted to hospital, under Dr. Wright, on November 17, 1879. She had been subject to attacks of indigestion, but otherwise appears to have been healthy. About four years ago she had several attacks of severe cramp-like pains in the abdomen, but she had no more for over two years, until the middle of September, 1879, when they came on again after a wetting. She had vomiting at this time, and such severe pains that morphia had to be adminis- tered hypodermically. Two days after she became deeply jaundiced. The attacks of pain recurred, and the vomiting was very troublesome, but in about two weeks she was able to go to her home, where she remained until her admission to hospital. The jaundice had persisted, and the "painful spells," as she called them, came on at intervals. When admitted she was suffering with jaundice, dyspepsia, and general debility. She remained in hospital during the winter, and I found her in Ward 23 when I took charge in April; and many of you had an opportunity of seeing her during the early part of the summer session. During a residence of five months and a half in hospital the chief symptoms were (1) jaundice, varying greatly in intensity, sometimes almost disappearing, but only to recur again in a few days; (2) ague- like paroxysms, chills, fever, and sweating, accompanied with severe abdominal pain, coming on at intervals of from three to ten days; (3) great impairment of appetite, dyspep- sia, and frequent vomiting, especially during and about the time of the paroxysms; (4) great tenderness, particularly at times, in the epigastrium, most marked near the right costal border. The way in which these paroxysms came on was usually as follows:—After an interval of a week or ten days, during which time the jaundice would diminish, the bile almost or entirely disappear from the urine, the faeces become slightly bile-tinged, the appetite improve, and the patient sit up, she 10 would have a chill, sometimes only a transitory feeling of cold, at others a severe rigor in which she would shake as in an ague-fit. This stage lasted a variable time, from fifteen minutes to four hours, depending on the severity of the attack, and was followed by heat of skin and general feeling of warmth, after which sweating came on. The entire paroxysm, when well marked, lasted several hours. The temperature, which was normal, or even subnormal, rose during the attacks, reaching from 1023 to 104°, and subsided quickly, sometimes sinking to 97°. The fever rarely lasted for twenty-four hours. On the evening of March 28 a severe paroxysm came on, and the temperature rose to 103°. She had a very bad night, and the thermometer indicated 104° at nine o'clock in the morning of the 29th. At 7 p.m. it was 973, and she was feeling comparatively comfortable. Among the concomitant symptoms of these attacks, vomit- ing and severe gastric pain were the most common. The pain usually gave indication of the onset, and resembled that of hepatic colic, being epigastric, radiating, and often complained of beneath the right shoulder-blade. It was scarcely the agonising pain of genuine biliary colic, but was often severe enough to require morphia. Before and after the attack the epigastrium was very tender, so much so that she even complained of the weight of the bed-clothes. Vomiting was a marked feature throughout the course of the disease, usually accompanying the paroxysms, and also frequent enough in the intervals, particularly after taking food. Bowels were moved each day, sometimes two or three motions. Colour depended on the intensity of the jaundice. For a long time the motions were filtered in the hopes of find- ing gall-stones. Invariably, after an attack the jaundice deepened, and we could generally tell the next day by her appearance alone whether she had had a paroxysm. The urine became bile-tinged, often deeply, and the stools clay- coloured. This would last for a day or so, and then the urine would get clearer, the bile-pigments disappear, and the stools get a little colour. In the intervals the pain sub- sided, the nausea and vomiting were less troublesome, but the appetite was very poor; for days she could not take anything but a little biscuit and milk. She usually remained in bed, but during a longer interval than usual would some- times get up. Itching of the skin was occasionally a prominent symptom. On April 8 I examined her carefully, and the following condition was noted : —" Is jaundiced and moderately wasted. Nothing special to be noted, on inspection of abdomen. On 11 palpation, decided tenderness in epigastric region, most marked towards the right costal border; no special fulness or sense of increased resistance in this part. Hepatic dulness in nipple line extends from upper border of sixth rib to within half an inch of the costal margin. To the left the dulness can be traced well into the hypochondriac region. Splenic dulness of two inches and a half. Nothing abnormal on examination of heart and lungs. Urine is bile-tinged, gives a play of colours with nitric acid; specific gravity 1020. Numerous darkly granular bile-stained casts, some contain- ing epithelial cells. Faeces clay-coloured, soft, a little offensive. Tongue is clean. Pulse 85; temperature normal. About the end of April she left the hospital, and went to her home in St. John's, where she was attended by Dr. Robert Howard, who diagnosed gall-stones, and gave bicarbonate of potash. She had several paroxysms, and continued jaundiced. On June 3rd she passed a large round gall-stone weighing sixty grains and measuring over 1 cm. in diameter. She improved very rapidly after this; the jaundice disappeared, and she has recovered her usual health and strength. Case 12.—Obstruction of the Common Duct lasting over Eighteen Months—Jaundice of Varying Intensity—Nume- rous Ague-like Paroxysms. On November 9, 1880, I was asked to see Mrs. S., aged fifty-five, a well-nourished woman, wife of a florist, and accustomed to work in the greenhouse. I found her deeply jaundiced, and suffering with intolerable itching. She had always been a healthy woman, and had borne five children. Present illness began in July, 1879, and I am indebted to Dr. Simpson for the following particulars of the onset and development of the disease:—" On July 8th and 12th, 1879, Mrs. S. consulted me at my house fora mildattackof jaundice, which she ascribed to having lately seen a disgusting object, emitting a most offensive odour, which had caused her to feel sick. When a young girl she had a similar attack from fright. On August 4 I was sent for to visit her. In the in- terval the jaundice had become less intense. I found her deeply jaundiced, and complaining of nausea, dull pains in the region of the liver, and general discomfort. She re- Wined in this state until the morning of the 6th, when she was seized with an alarming chill and intense pain below the ribs on the right side, extending to the epigastrium and to the right shoulder. It was increased by pressure and motion. The breathing was oppressed, and the anxiety of the patient most distressing. The chill in a couple of 12 hours gave place to a high fever, which was followed I >y a copious sweating, that stained the sheets of a deep yellow colour. The liver was found to be slightly enlarged. The intense pain gradually abated, but the tenderness per- sisted for several days. All of the essential phenomena of jaundice were present. She remained under my care until January, and during this period she suffered every two or three weeks from a paroxysm, varying somewhat in intensity and duration, such as I have described, except that the acute pain became less and less on each occasion, until at last there was scarcely any; but the chill, fever, and per- spiration were invariably present, constituting, with an increase of the jaundice, the entire paroxysm. Itching of the skin was a most distressing symptom throughout, often preventing sleep and rendering life almost unendurable. The stools were repeatedly strained for days together, but no gall-stones were found. The slight enlargement of the liver disappeared." I ascertained from her that during the early part of last year the attacks continued, but during the summer (under homoeopathic treatment) the jaundice almost disappeared, and she had not a paroxysm for several weeks. Latterly they have recurred every week or ten days. On the occa- sion of my first visit, she was intensely jaundiced, and suffering from the most terrible itching of the skin which I have ever witnessed, and for this she specially sought relief. Finding that most of the usual remedies had been tried, I ordered a warm alkaline bath, which had a very beneficial effect. During the night she became quite incoherent, and greatly alarmed her friends, who of course blamed the bath. In the morning the itching had almost disappeared and she was rational, but complained of a deep throbbing pain in the heart. I examined her care- fully, and made the following notes:—Body well nourished; thick layer of panniculus on abdomen. She says, however, that she has lost flesh in the past year. Skin of a deep greenish-yellow tint. In examining the abdomen, the edge of the liver cannot be felt; no tumour is evident below right costal border. She winces on firm pressure midway between navel and ensiform cartilage. Area of liver-dulness some- what diminished; no tenderness over it. Splenic dulness a little increased; seven inches in vertical diameter. Heart and lungs normal. Tongue red, and indented with the teeth. Bowels regular; stools clay-coloured and offensive. Urine very dark-coloured, and contains much bile-pigment. Pulse 80; temperature 98*4°. Appetite is poor and she can only take soft food. During the next three days she improved, 13 and the itching disappeared, except from the palms of the hands and soles of the feet. These she stated had been most troublesome throughout the attack, and the pads of the palms, at the bases of the fingers, were swollen and tender. By the 15th she was feeling much better, and the jaundice had begun to disappear. About noon on the 16th she had a severe paroxysm, the chill lasting nearly two hours, and at 5 p.m. I found her sweating pro- fusely and much prostrated. During the cold stage she had constant relays of hot flannels wrapped round her, and hot bottles applied to the feet. The shaking was some- times violent enough to move the bed and cause the room to vibrate. There was no vomiting with the attack, nor any special abdominal pain. On examination of the hepatic region no change was noticed. The following day the jaundice had become intensified and the urine much darker. From this time until Christmas-day she had seven attacks of varying intensity, five of which followed each other on the Fridays, coming on at noon. The temperature in one of the paroxysms reached 104°. The itching had come on again, but for some time starch powder gave relief; then it failed, and she returned to the use of cloths wrung out of hot brine, which had been found very serviceable. The " shake," on Friday, December 10, was very slight, and there was but little fever after it. The jaundice, which had been fading since the 3rd, did not become intensified, and on the 12th and 13th was less marked than at any time during my attendance. The urine was clear, and the fasces were of a brownish colour. On the 15th and 17th there were paroxysms, and on the 18th she was again deeply jaundiced. From this date she improved very much, and has not had a definite paroxysm since. The jaun- dice has almost gone, and she has been able to be up and to get about the house. The appetite, also, has im- proved, and she has gained strength. On two occasions she has had severe headache, accompanied with great bodily depression, lasting for an entire afternoon, and followed by copious sweating. The itching has been much less, but the palms of the hands have at times been very sore. A troublesome symptom has been profuse sweat- ing about the waist, sufficient to saturate the clothes and necessitating the wearing and constant renewal of cloths. The urine has been clear, free from bile-pigments, and the faeces have been dark-coloured. I have examined the liver on several occasions, but have not found any alteration; the spot of tenderness in the right of the epigastrium persists. 14 The temperature throughout the illness has been from 96° to 98"2°, rising in the paroxysms as high as 101'. The pulse has ranged from 60 to 90 per minute. During last summer there was an interval of nearly six weeks during which she had no paroxysm and the jaundice disappeared. The daily amount of urea was estimated for me by Dr. Henderson during a period of three weeks, but there did not appear to be any special diminution during the paroxysms. Acting on the suggestion of Dr. Kennedy, of Bath, Ontario, I gave her large doses of oil, in the hopes of inducing the passage of the calculus. She took three Florence flasks of it without any effect. Latterly she has been taking potassium bicarbonate and Bethesda water. The similarity of the clinical histories of these two cases is very striking; the chronic jaundice, varying in intensity, and the febrile paroxysms are, with trifling deviations, the exact counterparts, and let us hope that the parallelism will be still further carried out by the passages of a gall-stone in tlie second case. Considering how rich is the literature of gall-stones, I have been surprised to find very few references to this symp. torn. Occasionally in the reports of cases of chronic obstruc- tion by English writers, shivering fits are mentioned. Thus, Budd,* in the history of a case of impaction of a large gall- stone in the common duct, which lasted many months, says : " Has lately had many fits of shivering, and sweats much at night. Never had ague, and the spleen is not enlarged." In the second edition of his work on the Liver, Dr. Murchison speaks briefly of periodic paroxysms of intermittent fever occurring in connexion with the lodgment of gall-stones in the ducts. The only full account which I know of is in Charcot's work. He has been able to collect twenty cases for analysis, and his conclusions, briefly put, are as follows:— 1. The paroxysm begins suddenly with a chill, often severe enough to shake the bed ; the temperature rises to 102° or 105-8°, and profuse sweating succeeds. 2. The periods of apyrexia are clearly defined. The fever comes on with the regularity of a quotidian, tertian, or quartan ague ; but to this rule there are many exceptions. 3. In one instance Reynaud determined that the amount of urea was diminished during the paroxysm, whereas in true intermittent fever it is increased. 4. The paroxysms usually come on in the even- ing, while in genuine ague they most frequently occur in the morning. 5 The hepatic fever is chronic, and may last * •' On Diseases of the Liver," second American t^iLon, page 219. 15 two or three months, with intervals of eight, ten, or fifteen days between the paroxysms. As many as thirty-one attacks have been known to occur. 6. A favourable termination is possible, as shown by a case of Henoch's ; but a fatal issue ia the rule. Death may take place suddenly, with symptoms like a pernicious malarial fever, or as a remittent fever with typhoid characters. Dr. Charcot states that the condition of the bile passages which accompanies this fever is dilatation with inflamma- tion of the mucous membrane, and the presence of pus or muco-pus. He suggests, in explanation, that a septic principle or pyrogenic material is developed by changes in the bile, and getting into the blood induces the chills and fever. Though the cases which I have detailed to you conform in all essentials with Charcot's description, there are a few additional points of interest. In both the course of the disease seems to have been, com- pared with other cases, greatly prolonged; nine months in the one, eighteen in the other. The recurrence of the pyrexial attacks did not follow any definite order like true ague, but came on irregularly at intervals of from two to sixteen days. In Case2,the "shakes " recurred on Friday, at noon, for five weeks. One very remarkable feature in these cases I do not see mentioned, and that is the deepening of the jaundice after the attacks. No symptom was more constant, as some of you doubtless remember, in Case 1. It was rarely necessary to ask wh ether there had been a paroxysm, the colour of the face was a sufficient index. In the case of Mrs. S. the jaundice intensified very rapidly, often within eight or ten hours after the onset of the chill. The cause of these repeated paroxysms must be confessed to be very obscure. Charcot supposes, as I told you, that a septic principle is developed in . the dilated bile passages. Murchison suggests that " they are due to the simple irrita- tion of the stone, and are analogous to the febrile paroxysms resulting from the passage of a catheter along the urethra." Certainly, in Case 12, the deepening of the jaundice and the absence of bile in the stools after the paroxysm favour the idea that a calculus, permanently lodged in the common duct, had shifted its position and had become for a time more closely wedged. Pardon and Sons, Printers, Paternoster Sow, London. H" RENAL CIRRHOSIS. Re-printed from the "Canada Lancet," August, 1881. RENAL CIRRHOSIS. WITH SPECIAL REFERENCE TO ITS LATENCY AND TO SUDDEN, FATAL MANIFESTATIONS OCCURRING IN ITS COURSE. Being a Clinical Lecture delivered May 28th, 1881, in the Summer Session Course, by William Osler, M.D., M.R.C.P. Lond., Professor of the Institutes of Medicine, McGill University; Physician and Pathologist to the Gen. Hospital, Montreal. (Stenographical Report by S. A. Abbott, Eso., 0/the "Hansard" Staff.) Gentlemen,—I speak to you to-day upon renal cirrhosis, or chronic interstitial nephritis. The various modes of onset of disease constitute an exceedingly important and interesting subject of study. You know that one of the very first questions we ask a patient is, how did the disease begin ? The answers got to this question are very varied. One patient will say, it began suddenly; I was feeling quite well; it came on with a head-ache; I got feverish; I had a pain in my back ; I was taken with vomiting; and various other answers, all of you have, no doubt, received in ascertaining the clinical history of cases. In another set of answers the patient will tell you that he cannot fix definitely the commencement of the disease; that he has not been feeling very well, but cannot state the precise time at which the failing health began. Now I wish to call your attention in this particular affection to its remarkably stealthy method of onset. There is no disease with which we are acquainted which comes on so insidiously and so stealthily. Indeed, its victim may know nothing whatever of 2 the existence of any grave disease until he is prostrated by one of its severe accidents to which I shall shortly refer. It is this insidious course which makes it at once an exceedingly formid- able affection and one worthy of your closest attention. The patient before you offers a very good example of the dis- ease in question, and has many of its most characteristic symp. toms. I will read to you a concise clinical history of his case as obtained by Mr. R. J. B. Howard :— E. L., set. 31, sailor, large, strongly-built man, admitted May 18th, with headache, vomiting, and partial blindness. Has been a healthy man ; a beer drinker and has occasionally gone on "sprees." Has had bubo; no evidence of secondary syphilis. Two years ago lost his nose from frost-bite. , When coming across on his last voyage, about 12 days ago, had a slight pulmonary disorder; the doctor called it inflamma- tion. A week ago he had swelling and inflammation at inner can- thus of right eye from lachrymal abscess. During these attacks he had headache, and latterly the feet have been swollen. On the 17th, the headache became much worse and partial blindness came on. Vomiting had been present for several days. Condition on examination was as follows :—Well nourished man, good complexion, complains of headache and blindness, cannot see fingers six inches in front of the eye. Has perception of light. Pupils of medium size, respond to light, but there is a peculiar dull look about the eyes. Dr. Buller reports, " optic discs somewhat hypersemic and indistinct at margins, nothing ab- normal, retina present. Headache is general. Vomited last night and this morning. Bowels are freely opened. Tongue a little furred. Temperature normal. Chest well formed; apex beat half an inch outside the nipple line; impulse slow, heaving and forcible. Pulsations 60 per minute. Heart's dulness slightly increased. On auscultation, no murmur; sounds loud and dis- tinct. There was nothing of special note in lungs. Examination of abdominal organs negative. Urine clear, light colored, sp. grav. 1009, acid, contains a moderate amount of albumen and numerous pale casts. Radial artery feels firm, pulse hard and strong, tension greatly increased." The patient improved very rapidly. On the 20th he could count fingers, but could not see to read. The amount of urine 3 passed has been estimated, and found to be about ioo ozs. daily. Urea diminished, only 299 grains for the 24 hours. The headache has gradually disappeared and the vomiting is now checked. The feet are not swollen. The state of the urine re- mains unchanged. The circulatory symptoms persist; the high . degree of arterial tension which exists is well shown by this sphygmographic tracing which I hand round. Summing up the chief symptoms which this man had, they were : headache, vomiting, and disturbance of vision. These were the symptoms he complained of; but the symptoms which we dis- covered, and of which he had no knowledge, were—that he was passing nearly double the normal quantity of urine, that it was albuminous and contained hyaline and finely granular casts ; that his heart was hypertrophied; that he had increased arterial ten- sion, and that there was slight dropsy of the feet. This latter group of symptoms which I have mentioned, excluding altogether those he complained of when he came in, is alone sufficient to enable you to frame your diagnosis of the disease, particularly if they occur in connection with slight degrees of dropsy. There may be exceptions, but in the great majority of cases they will be sufficient for your purpose. The affection which is indicated by them is one of the forms of chronic Bright's disease. The three varieties of this disease, characterized according to the special morbid condition of the kidneys, are : first, that associated with the large white kidney ; second, the form associated with the waxy kidney; and third, the form associated with the contracted kidney. It is the latter which this man suffers from. Now in this disease the condition of the kidney is shown in the description of these organs from the girl who died in the hospital ten days ago, and the post mortem on whom most of you saw. Firstly, the kidneys are reduced in size. Secondly, on stripping off the capsule, you find it is thickened and opaque. Thirdly, the surface of the organ, instead of being smooth, presents a number of irregular nodular projections, or granules, large and small,—hence the term granular kidney. In stripping off the capsule, portions of the kidney substance adhere to it. Fourthly, on section, the organ cuts with great resistance, and it feels tough and hard. Fifthly, on examining the organ, you find that the cortical substance is greatly reduced, forming a very narrow zone 4 above the pyramids. In some places the pyramids approach to within a line or a line and a half of the surface. Sixthly, the arteries are noticed to be unusually distinct, particularly those at the bases of the pyramids, and they often project above the level of the substance. Small cysts are also common, but they are not seen in this specimen. The color of the organ, in this special instance, was pale and not reddish. The pyramids were reddish, but the general color of the organ was pale grey. These are the coarse features of the kidney in this form of Bright's disease. Microscopically, as you will see in a section taken from this organ, the chief characteristic is an enormous increase in the fibroid elements of the organ. In a healthy kidney there is only a very small amount of fibrous tissue between the tubules, around the Malpighian tufts, and about the arteries of the organ. The amount is so small that Dr. Beale, one of the leading histologists in England, denies the presence of a special fibroid framework of the kidney. But in this affection you will see that between the tubules, there is a large amount of a new growth of fibrous tissue. The tubuli uriniferi, instead of being in close apposition, are separated from each other by distinct zones of fibrous tissue, and the Malpighian bodies are also surrounded with the new growth. The arteries are much thickened, both in the adventitia and in the muscularis. The condition of the renal epithelium in the tubes varies a good deal. In some tubules you will find it healthy looking, in others it is degenerated, granular and fatty; so that in reality the essence of the process is, just as in the case of the fibroid lung of which I spoke to you the other day, and as in the case of the fibroid liver, an over-growth of the connective tissue of the organ.* This produces atrophy of the secreting structure, and impairment of the function of the gland. Associated with the small, contracted kidneys you have a re- markable condition of the circulatory system. The arteries of the body are thicker and firmer than is natural, particularly the smaller ones. There is usually atheroma in the larger vessels. With reference to the special change which goes on in the smaller vessels, there is still a great deal of dispute. Drs. Gull and Sutton believe that the change is chiefly in the outer coat. They call this degeneration arterio-capillary fibrosis, a fibroid change in the small arteries and capillaries. Dr. Johnson believes that 5 the change is chiefly in the middle coat, resulting in hypertrophy of the muscular elements. Drs. Gull and Sutton hold that the changes in the arteries and the changes in the kidneys go on simultaneously, and are both the expression of a common cause; whereas other writers think that the changes in the arteries are secondary to the changes in the kidney. In addition to these muscular changes, the heart is found hypertrophied, more parti- cularly the left ventricle. It is increased in thickness and the muscular walls are hypertrophied. Thus cirrhosis of the kidney, arterial degeneration, any hypertrophy of the heart, are the three main pathological features of this form of Bright's disease which you meet with in a post mortem. The hypertrophy of the heart, which is a very constant symp- tom, is supposed by Traube to be due to the increased difficulty with which the blood circulates through the kidney, owing to the destruction of a large number of Malpighian tufts. It is, accord- ing to this view, a compensating hypertrophy, that is to say, hy- pertrophy makes up for the destruction of a considerable vas- cular area in the kidneys. Others think that the hypertrophy is the result of chronic changes in the arteries, in which the arteries of the kidney participate. Bright's view with reference to the hy- pertrophy of the heart was, that the blood in kidney disease not being so pure as in health, did not circulate through the capilli- aries of the body with the same facility; hence the need of the heart to increase its force' of contraction in order to propel the blood. A knowledge of the condition of the heart and arteries is a kev to explain many of the symptoms of this form of kidney disease. Thus, one of the remarkable features of this disease, remarkable in contrast to the other varieties of Bright's disease, is the large amount of urine secreted. This man has been secreting double the normal amount of urine. This would appear to be due to the hypertrophy of the left ventricle, and to the increased blood pres- sure within the arteries. You know how much the watery part of the urine depends upon vascular pressure. As a rule, the greater the blood pressure within the renal vessels, the greater the amount of water which is filtered through the Malpighian tufts. Though there is a gieat destruction of these tufts in renal cirrhosis, still the compensating hypertrophy of the heart is not only sufficient 6 to counterbalance their loss, but even so to increase the pressure in the remaining tufts that a larger amount of urine is filtered off. That this is the case is shown by several circumstances. In the first place, if you keep a patient with this form of kidney disease absolutely at rest the amount of urine diminishes. This fact has been established by Bartels after several very careful observations. At rest the blood pressure is not so great as when the patient is moving about, as the pulsations of the heart are not so forcible. Then, so soon as hypertrophy of the left ventricle begins to fail, when degeneration comes on, the amount of urine diminishes while its specific gravity increases.' Among the most remarkable symptoms of chronic Bright's disease, are those which come under the heading of uraemia. This term was first used when the symptoms grouped under it were all believed to be due to the poisoning of the blood with urea. That view has now been considerably modified, but the old term which embraces these symptoms is still retained. I shall not speak fully with reference to the supposed causes of uraemia further than to mention that some still suppose it to be caused by the retention of urea; others, that it is due to the presence of carbonate of ammonia in the blood. A third view is that it is neither of these substances, but those bodies which we call the antecedents of urea, creatinin, tyrosin, &c, the various nitrogenous excreta, or the products of the waste of the tissues. A fourth view is that these symptoms of uraemia are due to oedema of the brain. Now, among these manifestations of uraemia some are trifling and others are exceedingly grave. Among the minor manifesta- tions may be mentioned those which this patient has suffered from—headache, vomiting and impairment of vision. The more severe symptoms are convulsions, delirium, coma, sudden oedema of the lungs or of the glottis, inflammation of a serous membrane, pleurisy, pericarditis, and meningitis. This patient before you has only suffered from the minor manifestations of uraemia, but I would like you all to have this case fully impressed upon your minds, particularly with reference to what I am going to tell you later as to the insidious nature of this disease. You remember that when we first saw this man we did not think of any kidney trouble, but from his symptoms and appearance that he most 7 probably had some cerebral disease. When I first saw him on the day of his admission my first thought was that he had pro- bably cerebral syphilis, mistaking the ragged condition of his nose for an effect of lues. He had the vomiting, the headache, and the disturbance of vision, three important symptoms of intra-cranial mischief. I would direct your attention specially to the disturbance of vision inasmuch as it is an. important symptom, and you will probably not see this form of visual disturbance for some time again. It is what is known as urcemic amaurosis. I mention it because I wish you to distinguish it carefully from another form of impaired vision common in chronic Bright's disease, viz., retinitis albuminurica. In uraemic amaurosis the cause of the impairment of vision is cerebral. The examination of the retina is negative. Its clinical features may be briefly summed up in the rapidity of its onset, the shortness of its duration, and the quickness of its departure. It rarely lasts any length of time—in this man only three days—whereas in the retinitis albuminurica, the im- pairment of vision comes on slowly, the cause is peripheral, and there is a definite lesion in the retina, chiefly seen about the macula, in the form of small hemorrhages, and with these there is usually some swelling of the disc. In this form the impairment of vision comes on slowly and is rarely so severe as in the uraemic amaurosis. But that to which I wish specially to call your attention to-day —and I am sorry to have had to take up so much time in clear- ing the ground—is the fact that these severe symptoms of renal cirrhosis may break out in all their violence in an individual who may consider himself in perfect health, and who may be so considered by his friends, and even by his medical adviser, if the latter has not carefully examined into his case. The case of the patient who was admitted under my care on the 7th of May, and who died after a residence of two days in the hospital, has directed my attention to certain points in connection with the insidious course of cirrhosis of the kidney. The first manifestation of the disease may be the onset of severe cerebral symptoms, convulsions, delirium or coma. Cases in point are as follows :—A friend of mine, aged 30, a fellow student, and a man whom I had known since 1863, a grad- uate of McGill College, a strong healthy man, and in active 8 practice, was suddenly seized with convulsions which came on at night with few, if any, premonitions. The day previous to their onset he had done his work as usual and appeared to be, as his wife expressed it, •' in radiant health." The examination of his urine by the attending physician showed the presence of albumen and tube casts, and the diagnosis of chronic Bright's disease was made. He became comatose and died in a few days- I saw him a few months before his death and he looked in his usual vigor. He made no complaints of failing health nor were any alterations perceptible on his countenance. Six or eight months before he had had considerable domestic and mental trouble, owing to the sudden death of his father, and he had not been well for several weeks at that time, but apparently had recovered completely. He had no idea whatever that he was in this danger- ous condition. It is to be noted that prior to this attack he was a good deal worried and anxious about his children who were ill. The first manifestation may be delirium passing on to coma. That was seen in the patient named Weir who was admitted on the 7th of May. I will briefly call your attention to the main features of his case. This patient was a vigorous and healthy man, aged 44, a fore- man in G. T. R. employ. Habits temperate for past ten years, previously had been a drinker. Had been in usual health, but had complained of headache, and his wife stated that he had passed water more frequently of late. On May 6th he was admit- ted with an active delirium which had come on suddenly 36 hours before. Urine found to be albuminous and contained granular casts. The symptoms were regarded as uraemia He became comatose on the 7th, and he died at 2 a.m. on the 8th, after an illness of a little over three days. A point to be noted in connection with this case was that the patient had had a great deal of mental worry at the time as a strike was going on. Thepost mortem did not reveal extensive renal cirrhosis, as was anticipated, for the kidneys, as you see, are not reduced in size and do not present the external characteristics of in- terstitial nephritis, but they were firm, and on microscopical examination there is evidence of a chronic nephritis. The arteries are thickened, some of the Malpighian tufts are degenerated, and there is an increase in the fibrous tissue about the capsules. A fact to be learned from this case is that severe uraemic symptoms 9 may develope at a very early stage in renal cirrhosis, even before the characteristic contraction of the organ occurs. This is, of course, very uncommon, but that it does take place is evident from this case. The third case illustrating the suddenness of the onset of cerebral symptoms in this disease was that of the girl who died about ten days ago, and from whom these kidneys were taken. She was 26 years of age, and up to the time of her admission to the hospital had not suffered from special symptoms of kidney disease. She came in suffering from headache, vomiting, and haemorrhage from the nose, uterus and navel. She got dizzy, had convulsions, became comatose and died. The urine was albuminous and contained casts. The condition of the kidneys was as you now see in these specimens. The occur- rence of haemorrhage is worthy of your attention, as it is occa- sionally seen as one of the severe symptoms in Bright's disease. In the case of this patient it is also worthy of remark that she was friendless and had been ill-treated for years. These three cases will serve very well to illustrate the fact which I wish par- ticularly to impress upon you, namely, that severe uraemic symptoms may be the very first manifestations to the patient, to his friends, or his physician of the existence of kidney disease. The importance of a knowledge of these facts is also very evident from a consideration of the medico-legal aspect of such cases. You may be called to attend a man in a profound coma, who has been stricken down suddenly without any premonition, and while attending to his business, and he even may die in three or five hours under circumstanoes at first suggesting narcotic poisoning. The first manifestation may be an apoplectic seizure. In October, 1879, one afternoon as I was going down stairs prior to my lecture at the College, one of the veterinary students, aged about 25, while coming in through the side entrance, was taken with apoplexy before my very eyes. He leaned against the wall and stated that he was powerless in his left side. We helped him into the waiting-room, and from the suddenness of the onset I supposed at once he must have heart disease and apoplexy. On placing my ear on his chest I perceived a pro- nounced, heaving impulse of the heart but no murmur. There 10 was marked cardiac hypertrophy. By the time we got him to his boarding house the paralysis was complete on the left side; he had lost consciousness and was becoming comatose. He was taken to the hospital and we examined his urine, which was clear, albuminous, and contained numerous casts. The arterial tension was increased. He died in 24 hours. That young man had never suffered from any special symptom pointing to renal disease. He had been attending to his work as usual, though he had never been very strong, and on several occasions I looked at him thinking he might have some constitutional disease. He did not look healthy, but the only things he had complained of, had been occasional headaches and palpitation of the heart, and so far as I remember he had not consulted a doctor. Another case in which the first severe symptom of renal cirrhosis was apoplexy occurred under Dr. Ross' care two years ago in 23 Ward. A woman came in with hypertrophy of the heart, high arterial tension, albuminous urine, and casts, finely granular in character. Cirrhosis of the kidney was diagnosed, and she was placed under suitable treatment. Three days after admission to the hospital she died in two hours with an enormous apoplectic effusion into the brain. The arterial degeneration in this affection renders the vessels fragile, and the powerful contraction of the hypertrophied left ven- tricle is a source of constant danger. A large proportion of all cases of apoplexy occur in connection with contracted kidneys, owing to the existence of these two factors. A third way, in which this disease may declare itself is by in- flammation of some serous membrane, the pericardium, the pleura or the meninges of the brain. A case which early called my attention to the insidious nature of this disease was the following:—A florid, full-blooded Englishman, an old sailor, aged 63 years, who had usually en- joyed excellent health, though he had occasionally, I believe, suffered twinges of gout, was suddenly seized with symptoms of an acute febrile affection, had high fever and considerable con- stitutional disturbance. To make a long story short, he died at the end of four days of acute sero-fibrinous pericarditis. He had a large exudation in the pericardium. The only other disease found in his body was fibroid kidneys, perhaps of gouty origin, 11 as gout may be a very important factor in the production of this disease. The fourth sudden manifestation in this disease to which I will direct your attention is oedema of the glottis, or more frequently of the lungs. Three years ago an old man was brought from the House of Refuge to the Hospital, suffering from intense dyspnoea. On examination of the lungs hydro-thorax of the left side and oedema of the left lung were diagnosed. He refused all treatment, and died within 36 hours of his admission. The. post-mortem re- vealed small contracted kidneys, intense oedema of the left lung and hydro-thorax of the opposite side. The effusion and tran- sudation of serum takes place sometimes into the pleural cavity and sometimes into the lungs. In this case there were no ad- hesions on the left side, while in the other side there were exten- sive adhesions and the transudation took place into the lungs. There was no oedema of the legs in this instance. The urine was albuminous and there were casts. An interesting point in connection with the occurrence of this oedematous effusion is the fact that Traube attributed the uraemic symptoms in this disease to the serous transudations, and the post mortem of the man Wier favors this view, as there was considerable oedema of the membranes of the brain and a good deal of moisture throughout the substance. These are certain of the modes of termination of cirrhosis of the kidney with which you should be acquainted and which it is exceedingly important you should bear in mind. Now, among other symptoms which I will only mention in connection with this chronic form of Bright's disease, there is the occurrence of a dyspnoea, uraemic asthma, without evidence of oedema of the lungs or chronic bronchitis, dependent upon cerebral causes. It is of rare occurrence, but it is a condition which you should bear in mind. The bronchitis, the vomiting, and diarrhoea are also symptoms to which I will not further refer. The importance of a knowledge of these symptoms and these sudden manifestations in renal cirrhosis cannot be over-estimated. I have had two life insurance cases referred to me within the past few years, both of which bear directly upon this question. In one the patient had an Accident Insurance Policy. He fell 12 on ihe ice and was stunned ; felt unwell for some days, but did not see a doctor. Three or four months after, I forget the ex- act time, he was seized with apoplexy. The post mortem re- vealed contracted kidneys. The question was brought up as to the connection of the accident with the subsequent event. My opinion was asked, as the friends had some idea of contesting the case in the courts, but the existence of renal cirrhosis was to my mind quite sufficient to account for the apoplexy. In the other, a middle-aged manlhad insured his life about seven months before his death, which took place quite suddenly. The autopsy disclosed very great atrophy of one kidney and a large red state of the other. No very satisfactory report was obtained of the state of the other organs, and the actual cause of the sudden death remains doubtful. But I have no doubt whatever that it was connected with the condition of renal inadequacy. My opinion was asked as to the possibility or probability of this man not being aware that he was unsound at the time of insuring. After the cases which I have narrated, illustrating the latency of chronic renal disease, you need not ask what my answer was. From the point of view of life insurance, there is no disease about which a company should be more on its guard. Its peculiar insidiousness will have become evident to you by the cases I have cited. The stealthy nature of the disease is increased by the fact, that albumen is not constantly present in the urine. A single examination is not sufficient to enable you to state positively upon its presence or absence, and it is often very slight in amount; and though you may examine for casts, you may go over a dozen sildes before finding one. A patient may come to you who is passing a large quantity of urine, so that he has to get up, perhaps, two or three times in the night (that may be what he comes to complain of); the urine is of low specific gravity and contains albumen—per- haps only in traces. The daily amount of urea is decreased. It deposits, not a thick heavy sediment, but a light cloudy one, which on examination is found to contain hyaline and finely granular casts. There may or may not be oedema of the ankles. If you also find on examination that his heart is hypertrophied, that the arterial tension is increased, you may be tolerably positive with reference to your diagnosis—the man has fibroid degen- eration of the kidneys. To be forewarned in such a case is to 13 be forearmed, and a knowledge of what you may expect in these cases will enable you to take measures for the prevention, if possible, of the severe manifestations of which I have spoken. If a patient comes before you with these symptoms, you should see that the amount of his urine is kept up, and on no account allow it to diminish; that his pulse is kept thoroughly well regulated, and that he lives a quiet regular life and does not go to any excess in eating or drinking. The treatment of the affection is in great measure a treatment of symptoms. Acting with cathartics upon the bowels and keeping the amount of urine up to the stan- dard, are among the most important means to be taken. Note.—June 7th. The patient who was shown to the class on the occasion of the above lecture was recently discharged, feeling as he expressed it quite well. He was still passing about 80 ounces of urine in the day, with albumen and a few casts. He looked well, fit for life insurance, and would pass in many ex- aminations such as I have witnessed. Yet I know of no more likely candidate for sudden death than this same patient, who has the sword of Damocles hanging over his head, ready to fall with fatal effect when the tiny hair which suspends it is suddenly broken by the onset of convulsions, or one of the other accidents to which such patients are liable. Dudley & Burns, Toronto, 16S1. NOTES ON Intestinal Diverticula. ^b By WILLIAM OSLER, M.D., OF MONTREAL. V REPRINT. BROOKLYN, N.Y. : Annals of Anatomy and Smgery, 28 Madison Street. NOTES ON INTESTINAL DIVERTICULA. By WILLIAM OSLER, M. D., M. R. C. P., Lond., * OF MONTREAL, CANADA, PROFESSOR OF THE INSTITUTES OF MEDICINE IN MC GILL UNIVERSITY, HAVING found a somewhat unusual specimen of the above abnormality at a recent autopsy, I was re- minded of other instances which had come under my notice, and have thought that a few notes on the subject might be of interest to the readers of the Annals of Anatomy and SURGERY, particularly as the information to be obtained from ordinary anatomical works is exceedingly meagre. Even in Henle's large work the matter is dismissed in a few lines. Some of the text-books on morbid anatomy contain very good accounts, as in Jones and Sieveking (Payne's ed.), and Birch-Hirschfeld ; but for a full and satisfactory descrip- tion we must go to the works of the great Meckel (whose name the single diverticulum ilei commonly bears) where, in the " Handbuch der Pathologischen Anatomie " (1812), the subject is treated at great length, and we have an admirable example of the thoroughness with which the older anato- mists did their work. No detail has escaped him, and I doubt if any new point in structure or mode of development has since been determined. A division is made of the forms of diverticula into true and false, or congenital and acquired. The true diverticulum, Meckel's diverticulum ilei, is a rather Reprinted from the Annals of Anatomy and Surgery, Vol. iv., No. 5, November, 1881. 2 WILLIAM OSLER. common abnormality, occurring, in my experience, in some- what over two per cent, of bodies. I have met with twelve instances in about 550 inspections. It is invariably solitary, springs from the ileum opposite the mesenteric border, at a distance of three or four feet from the valve, and is distin- guished from a false diverticulum by the presence of all the tunics of the bowel. It varies in length, in the specimens which I have examined, from one to six inches, and, when distended, is cylindrical in form or, in the small ones, funnel- shaped. The size of the canal is usually smaller than that of the intestine; in one instance only have I seen it of equal width. It is sometimes wider at the distal end than at the orifice, which may be protected by a valvular fold. The blind extremity frequently presents one or two saccular di- latations. It is usually attached at right angles to the bowel, but in several of my specimens the direction is oblique. The extremity may be free or have attached to it a fibrous cord, which passes to the abdominal wall in the region of the navel. In one instance I found a fibrous and fatty cord passing from the end of the diverticulum to the adjacent mesentery, forming a noose which admitted three fingers. Specimens have been described with a definite fold of mes- entery attached along one border. When inverted the mu- cosa resembles that of the ileum, and large specimens often contain Peyer's patches. Prior to Meckel's observations, this process was believed to originate either by distension of the bowel or by the dragging of adhesions from without. He showed that it was congenital, and offered a rational explanation of its oc- currence as a remnant of the omphalo-mesenteric duct which connects the primitive intestine with the umbilical vesicle. The different degrees of malformation which may arise from the existence of this communication are thus described by Birch-Hirschfeld,1 and it was the existence of these various 1 Loc. cit. NO TES ON INTESTINA L DIVER TICULA. 3 grades that led Meckel to the happy solution of the ques- tion: "The malformation, which is to be regarded as an arrest in the development of the bowel at one of the steps when it is in connection with the umbilical vesicle, exists in the most extreme degree when there is a fissure in the ab- dominal wall below the navel, through which the ileum opens. The lower part of the bowel is, as a rule, very nar- row or completely closed, and the faeces pass through the opening at the navel. In the next grade the abdominal fis- sure also exists, and the ileum is in direct communication with the opening at the navel by means of the patent ductus omphalomesaraicus, but at the same time the lower part of the bowel is well developed and the faeces pass into the colon. Then, there are those instances in which the ventral fissure is closed, and a blind process of the ileum exists which is united to the navel by the obliterated ductus mes- araicus, represented as a solid fibrous cord ; and, lastly, as the slightest grade, the omphalo-mesenteric duct remains as a free diverticulum from the ileum." The interest in this abnormality is not merely anatomical, as its presence is accompanied with certain dangers, and in a large number of cases it has been the cause of fatal mis- chief. In a few instances in which the process has extended into the navel-string as a narrow canal, it has been cut in the separation of the child. The chief danger arises wheit the extremity of the diverticulum is attached to the abdominal wall or contiguous parts. Many cases of strangulation of the bowel have been reported from this cause. More rarely acute obstruction has occurred from constriction of the bowel in the neighborhood of the process—Dr. Southey has reported two such cases.1 When unattended it is seldom a source of trouble. Occasionally foreign bodies enter and excite inflammation, as in a case reported by P. Beale,2 in 1 Clinical Society Transactions, vol. v. a Path. Society Transactions (London), vol. v. 4 WILLIAM OSLER. which cherry-stones and orange-pips were found, and in one by Mr. Doran,1 in which a pea had excited ulceration. I have not met with a recorded instance of trouble from im- paction of hardened faeces. Typhoid ulceration has been found in a Peyer's patch in the diverticulum. I saw an in- teresting specimen of this at the New York Pathological Society last Winter, and a case of perforation of such an ulcer is reported by Dr. Galton.2 The process sometimes finds its way into one of the peritoneal rings as a hernia. Littre (1700) and Mery (1701) are quoted by Meckel as hav- ing reported cases of this kind. Dr. Dowse has recorded 3 a curious instance of a woman aged yy, who was attacked with vomiting and pain in the groin, where ultimately a faecal fistula became established. Patient died three months after, when a diverticulum ilei was found to have passed into a direct inguinal sac, becoming adherent, inflamed and perforated. Dr. Hare4 met with a diverticulum 1% inches long in the inguinal canal in a patient who had had several attacks of abdominal pain, with vomiting and constipation, during one of which he died. The bowel was constricted above the process, which Dr. Hare regarded not as a con- genital diverticulum, but as a portion of the bowel which had become adherent at the ring and gradually drawn in. I met with a somewhat similar instance, and it was difficult to decide whether the small hernia was a true diverticulum or only a portion of the bowel drawn into the ring. The false diverticula occur in any part of the intestinal canal, often in large numbers, are usually situated at or near the mesenteric border, and seldom consist of more than the mucosa, which forms a sort of hernial protrusion. If we except the little saccular diverticula the size of small peas, 1 Ibid, vol. xxix. 8 Ibid, vol. xxiii. 8 Lond. Path. Soc. Reports, xxvi. 4 Ibid, vol. vii. NOTES ON INTESTINAL DIVERTICULA. 5 of which an occasional instance is not uncommon, this vari- ety is less frequent than the other. I have notes of only three or four such. In one a protrusion the size of a walnut existed in the duodenum just below the papilla. It com- municated with the bowel by a wide orifice, and appeared to consist chiefly of the mucous coat, though no rent was evi- dent in the muscular coat, which appeared rather thinned and wasted. I met with a most remarkable instance a few weeks ago in the person of a man aged 65, who died of an acute enteric attack with melaena.1 The jejunum presented fifty-three diverticula on the mesenteric border—all of hemi- spherical shape and attached by broad bases. They ranged in size from a cherry to a large apple. One measured 8 by 6 cm. Six of them were larger than billiard balls. The walls were somewhat thinner than those of the intestine, but the larger ones presented a distinct though thin muscular invest- ment. All contained fluid faeces; two of the larger ones were fully distended. The mucous membrane looked nor- mal, but was, perhaps, a little thinner than in the bowel. The valvulae conniventes were absent. When distended with air and dried, and openings made in the bowel opposite the di- verticula, it was seen that some of them had imperfect valv- ular folds at the margins of the orifices. They lay between the peritoneal surfaces of the mesentery, and numerous blood vessels coursed over them. There were not any in the ileum or colon. They were not connected with the acute enteric trouble which caused death, and which was situated in the lower part of the ileum. So far as could be ascer- tained, the patient had not been a very constipated man, but had for years been subject to colicky pains in the abdomen, which may have been associated with these diverticula. 1 I am told by Dr. Trenholme that for years the patient had suffered much from loud rumbling noises in the belly, particularly after each meal. So loud were they that it was his habit, shortly after eating, to go out to take a walk and keep away Irom people, as the noises could be heard at some distance. 6 William osleR. In the large intestine I have met with two instances of curious diverticula forming globular sacculi the size of large peas or cherries; very numerous in one case along the whole colon, in the other, confined to the lower part, and consisting of thin pouches of the gut filled with firm fascal concretions. The number and arrangement gave a very pe- culiar appearance to the bowel when distended. They were not connected in any special way with the appendices epi- ploicae. In one case the faecal masses were of almost stony hardness, owing to the presence of lime salts. Many cases of this sort are reported—one by Mr. Sidney Jones1 termi- nated by the ulceration of a sacculus into the bladder. The false diverticula are caused, in the majority of cases, by distension of the bowel either by faeces or gas, and are rarely more than hernial protrusions of the mucosa. The occurrence in such numbers as in the above reported case is uncommon. Dr. Gross, in his " Pathological Anatomy," 2d ed., p. 601, figures a somewhat similar specimen, and refers to other cases seen by Monro, Cruveilhier and Sir Astley Cooper. 1 Lond. Path. Soc. Transactions, vol. viii. NATIONAL LIBRARY OF MEDICINE NLfl DDEiafill 7 NLM002188117