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"': '■i'lt^i'-^'''ij'" ' ■''"-. .-".WW'i'j?'!"—■•* ■•• lipg;Y;; '■■■_';; ,:-;;,- Y^s^vY^^''^' ■'■ ■ ft." ,S>"X: . :ir ■ ■ - ■ . ^L-l'H^ftSu -?,*iS^S .;..yr^l(5g. .■IS'.;', A. ■. ;v : •irjfeira Bfeir;;.'. (P. A' . ,r. . ■. .., • 7 . ■ ■>■:)■,,.''. ,:;_>-.:-. -■ *»*r5f h^^f.\ ?Z3F55B .'..•'■.Y/;./-' -•' •' ' Yffig ^H-"- .' .' 1.- ', . ■..''<■'■• . . - --Sal j; JJ'^rWmttBH ^H' t i - ■ ;, jT*2$BBtln ^^^^^H *..^Vd'.Y--.J:.,-f.i.rV-- . ■L-------------------■ y/W CLINICAL LECTURES jV//rf PRINCIPLES AND PRACTICE OF MEDICINE. BY JOHN HUGHES BENNETT, M.D., F.R.S.E., PROFESSOR OF THE INSTITUTES OF MEDICINE, AND SENIOR PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF EDINBUROII ; Formerly Lecturer on the Practice of Physic, Physician to the Fever Hospital, Director of the Poli-Clinlc, Eoyal Dispensary, and Pathologist to the Royal Infirmary, Edinburgh; Member of various Scientific and Medical Societies in Edinburgh, St. Andrews, Philadelphia, New York, Paris, Vienna, Berlin, Jena, Stockholm, Copenhagen, Amsterdam, etc., etc. SECOND AMERICAN, FROM THE LAST EDINBURGH EDITION. With Jibe punkeb Illustrations ok SSSfoob. LIBP.AP.T. NEW YORK: WILLIAM WOOD AND COMPANY 61 WALKER STREET. 1863. JOHN V. TEOW, I'K.RKOTYPER, AND ELECTH0TYPF.B, I* & 50 Greene Street, Sew York. PREFACE. In consequence of the rapid exhaustion of a second edition of this work, I have been called upon to prepare a new one much sooner than I could have anticipated. The whole of it, not- withstanding, has been most carefully revised, and the volume extended by the addition of fifty pages, with twenty-one new cases and thirty-four new wood-cuts. I have endeavoured throughout, by reference to indisputable facts, to demonstrate the correctness of the principles which have guided my prac- tice, and have, therefore, authenticated every case with the name of its reporter in the hospital books. I have availed myself of numerous illustrations engraved on wood, having long been persuaded that mere description of morbid appearances, and especially of those that are made visible by means of the microscope, communicates only feeble or imper- fect ideas to others. Of these illustrations, such as are borrowed have the names of their authors appended ; such as have no name attached are original. I have again to express my warmest thanks to numerous friends for aid rendered to me in various ways, but more espe- cially to Dr. Markham of London, and to Dr. John Glen, now Medical Superintendent of the Royal Infirmary, Dundee. Dr. Markham has done me the honour to make a most careful study and critical analysis of the book, and has favoured me with numerous valuable remarks and suggestions, of which I have gladly taken advantage. Dr. Glen, by correcting the sheets during their progress through the press, has not only added to the obligations I formerly owed him, but has enabled me to IV PREFACE. produce the present edition long before it would have been pos- sible for me, otherwise, to have completed the undertaking. I am still, however, deeply sensible of the many imperfec- tions with which this work is chargeable, and for which I must solicit the kind indulgence of my medical brethren. To exem- plify the entire subject of practical medicine by means of cases in a work of moderate compass, is obviously impossible. But sufficient examples, I trust, have been given to illustrate the more important modifications, which the advanced state of diagnosis and pathology has effected in the treatment of diseases. The flattering manner in which it has been received by the pro- fession, and noticed by the press, confirms the conviction 1 formerly ventured to state, viz., that such modifications will be shown by further experience to be not merely temporary changes, but permanent improvements in the practice of the art. J. HUGHES BENNETT. Edinburgh, April, 1859. PREFACE TO THE SECOND AMERICAN EDITION. The American publishers tender their thanks to the profes- sion for the countenance extended to the " Clinical Lectures on the Principles and Practice of MediciiM^' But little more than two years have elapsed since the first American edition of this able work was issued from the press; and in view of the un- happy state of the country, its sale has exceeded the best hopes of the publishers. In issuing the second edition they respect- fully ask for a continuance of public favor. New Yoke, 1863. CONTENTS. List of Illustrations .... Introduction ..... The relation of the science to the art of medicine Mode of conducting the clinical course The political state of the medical profession The social state of the medical profession The present state of practical medicine Page xvi 1 2 6 9 12 13 SECTION I. EXAMIXATION OF THE PATIENT 18 Arrangement of symptoms, etc. ..... 19 Inspection of the dead body ..... 24 Relative position of internal organs .... 26 Inspection . . . . . . . . 28 Inspection of the general posture ..... 28 of the countenance ..... 29 of the chest ...... 29 of the abdomen ...... 30 Palpation ........ 30 Increased or diminished sensibility of parts ... 30 Altered form, size, density, and elasticity .... 31 Alterations of movement ...... 31 Mensuration ........ 32 Percussion ........ So Of the different sounds produced by percussion ... 37 Of the sense of resistance produced by percussion ... 38 General rules to be followed in the practice of mediate percussion . 38 Special rules to be followed in percussing particular organs . 40 in percussing the lungs . . 40 in percussing the heart . . -13 VI CONTENTS. Special rules to be followed in percussing the liver in percussing the spleen in percussing the stomach and intestines in percussing the kidneys in percussing the bladder Auscultation ...... General rules to be followed in the practice of auscultation Special rules to be followed during auscultation of the pulmonary organs ..... Of the sounds produced by the pulmonary organs in health and in disease ..... Special rules to be followed during auscultation of the circulatory organs ..... Of the sounds produced by the circulatory organs in health an disease ..... Auscultation of the abdomen Auscultation of the large vessels Use of the Microscope .... Description of the microscope Mensuration and demonstration How to observe with a microscope Principal Applications ok the M Saliva Milk The Blood . Pus Sputum Vomited matters Fceces Uterine and vaginal discharges Mucus Dropsical fluids Urine Cutaneous eruptions and ulcers Usk of Chemical Tests To detect albumen in the urine To detect bile in the urine . To detect sugar in the urine To detect chlorides in the urine CROSCOPE TO DlAGXOS SECTION II. PRINCIPLES OF MEDICINE On tiie General Laws of Nutrition in Health and Disease Function of nutrition .... Function of innervation .... 97 99 99 108 CONTENTS. vii Pathology and Treat - General anatomy and physiology of the nervous system G cneral pathology of the nervous system Simple, Cancerous, and Tubercular Exudations—their Pathology General Treatment , Production of exudation Theory of exudation Vital transformations of the exudation Simple exudation Cancerous exudation Tubercular exudation Pathology of three kinds of exudation Death of the exudation Mortification or moist gangrene Ulceration General treatment of exudation Morbid Growths of Texture—their ment . Classification Fibrous growths Fatty growths . Cystic growths . Glandular growths Epithelial growths Vascular growths . Cartilaginous growths Osseous growths Cancerous growths General pathology of morbid growths General treatment of morbid growths Morbid Degenerations of Texture Albuminous degeneration Fatty degeneration . Pigmentary degeneration Mineral degeneration Concretions Albuminous concretions Fatty concretions Pigmentary concretions Mineral concretions . Urinary concretions . Prostatic concretions Hairy concretions Vegetable fibrous concretions Amyloid and amylaceous concretions viii CONTENTS. SECTION III. Pago ON THE RECENT CHANGES IN THERAPEUTICS, OCCASIONED BY AN ADVANCED KNOWLEDGE OF DIAGNOSIS AND PATHOLOGY ....... 250 The Diminished Employment of Blood -letting ard other Antiphlo- gistic Remedies in the Treatment of Acute Inflammations . 251 Proposition 1.—That little reliance can be placed on the experience of those who, like Cullen and Gregory, were unacquainted with the nature of, and the mode of detecting, internal inflammations . 252 Proposition 2.—That inflammation is the same now as it has ever been, and that the analogy sought to he established between it and the varying types of fevers is fallacious .... 254 Proposition 3.—That the principles on which blood-letting and anti- phlogistic remedies have hitherto been practised are opposed to a sound pathology . . . . . . . 257 Proposition 4.—That an inflammation once established cannot be. cut short, and that the object of judicious medical treatment is to conduct it to a favorable termination . . . . . 264 Proposition 5.—That all positive knowledge of the experience of the past, as well as the more exact observation of the present day, alike establish the truth of the preceding principles as guides for the future ........ 269 Tin: Influence of Predominant Ideas on the Healthy and Disordered Functions of the Body ...... 292 SECTION IV. DISEASES OF THE NERVOUS SYSTEM . 303 On the Pathology of Cerebral and Spinal Softenings, and on the Necessity of employing the Microscope to ascertain their nature 305 Acute Hydrocephalus—Cases I. to III. ..... 312 Pathology and treatment . . . . . 31(5 Cerebral Meningitis, Acute—Cases IV. to VI. .... 319 Pathology and treatment ...... 323 Chronic—Cases VII. and VIII. .... 325 Cerebritis, Acute—Cases IX. and X. .... 329 Chronic—Cases XL to XIV. ..... 333 Pathology and treatment of cerebritis .... 343 Cerebral Disease from Obstruction of Arteries—Cases XV. to XVII. 34-, Pathology ........ 354 Cerebral Hemorrhage—Cases XVIII. to XXVIII. . . . 35q Pathology and treatment ...... 373 CONTENTS. ix Cancer of the Brain—Case XXIX. .... Dropsy of the Brain—Case XXX. .... Structural Diseases of the Spinal Cord—Cases XXXI. to XXXVII Treatment ...... Pathology ...... Functional Disorders of the Nervous System—Case XXXVIII. Classification of functional nervous disorders Pathology of functional nervous-disorders Treatment of functional nervous disorders Delirium tremens—Cases XXXIX to XLII. Poisoning by opium—Case XLIII. Poisoning by hemlock—Case XLIV. . Poisoning by lead—Case XLV. SECTION V. DISEASES OF THE DIGESTIVE SYSTEM . Diseases of the Mouth, Pharynx, and (Esophagus—Cases XLVI. to L. Functional Disorders of the Stomach—Cases LI. to LIII. General pathology and treatment of dyspepsia Vomiting of sarcinas—Cases LIV. and LV. Organic Diseases of the Stomach ..... Chronic ulcer of the stomach—Cases LVI. and LVII. Chronic ulcer of the stomach, with perforation—Cases LVIII. and LIX........ Pathology and treatment ..... Cancer of stomach—Cases LX. and LXI. Diseases of the Liver ...-•■ Acute congestion—Case LXII. .... Jaundice—Cases LXIII. and LXIV. .... Jaundice from cancer compressing the ducts—Cases LXV. and LXVI Enlargement of the liver—Case LXVII Fatty enlargement—Case LXVIII. Cirrhosis—Cases LXIX. and LXX. Cancer of the Liver—Case LXXI. Diseases of the Intestines Diarrhcea—Cases LXXII. and LXXIII Dysentery—Cases LXXIV. to LXXVI Pathology and treatment of diarrhoea and dysentery . Obstruction of large intestine from cancer—Case LXXVII Strangulation of small intestine from inguinal hernia—Case LXXVIII Intestinal Worms—Cases LXXIX. to LXXXII. Peritonitis—Cases LXXXIII. to LXXXVI. X CONTENTS. SECTION VI. DISEASES OF THE CIRCULATORY SYSTEM Pericarditis—Cases LXXXVII. to XCII. Pathology and treatment . Valvular Diseases of the Heart—Cases XCIII. to CIII. . Enlarged foramen ovale—Case CIV. Pathology of valvular and organic diseases of the heart Treatment of valvular and organic diseases of the heart Functional Diseases of the Heart Aneurism—Cases CV. to CXIII. General diagnosis of thoracic aneurisms Physical phenomena of abdominal aneurisms Pathology and treatment of aneurisms SECTION TIL DISEASES OF THE RESPIRATORY SYSTEM Laryngitis—Cases CXIV. to CXVII. .... Treatment by topical applications .... Diagnosis of laryngitis ..... Bronchitis—Cases CXVIII. to CXX1I. .... Pathology and treatment ..... On injections into the bronchi in pulmonary diseases . Pleuritis—Cases CXXIII. to CXXVII. .... Pathology, diagnosis, and treatment of Pleuritis Empyema—Case CXXVIII. ..... Pneumonia—Cases CXXIX. to CXLIII. .... On the diagnostic value of the absence of chlorides from the urine in pneumonia—Case CXXXVIII. .... Chronic pneumonia and gangrene of the lungs—Cases CXXXIX to CXLIII. . . . . ... General pathology and treatment .... Phthisis Pulmonalis—Cases CXLIV. to CL. On the natural progress of phthisis pulmonalis—the tendency to ulceration—the modes of arrestment Pathology and general treatment of phthisis pulmonalis Special treatment of phthisis pulmonalis Cancer of the Lung—Case CLII. ..... Carbonaceous Lungs—Cases CLIII. and CLIV. Pathology and treatment ..... CONTENTS. XI SECTION VIII. DISEASES OF THE GENITO-URINARY SYSTEM Page 706 Ovarian Dropsy—Cases CLV. to CLVII. Pathology of ovarian dropsy Treatment of ovarian dropsy Nephritis and Pyelitis—Cases CLVIII. and CLIX. Desquamative nephritis—Cases CLX. to CLXII. Suppurative nephritis—Case CLXIII. Scrofulous nephritis—Case CLXIV. Calculous nephritis—Case CLXV. . Chronic pyelitis—Case CLXVI. Pathology of cystic kidney .... Persistent Albuminuria, or Brigiit's Disease—Cases C CLXXVI. ...... Pathology of Bright's disease Diagnosis of Bright's disease Treatment of Bright's disease XVII. 706 721 724 726 730 737 740 742 745 747 748 765 769 77:> SECTION IX. DISEASES OF THE INTEGUMENTARY SYSTEM 774 Classification of Skin Diseases Diagnosis of Skin Diseases Porrigo The Treatment of Skin Diseases Dermatozoa Acarus scabiei Entozoon folliculorum Dermatophyta Favus—cases CLXXVII. to CLXXXII. History of favus as a vegetable parasite Mode of development and symptoms of favus Causes Pathology . Treatment . 775 779 782 763 789 789 792 794 794 798 798 801 803 810 Xll CONTENTS. SECTION X. DISEASES OF THE BLOOD Leucocythemia—Cases CLXXXIII. to CLXXXV. Pathology and treatment Discovery of leucocythemia . Chlorosis and Anaemia—Case CLXXXVI. Ichor . J ° . . „ ., , iot„„ All that is necessary in examining fluid substan- ces, is to place a drop in the centre of a slip of glass, and letting a smaller and thinner piece of glass fall gently upon it, so as to exclude air bubbles, place it upon the stage under the objective. In this way the fluid substance will be diffused equally over a flat surface, and evaporation prevented which would dim the objective. The illumina- tion must now be carefully arranged, and the focus obtained, first by means of the coarse, and then by means of the fine, adjustment. It will save much time, in examining structures, to employ always, at one sitting, the same slips of glass, as it is easier to clean these with a towel, after dipping them in water, than to be perpetually shifting the coarse adjustment. The action of water, acetic acid, and of other re-agents, on the particles contained in a fluid, may be observed by mixing with it a drop of the re-agent before covering with the upper glass; or if this USE OF THE MICROSCOPE. 69 be already done, the drop of re-agent may be placed at the edge of the upper glass, when it will be diffused through the fluid under examina- tion by imbibition. The mode of demonstrating solid substances will vary according as they are soft or hard, cellular or fibrous. The structure of a soft tissue, such as the kidney, skin, cartilage, etc., is determined by making very minute, thin, and transparent slices of it in various directions, by means of a sharp knife or razor. These sections should be laid upon a slip of glass, then covered over, and slightly pressed flat, by means of an upper one. The addition of a drop of water renders the parts more clear, and facilitates the examination, although it should never be forgotten that most cell-structures are thereby enlarged or altered in a shape from en- dosmosis. Acid and other re-agents may be applied in like manner. The double-bladed knife of Valentin will enable you to obtain large, thin, and equable sections of such tissues, and permit you to see the manner in which the various elements they contain are arranged with regard to each other. Harder tissues, such as wood, horn, indurated cuticle, etc., may also be examined after making thin sections of them. Very dense tissues, such as bone, teeth, shell, etc., require to be cut into thin sec- tions, and afterwards ground down to the necessary thinness. Prepara- tions of this kind are now manufactured on a large scale, and may be obtained at a trifling cost. A cellular parenchymatous structure, such as the liver, may be examined by crushing a minute portion between two glasses. If it be membranous, as the cuticle of plants, epithelial layers, etc., the membrane should be carefully laid flat upon the lower glass, and covered with an upper one. A fibrous structure, such as the areolar, elastic, muscular, and nervous tissues, must be separated by means of needles, and then spread out into a thin layer before examina- tion, with or without water, etc. The commencing observer should not be discouraged by the diffi- culties he will have to encounter in dissecting and displaying many tissues. He must remember that the figures he sees published in books are generally either fortunate or very carefully prepared specimens. Practice will soon enable him to obtain the necessary dexterity, and to convince himself of the importance of this mode of inquiry. He should early learn to draw the various objects he sees, before and after the action of re-agents, not only because such copies constitute the best notes he can keep, but because drawing necessitates a very careful and accurate examination of the objects themselves. A note-book and pen- cil for the purpose should be the invariable accompaniments of every microscope. How to Observe witii a Microscope. The art of observation is at all times difficult, but is especially so with a microscope, which presents us with forms and structures concerning which we had no previous idea. Rigid and exact investigation, there- fore, should be methodically cultivated from the first, in order to avoid those errors into which the tyro, when using a microscope is particu- larly liable to fall. Thus, you should carefully examine the physical properties of the particles and ultimate structures you may see, and not 70 EXAMINATION OF THE PATIENT. hastily conclude that you have under observation so-called pus, tubercle, or cancer corpuscles, because they were obtained from what was, a priori, believed to be pus, tubercle, or cancer. Nothing has been more clearly demonstrated by the progress of histology, than the fact, that the naked -io-ht has confounded different structures together, from a similarity of external appearance, and that the greatest caution is required at all times, but especially by learners, in forming opinions as to the nature of different tissues. ... • v. • The phvsical characters which distinguish microscopic objects consist of__1 st Shape ; 2d, Colour; 3d, Edge or border ; 4th Size ; 5th Trans- parency; 6th, Surface; 7th, Contents; and 8th, Effects of re-agents. These we may notice in succession. 1. Shape.__Accurate observation of the shape of bodies is very neces- sary, as many of these are distinguished by this physical property. Thus the human blood globules, presenting a bi-concave round disk, are in this respect different from the oval corpuscles of the camelidae, of birds, rep- tiles, and fishes. The distinction between circular and globular is very necessary to be attended to. Human blood corpuscles are circular and flat, but they become globular on the addition of water. Minute struc- tures seen under the microscope may also be likened to the shape of well- known objects, such as that of a pear, balloon, kidney, heart, etc., etc. 2. Colour.—The colour of structures varies greatly, and often differs, under the microscope, from what was previously conceived regarding them. Thus the coloured corpuscles of the blood, though commonly called red, are in point of fact yellow. Many objects present different colours, according to the mode of illumination—that is, as the light is reflected from, or transmitted through their substance, as in the case of certain scales of insects, feathers of birds, etc. Colour is often produced, modified, or lost, by re-agents, as when iodine comes in contact with starch corpuscles, when nitric acid is added to the granules of chlorophyle, or chlorine water affects the pigment cells of the choroid, and so on. 3. Edye or Border.—The edge or border may present peculiarities which are worthy of notice. Thus, it may be dark and abrupt on the field of the microscope, or so fine as to be scarcely visible. It may be smooth, irregular, serrated, beaded, etc. etc. 4. Size.—The size of the minute bodies, fibres, or tubes, which are found in the various textures of animals, can only be determined with exactitude by actual measurement, in the manner formerly described. It will be observed, for the most part, that these minute structures vary in diameter, so that when their medium size cannot be determined, the variations in size from the smaller to the larger should be stated. Human blood globules in a state of health have a pretty general medium size, and these may consequently be taken as a standard with advantage, and bodies may be described as being two, three, or more times larger than this structure. 5. Transparency.—This visible property varies greatly in the ultimate elements of numerous textures. Some corpuscles are quite diaphanous, others are more or less opaque. The opacity may depend upon corru- gation or irregularities on the external surface, or upon contents of dif- ferent kinds. Some bodies are so opaque as to prevent the transmission of the rays of light, when they look black by transmitted light, although USE OF THE MICROSCOPE. 71 they be white, seen by reflected light. Others, such as fatty particles and oil globules, refract the rays of light strongly, and present a peculiar luminous appearance. 6. Surface.—Many textures, especially laminated ones, present a dif- ferent structure on the surface from that which exists below. If, then, in the demonstration, these have not been separated, the focal point must be changed by means of the fine adjustment. In this way the capillaries in the web of the frog's foot may be seen to be covered with an epidermic layer, and the cuticle of certain minute fungi or infusoria to possess peculiar markings. Not unfrequently the fracture of such structures enables us, on examining the broken edge, to distinguish the difference in structure between the surface and the deeper layers of the tissue under examination. 7. Contents.—The contents of those structures, which consist of enve- lopes, as cells, or of various kinds of tubes, are very important. These may consist of included cells or nuclei, granules of different kinds, pig- ment matter, or crystals. Occasionally their contents present definite moving currents, as in the cells of some vegetables, or trembling rotatory molecular movements, as in the ordinary globules of saliva in the mouth. 8. Effects of Re-Agents.—These are most important in determining the structure aud chemical compositiou of numerous tissues. Indeed, in the same manner that the anatomist with his knife separates the various layers of a texture he is examining, so the histologist, by the use of re- agents, determines the exact nature and composition of the minute bodies that fall under his inspection. Thus, water generally causes cell formations to swell out from endosmosis; whilst syrup, gum water, aud concentrated saline solutions, cause them to collapse from exosmosis. Acetic acid possesses the valuable property of dissolving coagulated albu- men, and, in consequence, renders the whole class of albuminous tissues more transparent. Thus, it operates on cell walls, causing them either to dissolve or become so thin as to display their contents more clearly. uEther, on the other hand, and the alkalies, operate on the fatty com- pounds, causing their solution and disappearance. The mineral acids dissolve most of the mineral constituents that are met with, so that in this way we are enabled to tell, with tolerable certainty, at all events the group of chemical compounds to which any particular structure may be referred. PRINCIPAL APPLICATIONS OF THE MICROSCOPE TO DIAGNOSIS. A perfect application of the microscope, for the purpose of diagnosis, can only be arrived at by obtaining, in the first instance, a complete knowledge of the tissues of plants and animals, both in their, healthy aud diseased conditions. The medical practitioner may be called upou to distinguish, not only the various structures which enter into every species of food, every kind of animal texture and fluid, aud every form of' morbid product, but he will frequently have to judge of these when more or less disintegrated, changed, or otherwise affected by the pro- 72 EXAMINATION OF THE PATIENT. cesses of mastication, digestion, expectoration, ulceration, putrefaction, maceration, etc., etc. In this place, however, I propose merely calling your attention to those points which are more likely to fall under your notice at the bed-side. No doubt, the practical, applications of the microscope are daily extending, and whilst there are many points which may be said to be scarcely investigated, those which have been most so require to be further studied. At the same time, a careful and perse- vering examination of the morphological elements found in the various excreta of the body, as modified by different diseases, or by constitution and diet, cannot but prove of great importance in the present state of practical medicine. Hence, besides shortly discussing what is known, I shall especially indicate what are those subjects which may be elucidated by such of you as, by previous histological observations, are qualified for the task. Saliva. The readiest way of examining saliva is to collect a drop of that fluid at the extremity of the tongue, and let it fall on the centre of a slip of glass. It should be allowed to remain quiescent for a minute or so, until most of the bubbles of air have collected in a mass on the surface. This should then be gently scraped off or placed aside with a needle, and the subjacent fluid covered with a thin glass. There will now be observed, with a magnifying power of 250 diameters linear,— 1st, The salivary corpuscles; 2d, Epithelial scales of the mouth; 3d, Molecules and granules. 1. The salivary corpuscles are colourless spherical bodies, with smooth margins, varying in size from the -^Vo to the tjVo °f an ^ncn m di- ameter. They contaiu a round nucleus, varying in size, but generally occupying a third of the cell; and between this nucleus and the cell wall are numerous molecules and granules, which communicate to the entire corpuscle a finely molecular aspect. The addition of water causes these bodies to swell out and enlarge from endosmosis. Acetic . o , acid somewhat dissolves the cell wall, and it '7^;@>-®jV.^^p^ becomes more transparent; while the nucleus . ( 7) °. f'|j^ appears more distinct as a single, double, or tri- ,[.V yi'"Y\°'-""'■ partite body. Both water and acetic acid ' >l\ *\l '/ °j \$ produce also coagulation of the albuminous '"/^■"l\v ,• '*/'"' V*' uiatter corjtained in the fluid of the saliva, ~v_'^\ '-•.'■ (^y.'. which assumes the form of molecular fibres, '® ||)'© .* 1*;^J^,- in which the corpuscles and epithelial scales become entangled, and present to the naked Fi? 25- eye a white film. 2. The Epithelial scales found in the saliva are derived from the mouth, and consist of flat plates, variously shaped, but generally pre- senting an oblong or squarish form, more or less curled up at the sides. Not unfrequently these have five or six sides, and are assembled together in groups, with their edges adherent. In size they vary from the ^th Fig. 2.">. Salivary corpuscles, epithelial scales, with molecules and granules, as seen in a drop of saliva. USE OF THE MICROSCOPE. 73 to the j^th of an inch in length. Embedded in their substance is a round or oval nucleus, together with numerous molecules and granules. Water produces no change in these bodies; but acetic acid renders the scale more transparent, and causes the nucleus to appear more distinct, with a darker edge. 3. Associated with the salivary corpuscles and epithelial scales are several molecules and granules, which vary in number in different people, and at various times of the day. There may also be occasionally found in the saliva various foreign substances derived from the food—such as granular debris of different kinds, starch globules or vegetable cells, muscular fasciculi, portions of areolar tissue, tendon, or spiral filaments, etc.—derived from pieces of texture which have adhered to the teeth during mastication. The saliva may present various alterations, dependent on disease of the mucous membranes of the mouth and tongue. This, when ulcerated, causes an increase in the molecular and granular matter. Many of the epithelial scales also lose their transparent character and be- come opaque, from an augmen- tation of granular matter in their substance. Not unfrequently, under such circumstances, they give rise to confervoid growths, which mainly spring up in the debris collected in the mouth, either on the surface of ulcers, ris-26- F'?- 27- in the sordes which collect on the teeth, gums, and tongue of individuals labouring under fever or even in the inspis- sated mucus of persons who sleep for a con- siderable time with the mouth open (Fig. 20). In infants the tongue and cavity of the mouth are not unfrequently covered with a yellowish flocculent matter, constituting the disease named muguet by the French, in which sporules and confervoid filaments, in a high state of development, may be detected in considerable numbers (Fig. 27). In epithelial cancroid of the tongue, the epithelial scales exhibit a great tendency to split up aud form fibies, and may frequently be found on the surface of the ulcer, present- ing the form here figured (Fig. 28). Fig.2S. An histological examination of the saliva, of the fur and load of the tongue, in the great majority of diseases, is still a desideratum. Fig. 26. Minute confervoid filaments springing from an altered epithelial scale, scraped from the surface of a cancroid ulcer of the tongue (Leptothrix bucealis). Fig. 27. Confervoid filaments and sporules, in the exudation on the mouth and gums, constituting Muguet in infants. Fig. 28. Fringe like epithelium, from the surface of an ulcer on the tongue. Magnified 250 diameters linear. tS^Pfi^S*, 74 EXAMINATION OF THE PATIENT. Milk. On examining a drop of milk* we observe a number of bodies rolling in a clear fluid. These bodies, in healthy milk, are perfectly spherical, with dark margins, smooth and abrupt on the field of the microscope, with a clear transparent centre, which strongly reflects light. In size they vary in different specimens from a point scarcely measurable, up to the"TS-Votu or 3oV»tn of an.inch in diameter. In excess of ether they are dissolved or "disappear; but if this re-agent be in small quantity, exosmosis takes place, and the field of the microscope is covered with loose globules of oil, of various forms. Water causes the milk globules to swell out but very slightly. Acetic acid coagulates the caseous fluid in which thev swim, and causes the globules to be aggregated together in masses. Several of the globules also exhibit, under the action of this re-agent, a certain flaccidity, and readily run into one another under pressure. These globules consist of a delicate envelope of casein, enclosing a drop of oil or butter. The membrane keeps them separate, so long as it is intact; but, dissolved by means of acetic acid, or ruptured by heat or mechanical violence (as in the churn), the butter is readily separated and collected. Cream is composed of the larger of these globules, which, owing to their low specific gravity, float on the surface of milk when allowed to repose. The richness of milk is determined by the quantity of these globules. An examination of cow's and human milk will at once show that the former contains a larger number than the latter. In all efforts, however, to determine the relative value of milk by microscopic examination, great care must be taken that the drop of fluid examined should be of the same bulk, that the same upper glass should be used in every case, aud that it should be applied and pressed down with the same force. It is very difficult at all times strictly to fulfil these conditions, for not only is great skill in manipulation required, but an intimate acquaintance with the appearance of milk as seen under the microscope, is necessary, before any confidence can be placed in this mode of testing the quality ••sfc'SSvflti c„° ° °s "« °f different specimens of the £i0M$*M$~°- sf°°^^P-4>4 flu^- At the same time, the £jtt^jv>'^;'^Si uifference m the amount of oily ^f&$£<§- i Jtix&'&**2ziS7 constituents between the milk £' ^BP^iPisil^Sj0 °^ tue cow' ass> an^ human 'i^l^ySMi/ ®^!Mfe&> female, may in this way be easily ?:§$2?S'?y •^W**®' determined. fv 2Q o ^n tne same manner the va- Fig. so. rious adulterations of milk are at once determined. Water, of course, separates the globules more and more from each other according to its amount. Flour will exhibit the * The mode of examining all fluids is the same, and is described p. 67. Fig. 29. Globules of cow's milk. _ Fig. 30. Colostrum of the human female, containing milk globules greatly varying in size, wit'i compound granular corpuscles. 250 diain. USE OF THE MICROSCOPE. 75 large starch corpuscles, which are changed blue by the action of iodine. Chalk shews numerous irregular mineral particles, which are soluble in the mineral acids; and broken-down brain will be distinguished by large oil globules, mingled with fragments of fine nerve-tubes. Milk, when acid, exhibits the same character that it does under the action of acetic acid. Healthy and fresh milk is indicatedby a certain uniformity in the size of the globules; by their perfectly globular form ; by their rolling freely over each other, and not collecting together in masses (Fig. 29). When the latter circumstance occurs, it is a sign of acidity. The milk first secreted after parturition is called the colostrum. It is yellow in colour, and may be seen under the microscope to contain glo- bules more variable in size, mingled with a greater or less number of granule cells (Fig. 30). These latter ought to disappear in the human female on the fifth or sixth day after parturition, but occasionally they remain, when the milk must be considered as unhealthy. In some cases I have seen them abundant so late as six weeks after the birth of the infant. On some occasions, milk maybe mixed with pus and blood, which are readily detected by the characters distinctive of each. Dr. Peddie has pointed out that milk can be squeezed from the mamma during the early months of pregnancy. Under such circumstances, it constitutes a most important sigu of the pregnant state, especially of a first pregnancy; for although the secretion at this time has seldom the external appear- ance of milk, but is serous-looking, and often very viscid and syrupy, still, if examined with the microscope, the characteristic milk globules will at once appear. See his valuable paper, " Monthly Journal of Medical Science," August, 1848. The Blood. On examining a drop of blood drawn from the extremity of the finger by pricking it, there will be seen a multitude of yellow round bi-concave discs, rolling in the field of the microscope, which soon exhibit a tendency to turn upon their edge, and arrange themselves in rolls, like rouleaux of coins. These rouleaux, by crossing one another, dispose themselves in a kind of net-work, between which may be seen a few colourless spherical corpuscles, hav- ing a molecular surface, and a few F's- si. Fig. 32. granules. The coloured blood corpuscles vary in size from the - u'oota Fig. 32. Blood-corpuscles, drawn from the extremity of the finger. On the left of the figure they are isolated, some flat and on edge, some having a dark and others a light centre, according to the focal point in which they are viewed. On the right of the figure several rolls have formed. Two colourless corpuscles and a few granules are also visible. Fig. 32. Blood-corpuscles altered in shape from exosmosi-. 2oi» diam. ®: m ^ # .; membrane, and occasionally projecting from it. rf^mp l?J°fi When seen edgeways they were flattened, and ^O^T.^r« existed in the proportion of one to seven of the i..^ • ^\ c^^K transverse diameter from the ^oVoth to the T5>ff7ta ® <^>® " of an inch. The addition of acetic acid caused Fi?- 35, them to swell out, dissolved their external wall, and liberated the granules. Aqua potassae rendered the whole structure paler, and a solution of muriate of soda rendered them more distinct, and of smaller size.* We have seen that, in a healthy condition, the blood possesses very few colourless corpuscles; but there is a certain state of that fluid I was the first to describe ip 1845, and have since called " Leucocythemia," or white-cell blood, in which they are very numerous, generally associ- ated with enlargement of the spleen or other lymphatic glands. The Fig. 36. Fig. 37. Vl^^fl^ if) ■■ ©; ■■'- ■ ■'•<& ■ v->" • * v. vL :._J : rx • ;to, ■. C: /■'•-. £•■ Q ^'"N in) Z!»)o *■' '-VAte^ {*. blood then presents the characters represented in the accompanying figures. (See also the section on diseases of the blood.) It has been affirmed that the colour and number of the corpuscles of the blood undergo a change in plethora, fever, jaundice, dropsies, cholera, etc., but exact observations are wanted to confirm the statement. I have never been able to satisfy myself that any such changes were observable in these diseases by means of the microscope. Iu chlorosis the number of the blood-globules is undoubtedly diminished; but this is determined by the size of the clot, rather than by microscopic demonstration. Occasionally the serum of the blood presents a lactescent appear- ance; and, on being allowed to remain at rest some hours, a white creamy pellicle forms on the surface. This consists of very minute * See Dr. Cowan's case—Monthly Journal of Medical Science. March, l$~A. Fig. 35. Appearance of blood once observed in a case of cholera. Fig. 3G. Appearance of a drop of blood, in Leucocythemia. Fig. :;7. The same, after the addition of acetic acid. Fipr. 38. The same after the blood has stood 2 i hours. 250 diam. 78 EXAMINATION CF THE PATIENT. particles of oil, which resemble the smaller molecules found in milk, aud in the chyle. Pes. Normal or good pus, when examined under a microscope, is found to consist of numerous corpuscles, floating in a clear fluid, the liquor fZ\ ^- pun's. The corpuscles are glo- ff ..■■^■K-^ZJ © bular iu form, having a smooth (®) (@> ) /'j©\ margin, and finely granular sur- •'-"0" /T5^" e^--'1 fv.ee. They vary in size from the ^-^#Q ?^o«th to the ^th of an inch ......^^^ (eJSPu'©^ i""' m diameter. In some of them pw V"-"'c*-—'S 9&; there may be generally observed a v—■' round or oval nucleus, which is Fig89' Fis'40- very distinct on the addition of water, when also the entire corpuscle becomes distended from endos- mosis, and its granular surface is more or less diminished. On the addition of strong acetic acid the cell-wall is dissolved, and the nuclei liberated in the form of two, three, four, or rarely five granules, each of which has a central shadowed spot. If, however, the re-agent be weak, the cell-wall is merely rendered transparent and diaphanous, through which the divided nucleus is very visible. Occasionally these bodies are seen surrounded by another fine mem- brane, as in Fig. 41. At other times they are not perfectly globular, .,-, __ but present a more or less ir- /^0£<£$f$!/^ii r&inM regular margin, and are associ- v,:,^2)/@F^V-.'--'''^^ <©$&£ -'/'^ ate(^ w**u numerous molecules GjS^'-fe^"^ anc^ granules. This occurs in what is called scrofulous pus, and various kinds of unhealthy dis- Fi„ 41 ^ Pi' 4^ charges from wounds and granu- lating surfaces. (Fig. 42.) In gangrenous and ichorous sores, we find a few of these irregular pus cor- puscles associated with a multitude of molecules and granules, aud with transformed and broken-down blood globules, the debris of the involved tissues, etc., etc. Sputum. A microscopic examination of the sputum demands a most extensive knowledge of both animal and vegetable structures. I have found in it,—1st, All the tissues which enter into the composition of the lung, such as filamentous tissue, young and old epithelial cells, blood-cor- puscles, etc. 2d, Mucus from the oesophagus, fauces, or mouth. 3d, Morbid growths, such as pus, pyoid, and granular cells; tubercle cor- puscles, granules, and amorphous molecular matter; pigmentary deposits of various forms, and parasitic vegetations, which are occasionally found Fig. 39. Pus corpuscles, as seen in healthy pus. Fig. 40. The same, after the addition of acetic acid. Fig. 41. Pus corpuscles, surrounded by a delicate eel I-wall. Fig. 42. Irregular shaped pus corpuscles, in scrofulous pus. 250 diam. USE OF THE MICROSCOPE. 79 on the living membrane of tubercular cavities. 4th, All the elements that enter into the composition of the food, whether animal or vegeta- ble, whicii become attached to the mouth or teeth, and which are often mingled with the sputum, such as pieces of bone or cartilage, muscular fasciculi, portions of esculent vegetables, as turnips, carrots, cabbages, etc.. or of grain, as barley, tapioca, sago, etc.; or of bread and cakes ; or of fruits, as grapes, apples, oranges, etc. All these substances render a microscopic examination of expectorated matters anything but easy to the student. To examine sputum, it should be thrown into water, when, on account oftheairit contains, it will generally float on the surface: while the more dense portions, such as masses of crude tubercle or cretaceous concretions, occasionally mingled with it, will fall to the bottom. It should be then teased, or broken up with a rod, when the various ele- ments and particles it contains will gradually disengage themselves, and may be separated from the mass without difficulty. Nothing is more common, on examining portions of sputum with a microscope, than to observe the various aggregations of molecular and granular matter here figured— Fig. 43. Fig. 44. Fig. 45. Fig. 46. Fig. 47. Occasionally little masses of a cheesy substance, and yellowish colour may be fouud entangled in the purulent mucus, or collected at the bot- tom of the vessel. These, when examined, present a number of irregular shaped bodies approaching a round, oval, or triangular form, varying in their longest diameter from the „\jtf to ^oV o of an incb- These bodies contain from one to seven granules, are unaffected by water, but are rendered very transparent by acetic acid. They are what have been called tubercle corpuscles. They are frequently mingled with a <^ multitude of molecules and granules, which are more numerous in proportion to the softness of the tubercle (Fig. 47). (See also description of the tubercular exu- dation.) Sometimes indurated or gritty little masses are brought up with the sputum, which are derived from the cretaceous or calcareous transformation of chronic tubercle in the lungs. They consist of irregular masses of phosphate of lime, combined with more or less ani- mal matter. On squeezing such as are friable between glasses, and examining their structure, they frequently may be seen to contain the elements represented in Fig. 48. Fig. 43. Mass, consisting of minute molecules, frequently seen in disintegrated tubercle ■ • Figs' 44 and 45. Musses composed of molecules and oily granules varying in size and mode of aggregation. ,,.»/.. Fig. 46. Mass partly composed of the debris of a fibrous structure. Fi° 47. Mass composed of tubercle corpuscles. Fig. 48. Fragments of phosphate of lime occasionally found in the sputum. -M di. Fig. 48. 80 EXAMINATION OF THE PATIENT. Sputum frequently presents the fibrillated appearance which is com- mon to all mucous discharges. It is caused by the deposition in viscid mucus of molecules, which assume a linear arrangement. This deposi- tion is increased by the addition of water and acetic acid, so that they consist of albumen. These fine molecular fibres (see Fig-. 55, 09, 72), must be distinguished from the areolar and elastic tissue of the lung, which is not unfrequently found in sputum, and which indicates ulcera- tion or sloughing of the pulmonary texture (Figs. 49, 50, 51). Schroeder van der Kolk has lately stated that these fragments may be found in the sputum before the physical signs of ulceration of the lung, as determined by auscultation, are well characterised. This fact I have confirmed, and believe it to be one of great diagnostic importance. Fig. 49. Fig. 50. Fig. 51. In acute pneumonia, the sputum frequently contains fibrinous casts of Fig. 52. Fig.'53. the minute bronchi, which present a branched mould of the- tubes. Fig. 49. Fragment of elastic tissue of the lung, in phthisical sputum. Fig. 50. Fragment of areolar and elastic tissue, still exhibiting the form of air cells, from phthisical sputum. Fig. 51. Another fragment.—(Van der Kolk.) Fig. 52. Fibrinous coagula in sputum, exhibiting moulds of the bronchi. Natural size.—(After Peacock.) Fig. 53. Fibres, with corpuscles, in a fibrinous coagulum from a bronchus. 250 diam. USE OF THE MICROSCOPE. 81 These casts (Fig. y2) may be readily separated in water, as previously described; and when examined with the microscope, are found to con- sist of molecular fibres, in which pyoid and pus corpuscles are infiltrated (Fig. 53.) The inspissated sputum, so commonly expectorated in the morning is derived from the fauces. It often presents a dirty green or brownish colour, passing into black. When examined with a microscope, it may be seen to consist of epithelial cells, more or less compressed together, and varying in size from the ^^th to the ^th of an inch in diameter! The smaller ones are round, aud closely resemble pus corpuscles; the larger ones are round or oval, with a distinct nucleus. In the dark- coloured portions of this sputum, the cells contain numerous granules aud molecules, several of which are black and quite opaque. This black matter consists of carbon, and .,.-.,..; .:vr^ is unaffected by re-agents. The addition of acetic acid causes coagulation of the mucus in which the cells are embedded ; aud whilst it produces little change iu the older cells, it dissolves, or renders transpa- rent, the walls of such as are Fig. 54. youug, displaying a rouud, oval, or divided nucleu (Fig. 55.) Iu the " black phthisis" of colliers the sputum is ink-black, and more or less teuacious. On examination with a microscope, the cells in it are Fig. 55. as seen in the figure- seen to be loaded with carbonaceous pigment. Several of these cells are perfectly opaque, whilst others are almost colourless; and between the two extremes there is every gradation as to intensity of blackness. This black pigment is unaffected by the strongest re-agents, nitro-muriatic acid, chlorine, and even the blow-pipe, failing to decompose it. It is, therefore, pure carbon, aud differs from the pigment contained in cells of similar appearance in melanotic tumours, as in these latter the re-agents just mentioned at once destroy the colour. (See Carbonaceous Luugs.) Fig. 57. Vomited Matters. The matters rendered by vomiting have not been made so frequent an object of microscopical observation as is necessary for the purposes of diagnosis. In organic diseases of the organ, nothing has beeu ascer- tained on this head. In other cases, it almost always happens, that the matters returned consist—1st, Of food aud drink, in various stages of Fig. 54 Epithelial cells, embedded in mucus, expectorated from the fauces. Some are seen to contain black pigment; others resemble pus corpuscles. Fig. 55. Another portion of expectorated mucus from the fauces, acted on by acetic acid, showing fibrillation and the changes in the young cells. Fig. 56 and 57. Cells loaded with pigment in the sputum of the collier. 250 diam. 6 82 EXAMINATION OF THE PATIENT. decomposition and disintegration; 2d, Of portions of the epithelial lining membrane of the stomach; oesophagus, or pharynx altered in its characters, and mingled with more or less mucus; 3d, Of certain new formations, which are produced iu the fluids of the stomach. 1 It would constitute a very interesting series of observations to determine, with the aid of the microscope the structural changes which various articles of food undergo during the process of dig estion ithe stomach This has not yet been done with accuracy, although there can be little doubt that compound tissues become disintegrated in the nverse order to that in which they are produced-that is to say fibres become separated, embedded cells become loose, and, when aggregrated together, their cohesion is destroyed. The cell-wal s then dissohthe nucleus till resisting the solvent process for some time; but at length the whole is resolved into a molecular and granular mass, which, in its turn becomes fluid. Such, however, are the differ- ent soluble properties of various edible substances, that, in a time sufficient for the perfect solution of some, others are scarcely affected. It may readily be conceived, that the transitions which these sub- stances undergo, may occasionally render their detection difficult; and such is really the case. Starch corpuscles, for instance, break down into rounded granules or molecules, and are very liable to puzzle an inexperienced observer. Tincture of iodine, from its peculiar reaction on these bodies, will always enable us to recognize them. ... , 2. The various epithelial cells which line the passages leading to the stomach, as well as the structures peculiar to that organ itself, may be found in the vomited matters -of course mingled with the debris ot c?W ''tfW8f*fc>;-iS6. : Fig. 59. edible substances. They also may have undergone various changes in appearance, from endosmosis, or even partial digestion. In cholera, the vomited matter consists principally of such altered epithelial cells or scales, many of which are derived from the fauces or oesophagus. 3. The new formations which may be produced in the stomach are principally vegetable fungi—such as various kinds of toruke (see Fig. Fig. 58. Appearance of starch corpuscles after partial digestion in.the stomach. Fig. 5!t. Flake in the rice water vomiting of a cholera patient, shewing, a, large epithelial cells; b, milk globules, and coagulated caseine ; c, torulos ; and d, half- digested epithelial scales, with liberated nuclei, more or less broken down. Fig. 60. Structures observed in certain rice-water vomitings from a cholera patient, shewing bodies which consist of the half-digested uredo in bread. 250 diam. USE OF THE MICROSCOPE. 83 59, c), and especially one first discovered in vomited matters by Mr. Goodsir, and which he has called Sarcina Ventriculi. It consists of square particles which apparently increase by fissiparous division in regular order, so that they present square bundles of four, sixteen, or some other multiple of four. Although at first supposed to be peculiar to the stomach, I have frequently found them in the foeces ; and in one case, in the urine. They have also been found by Virchow aud by myself, in the lung, and by Robin, inside the capsule of the crystalline lens. In addition to the bodies now alluded to, vomited matters may contain various morbid products, such as blood, pus, and cancer cells, colouring matter of the bile, etc. FcSCES. The same difficulty attends the examination 01 tne foeces as of the sputum; for there may be found in it,—1st, All the parts which com- pose the structure of the walls of the alimentary canal; 2d, All kinds of morbid products; and 3d, All the elements which enter into the com- position of food. The only difference is, that these last are generally more broken down or disintegrated. Under certain circumstances, the diagnostic value attached to the examination of the foeces, is greater than that of the sputum, or of vomited matters. For instance, when pus or blood globules are detected, we may infer that the more perfect these are, the nearer to the anus is their origin. Iu examples 4 and 6 (pp. GO, 61) I have shown how the detection of certain vegetable structures, used as food, was serviceable in diagnosis; but this subject merits more extensive attention than has hitherto been paid to it. Among the indigestible articles connected with the food, it was observed in the autuma of 1849, that curious-shaped bodies were detect- able, both in the vomited matters and stools of cholera patients. These were supposed to be parasitic formations connected with the cause of Fis. 62. Fig. 63. Fisr. 64. cholera, but were pointed out by Mr. Busk to be the uredo-segitum, occasionally found in bread. (Figs. 60 aud 62.) Fig. 61. Sarcina Ventriculi. Fig. 62. Portions of the uredo in bread, still further digested and disintegrated]than is observable in the vomited matters. (Fig. 60.) Some torulae are also present. Fig. 63 Structure of confervoid mass passed from the bowels. 250 diam. Fig. 61. The same, magnified 500 diameters linear, shewing their vegetable nature. 84 EXAMINATION OF THE PATIENT. 55^-'=^^gj In cholera the white stools consist of mucus, in Kig. 66. which the debris of epithelial cells is entangled; and as the nuclei of these cells resist disintegration for a long time, these round or oval bodies generally exist in considerable number (Fig. 60). Iu a disease very common in Edinburgh, especially in women, flakes of membranous matter are thrown off from the bowels in large quan- tities ; these present a very similar appearance to the cholera flakes just noticed. Fif. G5. a. Rounded masses of earthy matter, probably carbonate and phospate of lime. b. Crystal* of triple or ammoniaco-mainesian phosphate, e. Oval masses, probably fragments of a clot. In one to the left of the figure the outline of the blood corpuscles is more distinct than in most, and in a the individual corpuscles can be seen. e. Dark amorphous masses, probably derived from the fo >d. f. Ovum of an entozoon, probably an ascaris g. Small collection of blood globules.—(Beale.) Fig. 66. Structure of flakes in a rice-water stool, from a cholera patient. 250 diam. USE OF THE MICROSCOPE. 85 Uterine and Vaginal Discharges. The diagnostic indications to be derived from the microscopic ex- amination of these discharges, have not been much investigated; but there are few subjects whicii hold out the promise of more useful results to the medical practitioner. It can only be prosecuted by the obstetric histologist, who, on collecting the secretions poured out from the os uteri, or on the vaginal walls, by means of the speculum, should observe their structural peculiarities when quite fresh.* The menstrual discharge will be found to consist of young epithelial cells, old epithelial scales, and blood globules, the number of which Fig 67. Fig. 63. Fig 69. last will be greater or less according to the intensity of the colour. A leucorrhceal discharge always consists of old epithelial scales, which may be more or less loaded with fat, combined with numerous young epithe- lial cells (round or oval), and pus corpuscles. (Fig. 67.) The white gelatinous discharge, so frequently seen with the speculum to be derived from the os uteri, consists of gelatinous mucus, in whicii round or oval young epithelial cells are mingled. The mucus is copi- ously deposited in a molecular form,' on the addition of acetic acid or water, whilst the walls of the cells are rendered transparent, aud au oval granular nucleus made visible. (Figs. 68 and 69.) Not unfrequently leucorrhceal and other discharges contain groups of blood globules, the shapes of which are almost always more or less alter- ed by exosmosis, on account of the viscid fluid mingling with them (see Fig. 67). Indeed, the variations observable in these discharges are de- pendent for the most part on the excess of one or other of the elements just mentioned—namely epithelial cells or scales, pus or blood corpuscles, and gelatinous mucus. In dysmenorrhcea considerable patches of the *■ On this point Dr. Tyler Smith's work on Leucorrhoea may be consulted with ad- vantage. Fig. 07. Corpuscles seen in a chronic leucorrhoeal discharge, consisting of,—1st, Large epithelial scales, from the vagina and cervix uteri. On the lelt of the figure some of these may be observed to have undergone the fatty degeueration. 'Id, Nu- merous pus corpuscles ; and 3d, Blood globules, the external edges of which are more or les- dentated from exosmosis. Fig. (i8. Structure of gelatinous mucus from the os uteri. Fig. 69. The same, after the addition of acetic acid. 250 diam. t 86 EXAMINATION OF THE PATIENT. epithelial membrane desquamate, and even entire casts of the uterus or vagina have been separated. In addition to the fluid discharges poured out from the uterus and vagina, there are a variety of morbid growths connected with these organs', the diagnosis of which may be materially facilitated by micro- scopic examination. The separation of fibrous, epithelial, and cancerous tumours and ulcers belongs to this category, and must be conducted on the principles referable to the diagnosis of morbid growths in general. 1 have had abundant opportunities of satisfying myself of the importance of this mode of proceeding, in cases where the substance, mucous sur- face, or cervix of the uterus has been more or less involved. Mucus. Iu all fluids secreted from a mucous membrane, many of which have been noticed, there may be found a gelatinous material, which has long been called mucus. It may vary in colour from a milk-white to a yel- lowish brown or even black tint, these variations being dependent on the cell structures or pigment it contains. By some it has been supposed that there are certain cell formations peculiar to mucus, which have been called "mucus corpuscles;" but it has always appeared to me that the various bodies found in this secretion are either different forms of epithelium, on the one hand, or pus cells on the other. Thus the round epithelial cells found in mucous crypts, or the bodies constituting per- manent epithelium, when newly formed, before they have had time to flatten out, and become perhaps more or less affected by endosmosis, are represented, Figs. 54 and 68. These are the mucous corpuscles of some writers. Again, when exudation is poured out on a mucous surface, and is mingled in greater or less quantity with the gelatinous secretion, it presents a marked tendency to be transformed into pus corpuscles, and hence why all irritations of mucous surfaces are usually accompanied by purulent discharges. The pus corpuscles, under such circumstances, present all the characters formerly noticed as peculiar to these bodies (see Figs. 39 and 67). Hence, properly speaking, there is no such body as a mucus corpuscle, Figs. 70 and 71. Two specimens of cancerous juice squeezed from the uterus. 250 diam. USE OF THE MICROSCOPE. 87 the cells found in mucus being either epithelial or pus cells, the number of which present communicates certain peculiarities to the discharge. Thus, as we have seen, the white gelatinous mucus discharged from the os uteri contains the former, whilst the peculiar fluid characteristic of a gonorrhoea or catarrh, in either sex, abounds in the latter. The gelatinous substance, how- ever, in which these bodies are found (Mucin), is what is peculiar to the fluid secreted from mucous surfaces, containing, as it does, a large amount of albumen possessing a remarkable tendency to co- agulate in the form of molecular fibres. (Fig. 72.) When recent, these are few in number, but on the addition of water or acetic acid they are precipitated in such numbers as to entangle the cell formations, and present a semi-opaque membranous structure (Figs. 55 and 69). The more healthy a mucous secretion, the more it abounds in this viscous albuminous matter, and the fewer are its cell elements. On the other hand, when altered by disease, the cell elements increase, and the viscosity diminishes. Fig. 72. Dropsical Fluids. ^fe / W The fluids obtained by puncture of dropsical swellings, may in some cases, when examined microscopically, present peculiarities worthy of notice. Thus, in the serum collected within the tunica vaginalis testis, numerous spermatozoa may be found, constituting what has been called spermatocele. How these bodies find their way iuto this fluid is unknown, as no direct communication with the substance of the testicle has ever been seen; neither does their occur- rence seem to interfere in any way with the successful treatment of this kind of dropsy, by injections, as prac- Fig. 73. tised in hydrocele. In the fluid of ascites, when removed from the body, there may usually be observed a few epithelial scales from the serous layer of the abdomen, which are more abundant in some cases than in others. Occasionally blood and pus corpuscles may be detected in greater or less quantity. In ovarian dropsy, various products may be found in the evacuated fluid, according to the nature of the contents of the cyst. Pus and blood corpuscles are common elements, but more commonly.epithelial cells and scales, which occasionally accumulate in the cysts of ovarian tumours. (Fig. 74.) At other times, masses of gelatinous or colloid matter are Fig. 72. Viscid greyish yellow sputa of pneumonia, treated with dilute acetic acid, containing fibrinous mu.-in, pus corpuscles, and epithelial cells containing fatty and pigment granules.—(After Wedl.) 300 diam. Fig. 73. Spermatozoa as observed in the fluid of Spermatocele. 250 diam. 88 EXAMINATION OF THE PATIENT. evacuated, which present various appearances, according to the time that has elapsed since its formation (see Lol- •,<•• V'^l^.j^Vv loid Cancer and Ovarian Dropsy). i/^^^^%.^)- In the examination of dropsical fluids also, ••^£0^^H&* there can be little doubt that further research '/r^ifyl'A °°<°]'' will lead to very important results in diagnosis. •^ |,. Ukine. •\..... • ,l~^ Healthy human urine examined with the Fig. 74. microscope, when recently passed, is absolutely structureless. Allowed to repose for twelve hours, there is no precipi- tate ; occasionally a slight cloudy deposition may be observed in which may be discovered a few epithelial scales from the bladder, a slight sedi- ment of granular urate of ammonia, or a few crystals of triple phosphate. In certain derangements of the constitution, however, various substances are found in the'urine, which, in a diagnostic point of view, are highly important, and which we shall shortly notice in succession. To examine the deposits found in urine, this fluid should be poured, in the first instance, aud left to stand for a time, in a tall glass jar; the clear liquid should then be decanted, and the lower turbid portion put into a tall test tube, and the deposit again allowed to form. In this manner the structural elements are accumulated in the smallest possible compass, so that a large number of them are brought into the field of the microscope at once. The quantity of any salt or deposit in the urine can never be ascertained by the microscope. But in the great majority Fig. 75. Fig. 76. of cases, the appearances observed with that instrument, are sufficient in themselves to distinguish the nature of the various kinds of sediment met with, and these consequently are all that need be described in this place. Uric Acid.—Uric acid crystals are almost always coloured, the tint varying from a light fawn to a deep orange red. The general colour is yellow. They present a great variety of forms, the most common being rhomboidal. The lozenge-shaped and square crystals, which are more rarely met with, isolated and in groups, are represented, Fig. 75. Not unfrequently they present adhering masses or flat scales with transverse or longitudinal markings, as seen, Fig. 76. Occasionally they assume Fig. 74. Cells in fluid removed from an ovarian dropsy. Fig. 75. Lozenge-shaped and rhomboidal crystals of uric acid. Fig. 76. Aggregated and flat striated crystals of uric acid. 250 diam. USE OF THE MICROSCOPE. 89 the form of truncated rounded columns, as represented, with other struc- tures. Fig. si. Urate of Ammonia most commonly assumes a molecular and granular form, occurring in irregularly aggregated amorphous masses. (Fig. 78.) This may be separated from a similar-looking deposit of phosphate of lime by the action of dilute muriatic acid, which immediately dissolves the last-named salt, but acts slowly on urate of ammonia, setting free the uric acid. Some- times, however, it occurs in spherical bodies of a bistre brown colour, varying in size from the ^Votl1 t° the ^o'oo^ °f an mcn m diame- ter. The latter size rarely occurs. Occasion- ally they assume a stellate form, needle-like or spicular prolongations coming off from the spherical body. I have seen both these forms associated, and the former so curiously aggregated together as to assume the appearance of an organic membrane, for which by some observers it was mistaken, until it was found to dissolve under the action of dilute nitric acid. (Fig. 77.) Triple Phosphate or Ammonio-Phosphate of Magnesia—These crystals are very commonly met with in urine, and are generally well defined, presenting the form of triangular prisms, sometimes trun- cated, at others having terminal facets. (Fig. 7S.) If an excess of ammonia exists, or be added artificially, they present a star-like or foliaceous appearance, which, however, is sel- dom seen at the bed-side. Most of the forms of urate of ammonia are represented, Figs. 77 and 78, in the latter Fig 7S. they are associated with the triple phosphate. Oxalate of Lime most commonly appears in the form of octahedra, varying in size, the smaller aggregated together in masses. Once seen, tliese bodies are readily recognised (Fig. 79). Very rarely they present the form of dumb-bells, or of an oval body, the central transparent por- tion of which presents a dumb-bell shape, while the 4^ shadowed dark portion ^ 0 fills up the concavities. Cystine takes the form of flat hexagonal plates, presenting on their surface marks of similar irregular crystals (Fig. 80). Occa- sionally their centre is opaque, having radiations more or passing towards the circumference. Fig. 77. Urate of ammonia, in a granular membranous form, and in rounded rnas-es. with spicula. Fig. 78. Triple phosphate, with various forms of urate of ammonia. Fig. 79. Octahedral and dumb-bell shaped crystals of oxalate of lime. Fig. tO. Flat and rosette-like crystals of cystine. - diam. 90 EXAMINATION OF THE PATIENT. In addition to the various salts found in the urine, there may occasion- ally be found different or- fflfl ^■■.'■r.y- • ® tf/Qr-^ £°Y CCO £anic products, such as blood . iX^.Vte) oZy' dfyf^. and pus corpuscles, sper- af^i] , 8 y''-^j^)§L matozoa, vegetable fungi, "^ , exudation casts of the tubes, —*J or epithelial scales from the JP^ ' l*% "*' * ^a^er or mucous passages. P ^f i @ Frequently one or more of these are found together, as in the annexed figure. Very rarely casts of the tubes, principally composed of oily granules, may be seen, or epithelial cells, more or less loaded with similar granules, several of which also float loose in the urine, as in the accompanying figure :— Although these casts of the tubes were at one time confounded together, they may now be separated into at least four distinct kinds, namely,—1st, Fibrinous or exudative ; 2d, Desquamative; 3d, Fatty; and 4th, Waxy casts. The inferences to be derived from the presence of one or more of these will be espe- cially dwelt on in the section which treats of urinary diseases. Fisr. 82. &. At other times the cells are enlarged, flattened out, and more or less loaded with fat mole- cules and granules, or compressed concentrically round a centre, form- ing what have been called nest-cells. These growths, though generally denominated cancer, are at once distinguished by a microscopic examina- tion. The so-called chimney-sweep's cancer of the scrotum is essentially a similar formation (See Epithelioma). The cancerous ulcer of the skin is often difficult to distinguish micro- scopically from the epithelial ulcer, because the external layer, like it, is often composed of softened epidermis. When, however, a drop of can- cerous juice can be squeezed from the surface, it is fouud to contain groups of cancer cells, which, from their general appearance, may for the most part be easily distinguished. Considerable experience, however, Fig. 91. Epidermic cells from the edge of a softened epithelioma. Fig. 9:2. Other cells from the centre of the softened portion. Fig. 93. Appearance of section of cancerous ulcer of the skin,—a. Epidermic scales and fusiform corpuscles on the external surface, b, Group of epidermic scales. e. Fibrous tissue of the dermis, d, Cancer cello infiltrated into the fibrous tissue, and filling up the loculi of the dermis. -30 diam. 94 EXAMINATION OF THE PATIENT. in the knowledge, and skill in the demonstration, of cancerous and can- croid growths, are necessary in order to pronounce confidently on this point, and to this end an acquaintance with the whole subject of the histology of morbid growths is essential * USE OF CHEMICAL TESTS. The chemical examination of urine, blood, milk, and other animal fluids, as well as the detection of poison in vomited matters, or other organic mixtures and tissues, constitutes an extensive field of inquiry,— for a description of which, I must refer to works on chemistry and medical jurisprudence. At the bed-side much of this kind of investiga- tion is now superseded by the use of the microscope, which at a glance enables us to detect the poverty and adulterations of milk, the spissi- tude and altered condition of blood, the natures of various salts and pre- cipitates in urine, etc. The action of chemical re-agents on the cor- puscles, made visible by this instrument, has already been alluded to. Chemical tests are most valuable at the bed-side to determine the pres- ence of albumen, bile, sugar, or chlorides in the urine, to which points alone I shall in this place direct your attention. Before proceeding to test the urine for particular substances, notice should be taken of its general properties; such as its colour, odour, density, and re-action. The naked-eye characters of the cloud or pre- cipitate which appears in almost every kind of urine, when allowed to remain at rest for some time after emission, should also be observed, and its morphological constitueuts determined by means of the microscope. The observation of one or more such properties may lead at once to the establishment of a correct diagnosis, and will certainly direct the path we should take in the subsequent chemical investigation of the fluid. The Specific Gravity of the Urine is at once obtained by means of a urinometer, and should always be noted at the commencement of the examination of this fluid, as it furnishes important indications for further proceedings. Thus the specific gravity is generally diminished in chronic cases of Bright's disease, and increased in cases of Diabetes. To detect Albumen in the Urine.—Boil a portion of urine in a test tube over the flame of a spirit lamp, and observe the result. If the urine, which has in the preliminary examination proved to be acid, be- come hazy or coagulate, the presence of albumen is certain; but if it be neutral or alkaline in its reaction, the cloudiness may be occasioned by the deposition of earthy phosphates. One drop of nitric acid should therefore, in the latter instance, be added, which will immediately clear up the opacity of the fluid if due to phosphates, but serve to increase its turbidity if depending solely on coagulated albumen. To detect Bile in the Urine.—The test for bile pigment is nitric acid, whicii changes the fluid containing it in any quantity, first into a grass green, and then, if the test be added in excess, into a ruby-red or reddish brown tint. If the urine be very much loaded with bile, as sometimes * See the author's Treatise on Cancerous and Cancroid Growths. Edin. 1849. USE OF CHEMICAL TESTS. 95 happens in cases of jaundice, so that it resembles porter in appearance,' it is better to dilute it with water before adding the acid. If the test be applied to the urine, placed in a clean white plate, so as to form a thin layer over the surface, the play of colours may often be distinctly seen assuming green, violet, pink, and yellow hues. The same succession of tints may be induced by nitric acid acting upon urine containing an excess of indican (Schunck), in consequence of this substance being resolved into blue and red indigo, which are subsequently destroyed by the continued action of the acid. There is, however, little chance of fallacy arising from this source, as a marked excess of indican has hitherto only been observed in two cases (Carter), and never in connexion with urine presenting a bilious appearance. P ettenkofer1 s test.—Pettenkofer's test for bilin, or. rather, for the choleic acid of the bile, is applied in the following manner. A few drops of simple syrup are mixed with a small quantity of urine contained in a test-tube, or still better, in a porcelain capsule; concentrated sulphuric acid is then gradually added in con- siderable quantity. If choleic acid be present, the mixture will exhibit a most intense and beautiful purple colour. The vessel employed should be placed in cold water before the acid is added, in order to prevent the sugar being decomposed into certain brown compounds, which would tend to obscure the development of the reaction which has been described. True bile is seldom found in urine, even when large quanti- ties of the colouring matters exist. To detect Sugar in the Urine.—The three best tests for sugar in urine are those known as Moore's test, Trommer's test, and the Fermen- tation test. Moore's test consists in boiling urine for five minutes in a tube, with half its bulk of liquor potassae. If sugar be present, the liquid assumes a brownish bistre colour. Trommer's test consists in adding a few drops of a solution of sulphate of copper, so as to give the urine a pale blue colour; liquor potass* is then added until the hydrated oxide of copper thrown down is again dissolved, which will happen if the urine be saccharine. The clear deep blue solution which is formed must now be boiled ; when, if sugar be present in very minute quantity, it will be indicated by the mixture assuming a yellowish-red opalescent tint; but if in large amount, by its becoming perfectly opaque from the formation and precipitation of the yellow sub-oxide of copper. If the urine contain no sugar, a dark-green precipitate only is formed on ebul- lition. Fermentation test.—-A few drops of yeast should be added to urine and a test tube completely filled with the mixture inverted and allowed to remain in a saucer, containing a little more of the urine. The whole should theu be put in a warm place, of about 70 or 80 de- grees, for 24 hours. Fermentation ensues, and carbonic acid is formed, which collects at the top of the tube, displacing the fluid. This test is now but seldom employed, being tedious of application, and not giving such accurate results as was at one time supposed. The following solution is very useful when many observations are to be made for the detection of grape sugar in the urine. Take of bitar- trate of potash and crystallized carbonate of soda, of each 150 parts, of caustic potash 80 parts, of sulphate of copper 50 parts, and of water 1000 parts; dissolve the carbonate of soda and potash in part of the water boiling, then add the sulphate of copper powdered. When all 96 EXAMINATION OF THE PATIENT. the bitartrate is dissolved, add the rest of the water, and filter. A few drops of this solution added to a little urine in a test tube will, under the action of heat, throw down a dirty green or yellow precipitate of sub-oxide of copper, if sugar be present. To detect Chlorides in the Urine.—Add to urine in a test tube, about a sixth part of its bulk, of strong nitric acid, and then a few drops of a solution of nitrate of silver. If any soluble chloride be present, the chlorine will be thrown down in combination with the silver as a white precipitate; but if none exist, the fluid will remain clear. From the degree of turbidity or haziness occasioned by the addition of the silver solution, a rough estimate may be made of the amount of chlorides con- tained in the urine. In concluding this subject, allow me to impress upon you the great importance jof making yourselves acquainted with all the modes of ex- amination I have brought before you, rather than one or more of them. It too frequently happens that exclusive attention to a particular method of exploration, has rendered some medical men good observers of symp- toms, whilst they are unacquainted with physical diagnosis ; and again, among those who have cultivated the latter, there are some who can percuss and use the stethoscope with skill, who are ignorant of the use of the microscope. Now you should regard all instruments only as a means to an end. In themselves they are nothing, and can no more confer the power of observing, reflecting, or of advancing knowledge, than a cutting instrument can give the judgment and skill necessary for performing a great operation. We should learn to distinguish between the mechanical means necessary for arriving at truths, and those powers of observation aud mental processes which enable us to recognise, com- pare, and arrange the truths themselves. In short, rather endeavour to observe carefully and reason correctly on the facts presented to you, than waste your time in altering the fashion aud improving the physical properties of the means by which facts are ascertained. At the same time, these means are absolutely necessary in order to arrive at the facts on which all correct reasoning is based; and perhaps uo kind of know- ledge has been so much advanced in modern times by the introduction of instruments, and by physical means of investigation, as that of medi- cine. These enable the practitioner to extend the limits to which other- wise his senses would be confined. Chest measurers, pleximeters, ste- thoscopes, microscopes, specula, probes, etc. etc., are all useful, aud in particular cases indispensable. 1 do not say employ one to the exclu- sion of the other, but be equally dexterous in the use of each. Do not endeavour to gain a reputation as a microscopist, as a stethoscopist, or as a chemist; but by the appropriate application of every instrument and means of research, seek to arrive at the most exact diagnosis and knowledge of disease, so as to earn for yourselves the title of enlightened medical practitioners. Above all, do not be led away by the° notion that any kind of reasoning or theory will enable you to dispense with the careful observation of facts. What is called tact and skill is not a peculiar intuition, or a superior power of intelligence possessed by cer- tain persons, but is always the result of constant aud laborious examina- tion of symptoms and signs iu the living, combined with careful research into the nature of morbid changes discovered in the dead. SECTION II. PRINCIPLES OF MEDICINE. Every animated being has a limited period of existence, during which it is constantly undergoing a change. So long, however, as this change takes place uniformily in the different parts of which it is composed, its physiological or healthy condition is preserved. But immediately the action of one organ becomes excessive or weak in proportion to the other, disease, or a pathological state, is occasioned. This state may be induced by direct mechanical violence, but may also occur from the continued or irregular influence of several physical agents upon the body, such as temperature, moisture or dryness, certain qualities of the atmosphere, kinds of food, etc. etc. These are always acting upon the vital powers of the individual as a whole, as well as incessantly stimu- lating the various organs to perform their functions. Life, then, may be defined in the words of Beclard—" organization in action." Health is the regular or normal, and disease the disturbed or abnormal condi- tion of that action. While such may be assumed to be our notion of disease in the ab- stract, what constitutes disease in particular has been much disputed. From the time of Hippocrates to that of Cullen and his followers, the ex- ternal manifestation or symptoms constituted the only means of recognis- ing diseased action, and gradually came to be regarded as the disease it- self. Then these symptoms were arranged into groups, divided, subdivid- ed, and named, according to the predominance of one or more of them, or the mode in which they presented themselves. These artificial arrange- ments are the nosologies of former writers. All philosophical phy- sicians, however, have recognised that the true end of medical inquiry is, if possible, to determine rather the altered condition of the organs which produces the disordered function, than to be contented with the study of the effects it occasions. But the difficulty of this inquiry has been so great, and a knowledge of the means of prosecuting it so limited, that it is only within the last thirty years that medicine has been enabled to build up for herself anything like a solid scientific foundation. What has hitherto been accomplished in this way has been brought about by 7 98 PRINCIPLES OF MEDICINE. the conjoined cultivation of morbid anatomy, pathology, and clinical ob- servation, greatly assisted, however, by the advance of numerous col- lateral branches of science, and especially in recent times by chemical and histological investieation. The result has been a complete over- throw of nosological systems. We now attempt to trace all maladies to their organic cause ; and just in proportion as this has been successfully accomplished has medicine become less empirical and more exact. The organic changes, however, which produce or accompany many diseases have not yet been discovered, and consequently a classification of all maladies on this basis cannot be strictly carried out. The organic cause of epilepsy, hydrophobia, and of many fevers, for example, is as yet unknown. In the present state of medicine, therefore, when the morbid change in an organ is unequivocally the origin of the symptoms, we employ the name of the lesion to designate the disease ; but when there is disturbance of function, without any obvious lesion of a part, we still make use of the principal derangement to characterise the malady. Thus as regards the stomach we say a cancer or an ulcer of that viscus. and thereby express all the phenomena occasioned. But if we are una- ble to detect such cancer or ulcer, we denominate the affection after its leading symptom, dyspepsia, or difficulty of digestion. In endeavouring to carry out this distinction, however, modern phy- sicians have fallen into a great error, insamuch as they have continued to employ the nomenclature of our forefathers, and use the words simply expressive of the presence of symptoms to indicate the altered condition of organs which are the cause of those symptoms. Formerly the term inflammation meant the existence of pain, heat, redness, and swelling; it now represents to us certain changes in the nervous, vascular, and parenchymatous tissues of a part. Formerly, apoplexy meant sudden unconsciousness originating in the brain , now, it is frequently used to express haemorrhage into an organ, and hence the terms apoplexy of the lung and of the spinal cord. The two ideas are essentially distinct, and bear no reference to each other, because the same word may be, and often is, employed under circumstances where its original meaning is altogether inapplicable. Hence it is incumbent on every one who ap- plies to organic changes terms which have been long employed in medicine, to define exactly what he means by them. In this way old indefinite expressions, though still retained, will have a more precise meaning attached to them If, for instance, it be asserted that bleeding cuts short inflammation, let it be explained what is cut short—whether the symptoms, the physical signs, a congestion of the vessels, or an exu- dation of the liquor sanguinis. • But notwithstanding the confusion in our nosological systems, and the frequent change of ideas with regard to the nature of morbid actions, which have necessarily resulted from the rapid advance of medicine in late years, it still follows that disease is only an alteration in the healthy functions of organs. Hence all scientific classification of maladies must be founded on physiology, which teaches us the laws that regulate those functions. Therefore I venture to divide all diseases, in the first place, into two great classes, viz.—1, Diseases of nutrition ; and 2, Diseases of innervation. HEALTHY AND DISEASED NUTRITION. 99 ON THE GENERAL LAWS OF NUTRITION AND OF INNERVATION IN HEALTH AND DISEASE. There have not been wanting some pathologists who have ascribed the origin of all diseases to an altered condition of nutrition and of the blood, whilst others have regarded even this function as subservient to that of innervation. In man, it is true, we find them inextricably united, and it becomes exceedingly difficult at all times to separate with exacti- tude what are the purely nutritive, and what the purely nervous pheno- mena. But a consideration of animated nature at large must satisfy us, that in the vegetable world, as well as in some forms of animal life, nutri- tion may proceed independently of a nervous system. We also feel satisfied that in theory as well as in fact, the function of nutrition is capa- ble of being separated from that of innervation. Doubtless there is no lesion whatever which does not in the higher class of animals involve both nutritive aud nervous changes, but the only method of arriving at a knowledge of their conjoint action, of their mutual influence, or the manner in which sometimes one predominates over or mingles with the other, is by studying in the first instance the laws by which each seems to be governed. Function of Nutrition. The various modes iu which nutrition becomes impaired, and the blood diseased, can only be understood by passing in review the different steps of the nutritive process. We have already pointed out how patho- logy and practical medicine must be based upon anatomy and physiology, and there is no one subject perhaps which is so well capable of illustrat- ing this proposition as the one we are about to consider. For. ages medical men have been in the habit of considering the blood to be the primary source of numerous maladies. It will be our endeavour to shew, by an analysis of the process of nutrition, that the changes of the blood, and the diseases which accompany them, are for the most part not pri- mary, but secondary—that is to say, they are dependent on previously existing circumstances, to the removal of which the medical practitioner must look for the means of curing his patient. For the sake of convenience of description and reference, we shall di- vide the process of nutrition in man into five stages. 1. The introduction into the stomach and intestinal canal of appropriate alimentary matters. 2. The formation from these of a nutritive fluid, the blood, and the changes it undergoes in the lungs. 3. Passage of fluid from the blood to be transformed into the tissues. 4. The disappearance of the trans- formed tissues and their re-absorption into the blood. 5. The excretion of these effete matters from the body, in various forms and by different channels. These different stages comprehend not only growth, but the processes of assimilation, absorption, secretion, and excretion; and we believe that it is only by understanding the function in this enlarged sense that we 100 PRINCIPLES OF MEDICINE. can obtain a correct explanation of those important affections, which may appropriately be called diseases of nutrition. We shall first, however, consider each of these stages separately. 1. The introduction into the stomach and intestinal canal of appropri- ate alimentary matters.—Alimentary matters have been divided into several groups. The chemist has divided them into azotized and non- azotized substances. The most important azotized principles are fibrin, albumen, and caseine; the most important non-azotized are fat, starch, gum, and sugar. Both animal and vegetable aliments are capable of yielding similar proximate principles, although in different proportions. Those which are most subservient to nutrition are albumen and oil. Dr. Ascherson of Berlin was the first to point out the effects produced by a union of these, and their importance in the formation of every organized tissue. When we regard the proportions in which these principles enter into our food, their presence in milk (the nutural food of young animals), their universality in every blastema and organized tissue, and the nume- rous experiments which prove that they are capable, when united, although not alone, of furnishing the conditions necessary for the support of living animals, we are at once led to the conviction that albumen and oil are the chief alimentary matters destined for nutrition. W hilst albumen and oil may be considered as types of the chemical division of nutritive substances into nitrogenized and non-nitrogenized, they prove that other conditions than chemical ones are necessary for nutrition. AVhen mingled together they produce an emulsion, identical in structure with milk, that is, containing numerous globules composed of a minute drop of oil, enclosed in an albuminous membrane. The func- tion of the stomach and intestines consists in separating or converting from the contents submitted to them, albuminous and fatty matters in a fluid state, which, being absorbed, constitute that emulsion observed within the extremities of the villi when they are called into activity, as well as the fatty basis of the chyle. But fluid fat and albumen, together with the various kinds of drink, also hold in solution a third class of alimentary matters no less essential to nutrition—viz., mineral substances, such as phosphorus, sulphur, iron, potassium, sodium, calcium, and magnesium. These in different states of combination form a necessary constituent of every tissue and fluid, and some textures, as bone and teeth, are principally composed of them. It is from the albuminous, fatty, and mineral groups of alimentary principles that all the various tissues and organs are formed. The three enter into the composition of every texture and every fluid, but are dif- ferently proportioned in each. The fibrous tissues abound in the albu- minous, the adipose tissue in the fatty, and the osseous in the mineral principle. The excess or diminution of these three substances not only stamps certain features on the whole economy, but the morbid lesions of individual organs and textures are intimately connected with fibrous, fatty, and mineral formations. It is unnecessary to dwell at any length upon the fact that of all the causes of disease, irregularity of diet is the most common. Neither need I do more than merely allude to the equally well-known circumstance, that of all the means of cure at our disposal, attention to the quantity HEALTHY AND DISEASED NUTRITION. 101 and quality of the ingesta is by far the most powerful. The peculiar kind of interference with the aliment, which various diseases require, will be illustrated as we proceed further. 2. The formation from alimentary matters of a nutritive fluid—the blood, and the changes it undergoes in the kings.—The exact process by which blood is formed from alimentary matters has now been accurately traced by physiologists. During mastication, the food is mingled with the saliva, an alkaline viscous fluid. In the stomach it is subjected to constant trituration and to the action of the gastric juice—an acid fluid, supposed to operate especially on the albuminous constituents of the food. On passing through the pylorus the whole is reduced to a pulpy matter called chyme. In the duodenum the chyme becomes mixed with bile, which produces important changes in it, but the nature of these, and the true uses of the bile are subjects which have not yet been positively determined. The fatty constituents of the food are, by the conjoint action of heat, trituration with fluid albumen, and the influ- ence of the Brunnerian, pancreatic, and other glands, whicii pour out an- other alkaline fluid, reduced to an exceedingly fine state of division. The chyme thus operated upon is now gently propelled along the intestinal canal, by vermicular contractions, and its more fluid parts pass through the villi into the lacteals. The matter so absorbed forms chyle, which, being brought into contact with the cells elaborated by a series of lym- phatic or blood glands, is transformed into corpuscles floating in a fluid. When at length the chyle enters the torrent of the circulation, the cor- puscles are at once carried to the lungs, and become coloured in conse- quence of the action of the oxygen to which they are there exposed, and the fluid presents all the characters of blood. The blood must be examined structurally and chemically. In struc- ture it consists of numerous yellow corpuscles, a small number of colour- less corpuscles, and a few granules, floating in a yellowish fluid, the liquor sanguinis. The liquor sanguinis consists of fibrin dissolved in serum, which has the property, when drawn from the body, or under certain other circumstances, of coagulating. The facts connected with this sub- ject it is unnecessary to describe minutely here. It is exceedingly difficult to ascertain the exact chemical composition of healthy blood, but from the analyses which have been made, we may for practical purposes consider its various constituents to be present in 1000 parts in the following proportions : Water varies from 760 to 800 parts ; Fibrin from 1 to 3 parts; Albumen from 60 to 70 parts; Cor- puscles from 130 to 150 parts; Extractive matters and fat from 1 to 4 parts ; Salts from 5 to 10 parts. We know from the results of numerous analyses, that the relative proportions of these constituents are greatly changed in various diseases. What we are desirous of alluding to now, however, is the well-known fact that one of the most common causes of derangement in the blood is the different kinds of food. M. Denis mentions that in the blood of a young girl of good health the globules were represented by the pro- portion of 132. After 15 days of rigorous diet they were represented by 85. The other constituents, but more especially the water, albumen, fat, and salts, are modified to a like extent by changes in the diet. 102 PRINCIPLES OF MEDICINE. The alterations which the blood undergoes in the lungs are the recep- tion of a large amount of oxygen, which is thus conveyed through the arteries to all parts of the economy, and the giving off a quantity of carbonic acid gas, wdiich is brought to the lungs by the venous blood through the pulmonary artery. Hence the importance not only of dietetic regulations to furnis'li the material of the blood, but of a con- stant supply of fresh air to purify it and render it fit for the performance of its functions. The constant relation which exists between diet and the quantity and quality of the air breathed, is observable in the condi- tion of people inhabiting different parts of the world. 3. The passage of fluid from the blood to be transformed into the tissues. —From the blood a fluid blastema is continually passing through the capillaries for the formation and sustentation of the different tissues of the economy. It is necessary that this should take place to an amount proportionate to the matter supplied to the blood by assimilation on the one hand, and that dissipated by waste on the other. If more or less be given off. a morbid condition is occasioned. Thus, an increased amount in a part gives rise to hypertrophies, a diminished amount pro- duces atrophy. This important function is now considered to depend upon an inherent vital property peculiar to the tissues themselves, which exercise a force at the same time attractive and selective. By its agency each tissue and gland attracts from the blood that amount of matter which is neces- sary to maintain its bulk, and at the same time selects from it the pecu- liar substance necessary for itself, or for the secretion it is destined to produce Hence the liver keeps up its own nutrition, and at the same time selects the materials from the blood which serve to form bile. The kidney also is nourished, and forms urea; and so in like manner is it with all the glandular organs. In this way the matter drawn off from the blood is made subservient in numerous ways to the wants of the economy, here furnishing substance for growth or for replacing waste, and there giving material to supply the various secretions. It often happens that this attractive and selective power in the tissues is deranged, so as to produce increase or diminution in growth or in secretion, general or partial. Not unfrequently the selective power appears to be lost, and the attractive power so much increased, that the liquor sanguinis is drawn out through the vessels, so that its fibrin coa- gulates in a mass outside them. This result, preceded or accompanied by certain changes in the vessels themselves, and more or less stag- nation of the current of blood, constitutes the phenomena hitherto described as inflammation. Under these circumstances, other cells and tissues, altogether foreign to the healthy condition of the economy, are produced in what is now called the exudation, although the same gene- ral laws of growth and transformation preside over the abnormal as over the normal products, In this manner pus and cancer cells may be formed, or fibrous, cartilaginous, osseous, and other tissues causing dif- ferent kinds of morbid growth. 4. The disappearance of the transformed tissues, and their re-absorp- tion into the blood.—During life, whilst new tissue and new cells are HEALTHY AND DISEASED NUTRITION. 103 continually being formed, the old ones disappear. The manner in which this is accomplished in certain adult tissues, such as muscle, bone, and areolar texture, has not yet been demonstrated, as the intermediate stages of growth have in them only been seen in the embryo. There is every reason to believe that individual particles, as they are dissolved and absorbed, are replaced by other particles derived from the blood, without necessarily passing through the stage of cell formation. Secret- ing surfaces, however, are continually producing new cells, in which the especial secretion is elaborated, and this either serves some definite pur- pose in the economy, as in the case of the gastric juice, or is separated from the body, as is the case with urea. The result is, that a large quantity of matter, which has answered its purpose, breaks down, is dis solved, and again passes into the blood. A quantity of effete matter is thus continually entering the circulation, arising from the decay of all the tissues, but more especially from the muscular, osseous, nervous, adi- pose, and areolar tissues. The blood globules themselves dissolve after having performed their functions, and serve to swell the amount of effete matter in the blood. So long as the matters absorbed from the tissues correspond in quan- tity and quality to the matters exuded and transformed, the physiolo- gical or healthy state of the blood is preserved. We know, however, that this is continually liable to be disordered from any of the causes we have formerly noticed which derange nutrition. In some cases, ab- sorption takes place with great rapidity, as is occasionally observed after starvation or the formation of large abscesses. In others, this process is in no way proportionate to the quantity of matters exuded, as in plethora, hypertrophy, and morbid growths. The effete matters thus absorbed into the blood circulate with it, and always form an inherent part of its composition. It was first maintained by Zimmermann that they constitute the fibrin of the blood, which, in- stead of being exuded to form the tissues, as has been generally supposed, is excreted from the body by the different glands. It may be well to recapitulate some of the arguments in favour of this opinion. There is no fibrin in chyme, and very little in the chyle, and what is remarkable, much less in the chyle of carnivorous than of herbivorous animals, as horses and sheep. Hunger does not diminish its quantity in the chyle of horses, but, on the contrary, rather increases it, if we can rely upon the experiments of Tiedemann and Gmelin, who concluded that the fibrin must get into the chyle through the lymphatics. Since, then, there is no fibrin in the chyme of carnivorous animals, whilst it consti- tutes so large a portion of their food, the object of digestion must be the transformation of fibrin into albumen. Further, the blood of carnivora contains less fibrin than the blood of herbivora, and in the egg there is no fibrin, although organization is proceeding rapidly in it. These facts are sufficient to prove that fibrin is in no way necessary to cell develop- ment and formation of the tissues. On the other hand, all those circum- stances that cause exhaustion of the textures, or increase the amount of absorption from them, augment the amount of fibrin in the blood, as after inflammatory or other exudations, starvation, violent fatigue, preg- nancy, and frequent bleeding or haemorrhage. Both Nasse and Zim- mermann found the fibrin far more abundant in weak lymphatic persons, XQ4 PRINCIPLES OF MEDICINE. than in those who are strong and vigorous. Again, while there is little fibrin in the chyle of the lacteals, it exists in great quantity in the lymph of the lymphatics, as determined by Nasse in man, and by Miiller in frogs* It follows from these facts that the primary digestion must transform fibrin into albumen, rather than the latter into the former; and such is very probably also the result of the secondary digestion. How otherwise could so small a quantity of fibrin as from one and a half to three parts in a thousand, exist in healthy blood—an amount altogether disproportionate to what would be required, did this consti- tuent as such build up the tissues ? It appears, therefore, probable that the fibrin is formed partly from a solution of blood corpuscles, and partly from the effete matters of the tissues. Hence we may understand why absorption of exudations, or of the textures from exhausting causes, as well as anything that favours the disintegrating process of the blood corpuscles themselves, will produce an increase of this constituent in the blood. It has been maintained by some that fibrin is secreted by the blood corpuscles. Dr. Carpenter supposed this to be the especial function of the colourless cells,! and Mr. Wharton Jones, of the coloured nuclei.^ But there are facts proving that fibrin must have a double origin, as I have stated, one in the solution of both kinds of corpuscles, another from the tissues, of which its increase during inflammation and in rheu- matism are examples, although in these morbid states, increase of the colourless or coloured corpuscles is certainly not essential. Hence fibrin must be referred in its origin to a process of disintegration, rather than to one of evolution,—but, even in this capacity it may serve to produce higher elaboration of that complex fluid, the blood. § The pathological changes which take place in the blood, as far as they have been ascertained by Andral and Gavarret, Simon, and numerous other investigators, may be summed up in the words of Becquerel and Rodier, who ascertained—1st, That the simple fact of the development of a disease almost always modifies in a notable manner the compositiou of that fluid. 2d, That venesection exercises a remarkable influence on the composition of the blood—the more marked the ofteuer it is re- peated. Under these circumstances the blood is impoverished and ren- dered more watery—the albumen is slightly diminished—the fibrin, extractive matters, and free salts, are not influenced, but there is a decided diminution of the blood corpuscles. 3d, That in a plethoric condition of the system there is no relative increase in the number of the corpuscles, or, in fact, any other change in the composition of the blood ; it is simply the mass of the blood that is increased. 4th, That anemia is characterized by a diminution in the amount of the corpuscles. 5th, That inflammation induces an increase of the fibrin and of the cho- * Zur Analysis und Synthesis des pseudoplastischen Processe. Berlin 18-44 P 19 f British and Foreign Medical Review, vol. xv., pp. 272 *>78 t Ibid, vol. xiv., p. 597. PP ' ,T j I1haJe carefu11/ read the argument of an able writer in the British and Foreign Medicnl Review, vol vn. pp. 153. 473, and vol. x., p. 200, in opposition to the view ot Zimmermami and in favour of the old doctrine ; but I believe that all the facts he adduces may readily be shewn to favour, rather than overthrow, what appears to me the correct theory. l r HEALTHY AND DISEASED NUTRITION. 105 lesterine—the former varying from 4 to 10, and the latter being almost doubled. The albumen is diminished. 6th, That the amount of fibrin is diminished, and possibly its physical conditions altered under two classes of circumstances—the first embraces fevers, exanthematous dis- ease, and intoxication; the second starvation and purpura haemorrhagica. 7th, That when any of the. secretions are checked, their essential prin- ciples are contained in the blood in excess. For instance, when the secretion of the urine is suppressed, urea is found in the blood; when the bile is not excreted, it also abounds in the blood, etc. 8th, That there are three diseases in which the albumen of the blood is notably diminished, viz., in Bright's disease, in certain affections of. the heart accompanied by dropsy, and in severe cases of puerperal fever. 5. The excretion of the effete matters from the body in various forms and by different channels.—The circulating fluid having received the effete matters in the manner we have described, again parts with them through the agency of the glands, in the form of certain secretions and excretions. Glands are nourished like all other textures, but their cells are endowed with the property of secreting different substances from the blood. Thus the cells of the liver secrete bile; those of the kidney, urea; those of the mamma, milk; those of the testis, the spermatic fluid, etc., etc. In this way the carbonized and nitrogenized matters, as well as the albuminous and fatty principles, whether received from the assimilation of alimentary substances, or from the transformation of the tissues themselves, are again excreted from the system, as bile, urea, carbonic acid, etc. The mineral matters received into the blood pass through the same process. The lime and phosphorus absorbed from the alimentary canal, unite to form the constituents of bone, and when re-absorbed are ex- creted under new combinations in the urine and foeces. The muriate of soda is decomposed in the tissues. The acid is found in the gastric juice or is exhaled by the skin, while the soda is excreted largely with the bile by the liver. Sulphur, phosphorus, and the other minerals, also pass out of the system in various states of combination. To complete the physiological changes connected with the function of nutrition, it is only necessary to remember that carbonic acid gas, the result of decompositions in the tissues, and water, are continually given off by the lungs and skin; and that oxygen, which enters the blood through the lungs, is continually entering into new combinations with the bases of the solids and fluids. These chemical combinations and exchanges are accompanied by the evolution of heat, whereby the animal temperature is kept up. Thus we may consider that there are two kinds of digestion continu-' ally going on in the body—one in the stomach and intestines, the other in the tissues; that the blood is the recipient of both, distributing the results of the first to build up the tissues, and of the second to consti- tute the various excretions. In this manner the circulation of the blood may be compared to a river flowing through a populous city, which serves at the same time to supply the wants of its inhabitants, and to remove all the impurities that from numerous channels find their way into its stream. 106 PRINCIPLES OF MEDICINE. From the foregoing considerations, it follows that an eliminative function is to a certain extent brought about by all the processes of growth referred to, and that there can be no change, however limited, that is not necessarily associated with a general one in the system at large. As all the nutritive functions are connected with one another, an excess or diminution of local growth, by subtracting from or adding to the constituents of the blood, must produce an alteration in that fluid both as to quantity and quality. The idea of Treviranus, viz., il that each single part of the body, in respect of its nutrition, stands to the whole body in the relation of an excreted substance," has been ably shewn by Mr. Paget to account for various processes in health, under the name of " complemental nutrition."* The same notion has been still further extended by Dr. William Addison, who correctly points out, that in the distinctive eruptive fevers, such as small-pox, the nu- merous minute abscesses in the skin eliminate the morbid poison, which formerly existed in the blood, and are in this way essential to the cure. This provident action he denominates "cell therapeutics."! Hence there are fixed processes in abnormal as in normal nutrition, with which it is essential for the medical practitioner to be acquainted, in order that, instead of operating blindly or empirically, he may act scien- tifically, or in accordance with natural laws. Further, we cannot avoid observing that the process of nutrition is a continuous round, which in the natural world may be said to commence with the reception and terminate with the preparation of aliment, vege- table or animal; that this is observable not only in the " chemical balance of organic nature," so beautifully described by Dumas, but in the incessant chemical compositions and decompositions, as well as structural formations and disintegrations, which are peculiar to all vital entities. If so, it must be apparent that our knowledge of the animal economy and of the diseases to which it is liable, can only be elucidated by investigating the nature of such chemical and structural changes, together with the necessary relations that each one bears to the others, and that it is on such kind of knowledge alone that medicine, as a scientific art, can ever repose in security. We can now readily understand how derangement in one stage of the nutritive process more or less affects the others. Thus, if alimentary matters are not furnished in sufficient quantity, and of a proper quality, the blood is rendered abnormal, and it necessarily follows that the matters it gives off will be abnormal also, and its subsequent trans- formations more or less modified. Again, if secretion be checked, the blood is not drained of its effete matter; and if excretion be prevented, the secretions themselves may enter the blood, and act upon it as a poison. A diseased or morbid state of the blood, therefore, may arise from either of the stages of nutrition which we have described, being rendered irregular, or otherwise abnormal. In whatever part of the circle inter- ruption takes place, it will, if long continued, affect the whole. Thus, a * Lectures on Surgical Pathology. Lecture 2. t Addison on Cell Therapeutics. 1856. HEALTHY AND DISEASED NUTRITION. 107 bad assimilation of food produces through the blood bad secretions and excretions, whilst an accidental arrest of one of the latter reacts through the blood on the assimilating powers. The forms of disease thus arising may be endless, but as regards nutrition, they may all be traced to the following causes:— 1. An improper quantity or quality of the food. 2. Circumstances preventing assimilation or impeding respiration. 3. Altered quantity or quality of nutritive matters passing out of the blood. 4. The accumulation of effete matters in the blood. 5. Obstacles to the excretion of these from the body. Examples in which each of these causes, separately or combined, has occasioned disease, must have occurred to every practitioner. It is true that all general diseases are accompanied by certain changes in the blood, but these changes are to be removed, not by operating on that fluid directly, but by obviating or removing those circumstances which have deranged the stage of nutrition primarily affected. For instance, a very intense form of disease may be produced in infants, through improper lactation. The remedy is obvious; we procure a healthy nurse. Ischuria is followed by coma, in consequence of the accumulation of urea in the blood; we give diuretics to increase the flow of urine, and the symptoms subside. In the one case we furnish the elementary principles necessary for nutrition; in the other, we remove the residue of the process. In both cases the blood is diseased, but its restoration to health is produced by acting on a knowledge of the causes which led to its derangement. In the same manner we might illustrate the indications for correct practice in the other classes, of causes tending to derange the blood. Thus, although there be a proper quantity or quality of food, there may be circumstances which "impede its assimilation; for instance, a too great acidity or irritability of the stomach—the use of alcoholic drinks—inflammation or cancer of the organ. It is the discovery and removal of these that constitute the chief indications for the scientific practitioner. Again, the capillary vessels become over-distended with blood, and the exudation of liquor sanguinis to an unusual amount takes place, constituting inflammation. How is this to be treated ? In the early stage, topical bleeding, if directly applied to the part, may diminish the congestion, and the application of cold will check the amount of exudation. But the exudation having once coagulated out- side the vessels, acts as a foreign body, and the treatment must then be directed to furthering the transformations which take place in it, and facilitating the absorption and excretion of effete matter. This is accomplished by the local application of heat and moisture—the inter- nal use of neutral salts to dissolve the increase of fibrin in the blood, and the employment of diuretics and purgatives to assist its excretion by urine or stool. The general principle we are anxious to establish from this general sketch of the nutritive functions is—that diseases of nutrition and of the blood are only to be combated by an endeavour to restore the deranged processes to their healthy state, in the order in which they were impaired; that a knowledge of the process of nutrition is a pre- 108 PRINCIPLES OF MEDICINE. liminary step to the proper treatment of these affections; that the theory of acting directly on the blood is incorrect; and that an expect- ant system is as bad as a purely empirical one. Function of Innervation. The function of innervation is also made up of the performance of various actions, widely different from each other, although associated together. These actions lead to the manifestation of intelligence, sensa- tion, and combined motion. But as the connection between these is not capable of exhibiting such an order of sequence, as has been made appa- rent among the nutritive processes, it will be necessary to describe them in a different manner. General Anatomy and Physiology of the Xenons System. Structure and Arrangement of the Xervous System..—To the eye, the nervous system appears to be composed of two structures—the grey or ganglionic, and the white or fibrous. The ganglionic, when examined under high powers, may be seen to be composed of nucleated cells, varying greatly in size and shape, mingled with a greater or less number of nerve tubes, also varying in calibre. One important fact, with regard to these corpuscles is, that many of them may be demonstrated to throw out prolongations, which are in direct communication with, or constitute, the central band or axis of Remak and Purkinje within the fibres. The fibres, indeed, may be shewn to consist of minute tubes, which are smallest towards the periphery of the cerebrum, larger towards its base, and largest in the nerves. They are of three kinds—1st, Finely cylin- drical, as observed in the optic and auditory nerves ; 2d, "Varicose, as in the white substance of the cerebral lobes and of the spinal cord; and 3d, Larger and of regular size throughout, as in the nerves. There are also bundles of gelatinous or flat fibres, the nature of which is much dis- puted, very common in the olfactory nerve and sympathetic system of nerves. There can be no doubt that some nerve tubes run into the ganglionic corpuscles, whilst others originate from them. (Wagner, Kolliker.) It is also now rendered certain that the same ganglionic cell may receive and give off nerve tubes, each having distinct properties, the one of conveying the influence of impressions to, and the other of conveying influences from, the nervous centres. The peripheral termi- nation of the nerves is in loops or arcs. The general arrangement of the two kinds of structures should be known. By cerebrum, or brain proper, ought to be understood that part of the encephalon constituting the cerebral lobes, situated above and outside the corpus callosum; by the spinal cord all the parts situ- ated below this great commissure, consisting of the corpora-striata, optic thalami, corpora quadrigemina, cerebellum, pons varolii, medulla oblon- gata, and medulla spinalis. In this way, we have a cranial and a verte- bral portion of the spinal cord. In the cerebrum, or brain proper, the ganglionic or corpuscular HEALTHY AND DISEASED INNERVATION. 109 structure is external to the fibrous or tubular. It presents on the sur- face numerous anfractuosities, whereby a large quantity of matter is D F A E Fig. 94. capable of being contained in a small space. This crumpled up sheet of grey substance has been appropriately called the hemispherical ganglion. (Solly.) In the cranial portion of the spinal cord, the grey matter exists in masses, constituting a chain of ganglia at the base of the ence- phalon, more or less connected with each other and with the white mat- ter of the brain proper above, and the vertebral portion of the cord below. In this last part of the nervous system the grey matter is inter- nal to the white, and on a transverse section presents the form of the letter x, having two posterior and two anterior cornua,—an arrangement which allows the latter to be distributed in the form of nerve tubes to all parts of the frame. The white tubular structure of the vertebral portion of the cord is divided by the anterior and posterior horns of grey matter, together with the anterior and posterior sulci, into three divisions or columns on each side. On tracing these upwards into the medulla oblongata, the anterior and middle ones may be seen to decussate there with each Fi" 94. Transverse section of the spinal cord of the Salmo salar, about two inches from the brain.—A, anterior; B, posterior groove; C, central canal lined with epi- thelium ; D, areolar tissue surrounding the central canal, continuous with the ante- rior and posterior grooves; E, anterior root; F, commissural fibres; G, posterior root • II areolar tissue; I, vertical fibres of the white substance cut across in the transverse section; K, openings of blood-vessels cut across; L, ganglionic cells.— 110 PRINCIPLES OF MEDICINE. C A B D E F G C A c d lib a (i Fig 95. Fi?- 9(!- pyramidal tracts, send off a bundle of fibres, which passes below the olivary body, and is lost in the cerebellum—(Arciform band of Solly). The principal portion of the tract passes through the corpus striatum, and anterior portion of the optic thalamus, and is ultimately lost in the white substance of the cerebral hemispheres. The middle column, or olivary tract, may be traced through the substance of the optic thalamus and corpora quadrigemina, to be in like manner lost in the cerebral Fig. 95 Longitudinal section of the spinal cord of the Sahno salar cut obliquely from before inwards, in the course of the fibres of the anterior root.—A, blood-vessels filled with blood corpuscles; B, areolar texture; C, central canal; D, ganglionic cells; E, fibres of the white substance originating in the cells and going to the brain; F, fibres of the anterior root which pass through the white substance and pass into the cells; G, pia mater.—(Owsjannikow.) 100 diam. Fig. 96. Longitudinal section of the spinal cord of the Petromyzon fuviatilis. The right half.—A, areolar tissue between the broad fibres of the cord; B, areolar tissue between the ganglionic cells, which exist in large numbers; C, broad fibres; D, bipolar ganglionic cells on a level with the broad fibres, the extremities of which divide into a countless number of minute branches. The upper one is seen to commu- nicate with a spindle-shaped cell by a continuous fibre; E, fibres of medium width; F, spindle-shaped ganglionic cells, containing a nucleus and nucleolus ; longitudinal fibres of the white substance, passing upwards; a, a fibre going from the cell into the posterior root; b, a fibre cut across which passes into the anterior root; c, commis- sural fibre ; d, a fibre very difficult to follow, which was once seen to communicate with a round ganglionic cell in the centre of the cord ; e, a fibre passing out of the cell and running upwards.—(Owjannikow.) 100 diam. HEALTHY AND DISEASED INNERVATION. Ill hemispheres. The posterior column, or restiform tract, passes almost entirely to the cerebellum. In addition to the diverging fibres in the cerebral hemispheres which may be traced from below upwards, connecting the hemispherical ganglion with the structures below, the brain proper also possesses bands of transverse fibres, constituting the commissures connecting the two hemi- spheres of the brain together, as well as longitudinal fibres connecting the anterior with the posterior lobes. In the spinal cord it results from the investigations of Lockhart Clarke, that there is a decussation of various bundles of fibres throughout its whole extent. It is now also determined, that many of the fibres in the nerves may be traced directly into the grey substance in the cord—a fact originally stated by Grrainger, but confirmed by Budge and Kolliker. Further, it has recently been shewn that by means of these fibres an anastomosis is kept up between the various columns, even those on both sides of the cord, through the medium of nerve cells in the grey matter, an important fact principally demonstrated by the labours of Stilling, Remak Van der Kolk, Schilling, Kupffer, and Owsjannikow. Tliese later observations indeed open up to us the probability that the numerous actions hitherto called reflex, are truly direct, and are carried on by a series of nervous filaments running in different directions, which have vet to be described. There can be no doubt that they pass and operate through the cord, and hence the term diastaltic proposed by Marshall Hall instead of reflex, is in every way more appropriate. The importance of this view appears to me so great, that I would refer to the figures, pp. .109, 110, from the Thesis of Owsjannikow,* showing what he thinks to be the connection of nerves and ganglionic cells in the spinal cord of certain fishes, as indicative of probably similar relations yet to be discovered in man. Functions of the Nervous System.—The great difference in structure existing between the grey aad white matter of the nervous system would a priori lead to the supposition that they performed separate functions. The theory at present entertained on this point is, that, while the grey matter eliminates or evolves nervous power, the white matter simply conducts to and from this ganglionic structure the influences which are sent or originate there. The brain proper furnishes the conditions necessary for the manifesta- tion of the intellectual faculties properly so called, of the emotions, pas- sions, and volition, and is essential to sensation. That the evolution of the power especially connected with mind is dependent on the hemi- spherical ganglia is rendered probable by the following facts :—1. In the animal kingdom generally, a correspondence is observed between the quantity of grey matter, depth of convolutions, and the sagacity of the animal. 2. At birth, the grey matter of the cerebrum is very defec- tive, so much so, indeed, that the convolutions are, as it were, in the first stage of their formation, being only marked out by superficial fissures almost confined to the surface of the brain. As thecineritious substance increases, the intelligence becomes developed. 3. The results of experiments by Flourens, Rolando, Hertwig, and others, have shewn * Disquisitiones microscopicae de medullar spinalis textura, 1854. 112 PRINCIPLES OF MEDICINE. that, on slicing away the brain, the animal becomes more dull and stupid in proportion to the quantity of cortical substance removed. 4. Clinical observation points out, that in those cases in which the disease has been afterwards found to commence at the circumference of the brain and proceed towards the centre, the mental faculties are affected first; whereas in those diseases which commence at the central parts of the organ and proceed towards the circumference, they are affected last. The white tubular matter of the brain proper serves, by means of the diverging fibres, to conduct the influences originating in the two hemispherical ganglia to the nerves of the head and trunk, whilst they also conduct the influence of impressions made on the trunk, in an inverse manner, up to the cerebral convolutions. The other transverse and longitudinal fibres which connect together the two hemispheres, and various parts of the hemispherical ganglia, are proba- bly subservient to that combination of the mental faculties which char- acterises thought. The spinal cord, both in its cranial and vertebral portions, furnishes the conditions necessary for combined movements; and that the nervous power necessary for that purpose depends upon the grey matter, is rendered probable by the following facts:—1st, Its universal connection with all motor nerves. 2d, Its increased quantity in those portions of the spinal cord from whence issue large nervous trunks. 3d, Its collection in masses at the origin of such nerves in the lower animals as furnish peculiar organs requiring a large quantity of nervous power, as in the triglia volitans, raia torpedo, silurus, etc. 4th, Clinical observation points out that, in cases where the central portion of the cord is affected previous to the external portion, an individual retains the sensibility of, and power of moving, the limbs, but wants the power to stand, walk, or keep himself erect, when the eyes are shut; whereas, when diseases commence in the meninges of the cord or externally—pain, twitchings, spasms, numbness, or paralysis, are the symptoms present, dependent on lesion of the white conducting matter. The white matter of the cord acts as a conductor, in the same manner that it does iu the brain proper, and there can be no doubt that the influence arising from impressions is carried not only along the fibres, formerly noticed, which connect the brain and two portions of the spinal cord together, but along those more recently discovered, which decussate or anastomose in the cord itself (Brown-Sequard), and are connected with the ganglionic cells of the grey matter. The various nerves of the body consist for the most part of nerve tubes, running in parallel lines. Yet some contain ganglionic corpuscles, as the olfactory and the ultimate expansion of the optic and auditory nerves, whilst the sympathetic nerve contains in various places, not only ganglia, but gelatinous flat fibres. The posterior roots of the spinal nerves possess a ganglion, the function of which is quite unknown.. These roots are connected with the posterior horn of grey matter in the cord, while the anterior roots are connected with the anterior horns. As regards function, the nerves may be considered as —1st, Nerves of special sensation, such as the olfactory, optic, auditory, part^of the glosso-pharyngeal and lingual branch of the fifth. 2d, HEALTHY AND DISEASED INNERVATION. 113 Nerves of common sensation, such as the greater portion of the fifth, and part of the glosso-pharyngeal. 3d, Nerves of motion, such as the third, fourth, lesser division of the fifth, sixth, facial, or portio dura of the seventh, and the hypo-glossal. 4th, Senso-motory or mixed nerves, such as the pneumo-gastric, the accessory, and the spinal nerves. 5th, Sympathetic nerves, including t^e numerous ganglionic nerves of the head, thorax, and abdomen,—the exact function of which has not been determined, although they seem to influence nutrition and the pro- duction of animal heat, through their connection with the blood-vessels. All nerves are endowed with a peculiar vital property called sensi- bility, inherent in their structure, by virtue of which they may be excited on the application of appropriate stimuli, so as to transmit the influence of the impressions they receive to or from the brain, spinal cord, or certain ganglia, which may be considered as nervous centres. The nerves of special sensation convey to their nervous centres the influence of impressions caused by odoriferous bodies, by light, sound, and by sapid substances. The nerves of common sensation convey to their nervous centres the influence of impressions caused by mechanical or chemical substances. The nerves of motion carry from the nervous centres the influence of impressions, whether psychical or physical. (Todd.) The mixed nerves carry the influence of stimuli both to and from, combining in themselves the functions of common sensation and of motion. Although the sympathetic nerves also undoubtedly carry the influences of impressions, the direction of these cannot be ascer- tained, from their numerous anastomoses, as well as from the ganglia scattered over them, all of which act as minute nervous centres. But there are cases where certain psychical stimuli (as the emotions) act on organs through these nerves, and where certain diseases (as colic, gallstones, etc.) excite through them sensations of pain. Sensation may be defined to be the consciousness of an impression, and that it may take place, it is necessary—1st, That a stimulus should be applied to a sensitive nerve, which receives an impression ; 2d, That, in consequence of this impression, a something which we designate an influence, should be generated, and conducted along the nerve to the hemispherical ganglion; 3d, On arriving there, it calls into action that faculty of the mind called consciousness or perception, and sensation is the result. It follows that sensation may be lost by any circumstance which destroys the sensibility of the nerve to impres- sions •—which impedes the progress of the influence generated by these impressions, or, lastly, which renders the mind unconscious of them. Illustrations of how sensation may be affected in all these ways must be familiar to you, from circumstances influencing the ultimate extremity of a nerve, as on exposing the foot to cold,—from injury to the spinal cord, by which the communication with the brain is cut off, or from the mind being inattentive, excited, or suspended. The independent endowment of nerves is remarkably well illustrated by the fact, that whatever be the stimulus which calls their sensibility into action, the same result is occasioned. Mechanical, chemical, gal- vanic, or other physical stimuli, when applied to the course or the ex- tremities of a nerve, cause the very same results as may originate from suggestive ideas, perverted imagination, or other psychical stimuli. Thus 8 114 PRINCIPLES OF MEDICINE. a chemical irritant, galvanism, or pricking and pinching a nerve of mo- tion will cause convulsion and spasms of the muscles to which it is dis- tributed. The same stimuli applied to a nerve of common sensation will cause pain, to the optic nerve flashes of light, to the auditory nerve ring- ing sounds, and to the tip of the tongue peculiar tastes. Again, we have lately had abundant opportunities of seeing that suggestive ideas, or stimuli arising in the mind, may induce peculiar effects on the muscles, give rise to pain or insensibility, and cause perversion of all the special senses.—(See Diseases of the Nervous System.) Motion is accomplished through the agency of muscles, which are endowed with a peculiar vital property, called contractility, in the same way that nerve is endowed with the property of sensibility. Contractility may be called into action altogether independent of the nerves (Haller), as by stimulating an isolated muscular fasciculus directly. (Weber.) It may also be excited bya physical orpsychical stimulus,operating through the nerves. Physical stimuli (as pricking, pinching, galvanism, etc.) applied to the extremities or course of a nerve, may cause convulsion of the parts to which the motor filaments are distributed directly, or they may induce combined movements in other parts of the body diastalti- colly (Marshall Hall),—that is, through the spinal cord. In this latter case the following series of actions take place :—1st, The influence of the impression is conducted to the spinal cord by the afferent or esodic fila- ments which enter the grey matter. 2d, A motor influence is transmitted outwards by one or more efferent or exodic nerves. 3d, This stimu- lates the contractility of the muscles to which the latter are distributed, and motion is the result. Lastly, contractility may be called into action by psychical stimuli or mental acts—such as by the will and by certain emotions. Integrity of the muscular structure is necessary for contractile movements; of the spinal cord, for diastaltic or reflex movements; and of the brain proper, for voluntary or emotional movements.* r "' Diagram illustrative of voluntary and reflex motions. Fig. 97 refers to volun- tary motion and sensation. The first originates in a psychical stimulus—the will— in the hemispherical ganglion, the influence of which is propagated downwards through the fibres of the brain, a, to the spinal cord, and outwards by a motor filament in a com- pound nerve, b, to the muscles. The last originates in a physical stimulus, say the prick of a needle, at the extremity of the nerve, l b b, the influence of which travels in the op- ■-■-■■-::: posite direction, along a sensitive filament of that, compound nerve through the spinal cord, up to the hemispherical ganglion, there ex- citing the mental act of consciousness, and, as a result, sensation. In both cases the nerve fibres are continuous. _ Fig. 98 explains reflex or more properly \ diastaltic motion (8io, through, areWu, I \ g \ contract). They originate in a physical stim- \' \^ , ulus applied to the extremity of a sensitive \ *\f filament, a, the influence of which travels in- \ ^> wards to the spinal cord, and through its Fig_ 97 „. t grey matter again outwards along a motor sarilv hplnr, ™™„ * j j. x1?", "lament, b, to the muscles, without neces- sarily being propagated to the hemispherical ganglion, and thereby exciting con- HEALTHY AND DISEASED INNERVATION. 115 Thus, then, we may consider that the brain acting alone furnishes the conditions necessary for intelligence; the spinal cord acting alone fur- nishes the conditions essential for the co ordinate movements necessary to the vital functions; and the brain and spinal cord acting together furnish the conditions necessary for voluntary motion and sensation. The following aphorisms will be found useful, in endeavouring to rea- son correctly on the functions of the nervous system :— 1. The brain proper is that portion of the encephalon situated above the Corpus Callosum. 2. The spinal cord is divided into a cranial and a vertebral portion. 3. The grey matter evolves and the white conducts nervous power. 4. Contractility is the property peculiar to the fibrous texture, whereby it is capable of shortening its fibres. Motion is of three kinds, contrac- tile, dependent on muscle—diastaltic, dependent on muscle and spinal cord—voluntary, dependent on muscle, spinal cord, and brain. 5. Sensibility is the property peculiar to nervous texture, whereby it is capable of receiving impressions. Sensation is the consciousness of receiving such impressions. A more detailed account of the various cerebral, spinal, and cerebro- spinal functions, as they are performed separately or conjointly, belongs to the course of the Institutes of Medicine, and with these you are sup- posed to be familiar. It is important, however, that we dwell more at length on the General Pathology of the Xervous System. For the purposes of diagnosis and treatment, it is a matter of great importance to attend to the following pathological laws which regulate diseased action of the nervous centres. (1.) The amount of fluids within the cranium must always be the same so long as its osseous walls are capable of resisting the pressure of the atmospliere. There are few principles in medicine of greater practical importance than the one we are about to consider,—the more so, as many able practitioners have lately abandoned their former opinions on this head, and on what I consider to be very insufficient grounds. On this point, therefore, I cannot do better than condense and endeavour to put clearly before you the forcible arguments of the late Dr. John Reid, with such other considerations as have occurred to myself. That the circulation within the cranium is different from that in other parts of the body, was first pointed out by the second Monro. It was tested experimentally by Dr. Kellie of Leith, ably illustrated by Dr. Abercrombie, and successfully defended by Dr. John Reid. The views adopted by these distinguished men were, that the cranium forms a spherical bony case capable of resisting the atmospheric pressure, the only openings into it being the different foramina by which the vessels, nerves, and spinal cord pass. The encephalon, its membranes, and blood-vessels, with perhaps a small portion of the cerebro-spiual fluid, sciousness and sensation. The nature of the communication through the grey matter, instead of being broken or reflected, we have seen to be probably continuous and direct through the medium of ganglionic cells. (Fig. 94.) 116 PRINCIPLES OF MEDICINE. completely fill up the interior of the cranium, so that no substance can be dislodged from it without some equivalent in bulk taking its place. Dr Monro used to point out, that a jar, or other vessel similar to the cranium, with unyielding walls, if filled with any substance, cannot be emptied'without air or some substance taking its place. To use the illustration of Dr. Watson, the contents of the cranium are like beer iu a barrel, which will not flow out of one opening unless provision be made at the same time that air rushes in. The same kind of reasoning applies to the spinal canal, which, with the interior of the cranium, may be said to constitute one large cavity, incompressible by the atmospheric air. Before proceeding further, we must draw a distinction between pres- sure on, and compression of, an organ. Many bodies are capable of sus- taining a great amount of pressure without undergoing any sensible decrease in bulk. By compression must be understood, that a substance occupies less space from the application of external force, as when we squeeze a sponge, or compress a bladder filled with air. Fluids gene- rally are not absolutely incompressible, yet it requires the weight of one atmosphere, or fifteen pounds in the square inch, to produce a diminu- tion equal to ^o o o otu Part of tue whole. Now this is so exceedingly small a change upon a mass equal in bulk to the brain, as not to be appreciable to our senses. Besides, the pressure ou the internal surface of the blood-vessels never exceeds ten or twelve pounds on the square inch, during the most violent exertion, so that, under no possible circum- stauces, can the contents of the cranium be diminished even the 7jJ-Htb part. ^Yhen the brain is taken out of the cranium, it may, like a sponge, be compressed, by squeezing fluid out of the blood-vessels; but during life, surrounded, as it is, by unyielding walls, this is impossible. For let us, with Abercrombie, say, that the whole quantity of blood cir- culating within the cranium is equal to 10, this is 5 in the veins, and 5 iu the arteries; if one of these be increased to 6, the other must be diminished to 4, so that the same amount, 10, shall always be preserved. It follows, that when fluids are effused, blood extravasated, or tumours grow within the cranium, a corresponding amount of fluid must be pressed out, or of brain absorbed, from the physical impossibility of the cranium holding more matter. At the same time, it must be evident that an increased or diminished amount of pressure may be exerted on the brain, proportioned to the power of the heart's contraction, the effect of which will be, not to alter the amount of fluids within the cranium, but to cause, using the words of Abercrombie, '' a change of circulation" there. This is all, it seems to me, that is shown by the mgenious experi- ments of DonderSj who saw venous congestion through glass plates, fixed iu the crani of rabbits.* Dr. Kellie performed numerous experiments on cats and dogs, in order to elucidate this subject. Some of these animals were bled to death by opening the carotid or femoral arteries, others by opening the jugular veins. In some the carotids were first tied, to diminish the quantity of blood sent to the brain, and the jugulars were then opened, with the view of emptying the vessels of the brain to the greatest possible extent; while, in others, the jugulars were first secured, to prevent as much as * Nederlandeche.—Lancet, 1850. HEALTHY AND DISEASED INNERVATION. 117 possible the return of the blood from the brain, and one of the carotids was then opened. He inferred, from the whole inquiry, which was con- ducted with extreme care, " That we cannot, in fact, lessen, to any con- siderable extent, the quantity of blood within the cranium by arterio- tomy or venesection ; and that when, by profuse haemorrhages, destruc- tive of life, we do succeed in draining the vessels within the cranium of any sensible portion of red blood, there is commonly found an equivalent to this spoliation in the increased circulation or effusion of serum, serv- ing to maintain the plenitude of the cranium." Dr. Kellie made other experiments upon the effects of position imme- diately after death from strangulation or hanging. He also removed a portion of the unyielding walls of the cranium in some animals, by means of a trephine, and then bled them to death; and the difference between the appearances of the brain in these cases, and in those where the cranium was entire, was very great. One of the most remark- able of these differences was its shrunk appearance, in those animals in which a portion of the skull was removed, and the air allowed, to gravitate upon its inner surface. He says :—" The brain was sensibly depressed below the cranium, and a space left, which was found capable of containing a teaspoonful of water." It results from these inquiries, that there must always be the same amount of fluids within the cranium so long as it is uninjured. In morbid conditions these fluids may be blood, serum, or pus; but in health, as blood is almost the only fluid present (the cerebro-spinal fluid being very trifling), its quantity can undergo only very slight alterations. There are many circumstances, however, which occasion local congestions in the brain, and consequently unequal pressure on its structure, in which case another portion of its substance must contain less blood, so that the amount of the whole as to quantity, is always preserved. These circum- stances are mental emotions, hgemorrhages, effusions of serum, and mor- bid growths. Such congestions, or local hyperhemias, in themselves constitute morbid conditions ; and nature has, to a great extent, provided against their occurrence under ordinary circumstances, by the tortuosity of the arteries and the presence of the cerebro-spinal fluid, described by Magendie. The views now detailed, had been very extensively admitted into patho- logy, when Dr. Burrows, of St. Bartholomew's Hospital, endeavoured to controvert them, first in the Lumleian Lectures of 1843, and subse- quently in a work published in 1846, entitled " On Disorders of the Cere- bral Circulation, and on the connections between Affections of the Brain and Diseases of the Heart." Dr. Burrows, however, evidently misunder- stood the doctrine wTe are advocating. Thus, he is always combating the idea that blood-letting, position, strangulation, etc., cannot affect the blood in the brain; whereas the real proposition is, that they cannot alter the fluids within the cranium. By thus confounding blood with fluid, and brain with cranium, he has only contrived to overthrow a doc- trine of his own creation. Dr. Burrows has brought forward several observations and experi- ments, which he considers opposed to the theory now advocated. His facts are perfectly correct. I myself have repeated his experiments on rabbits, and can confirm his descriptions. It is the inferences he draws 118 PRINCIPLES OF MEDICINE. from them that are erroneous. For the paleness which results from hemorrhage, and the difference observable in the colour of the brain, when animals, immediately after death, are suspended by their ears or by their heels, is explicable by the diminished number of coloured blood particles in the one case, and by their gravitation downwards in the other. That the amount of fluid within the cranium was in no way affected, is proved by the plump appearance of the brains figured by Dr. Burrows, and the total absence of that shrunken appearance so well described by Dr. Kellie. Neither does our observation of what occurs in asphyxia or apnoea, oppose the doctrine in question, as Dr. Burrows imagines, but rather con- firms it. On this point the following observations by Dr. John Reid are valuable. He says :—" If any circumstance could produce congestion of the vessels within the cranium, it would be that of death by hanging; for then the vessels going to and coming from the brain are, with the ex- ception of the vertebral arteries, compressed and then obstructed. These two arteries, which are protected by the peculiarity of their course through the foramina of the tranverse processes of the cervical vertebra), must continue for a time to force their blood upon the brain, while a comparatively small quantity only can escape by the veins. Indeed, the greater quantity of blood carried to the encephalon by the vertebrals returns by the internal jugulars and not by the vertebral veins, which are supplied from the occipital veins of the spinal cord ; and the anasto- moses, between the cranial and vertebral sinuses, could carry off a small quantity of the blood only, transmitted along such large arteries as the vertebrals. _ And yet it is well known that there is no congestion of the vessels within the cranium after death by hanging, however gorged the external parts of the head may be by blood and serum." This is admitted by Dr. Burrows, although he endeavours to get rid of so troublesome a fact by a gratuitous hypothesis, which will not bear a moment's exami- nation, but for the refutation of which I must refer to the works of Dr. Reid.* On the whole, whether we adopt the terms of local congestion, of change of circulation within the cranium (Abercrombie), or of unequal pressure (Burrows), our explanation of the pathological phenomena may be made equally correct, because each of these modes of expression im- plies pietty much the same thing. But if we imagine that venesection will enable us to dimmish the amount of blood in the cerebral vessels, the theory points out that this is impossible, and that the effects of bleeding are explained by the influence produced on the heart, the altered pres sure on the brain, exercised by its diminished contractions, and the change of circulation within the cranium thereby occasioned I have entered somewhat fully into this theory, because, independent of its vast importance in a practical point of view, it is one which origi- stnnL 1 E.dlDWrSh Sch001 of Medicine. Singular to say, notwith- standing the obvious errors and fallacies in Dr. Burrows' work no sooner IdJJT**' l ^ the W^°le medical Press of England and Ireland hisTxce I r T1' aQdveVen Dr* Watson> iu the *™> 1** editions of his excellent work, also abandoned the theory of Monro, Kelly, aud * Physiological, Anatomical, and Pathological Researches, No. XXV. HEALTHY AND DISEASED INNERVATION. 119 Abercrombie. But so far is this theory concerning the circulation with- in the cranium from being shaken by the attack of Dr. Burrows, that it may be said now to stand on a firmer basis than ever, owing to that attack having drawn forth the convincing reasoning and unanswerable arguments of so sound an anatomist, physiologist, and pathologist, as the late Dr. John Reid. (2.) All the functions of the nervous system may be increased, per- verted, or destroyed, according to the degree of stimulus or disease operating on its various parts.—Thus, as a general rule it may be said, that a slight stimulus produces increased or perverted action; whilst the same stimulus, long continued or much augmented, causes loss of function. All the various stimuli, whether mechanical, chemical, electrical, or psychical, produce the same effects, and in different degrees. Circum- stances influencing the heart's action, stimulating drinks or food, act in a like manner. Thus if we take the effects of alcoholic drink, for the purpose of illustration, we observe that, as regards combined movements, a slight amount causes increased vigour and activity in the muscular system. As the stimulus augments in intensity, we see irregular move- ments occasioned, staggering, and loss of control over the limbs. Lastly, when the stimulus is excessive, there is complete inability to move, and the power of doing so is temporarily annihilated. With regard to sen- sibility and sensation, we observe cephalalgia, tingling, and heat of skin, tinnitus aurium, confusion of vision, muscae volitantes, double sight, and lastly, complete insensibility and coma. As regards intelligence, we observe at first rapid flow of ideas, then confusion of mind, delirium, and lastly, sopor and perfect unconsciousness. In the same manner pressure, mechanical irritation, and the various organic diseases, produce aug- mented, perverted, or diminished function, according to the intensity of the stimulus applied, or amount of structure destroyed. Then it has been shown that excess or diminution of stimulus, too much or too little blood, very violent or very week cardiac contractions, and plethora or extreme exhaustion, will, so far as the nervous functions are concerned, produce similar alterations of motion, sensation, and intel- ligence. Excessive hasmorrhage causes muscular weakness, convulsions, and loss of motor power, perversions of all the sensations, and lastly, unconsciousness from syncope. Hence the general strength of the frame cannot be judged of by the nervous symptoms, although the treatment of these will be altogether different, according as the individual is robust or weak, has a full or small pulse, etc. These similar effects on the nervous centres from apparently such opposite exciting causes, can, it seems to me, only be explained by the peculiarity of the circulation previously noticed. A change of circulation within the cranium takes place, and. whether arterial or venous congestion occurs, pressure on some portion of the organ is equally the result. The importance of paying attention to this point in the treatment must be obvious. (3.) The seat of the disease in the nervous system influences the nature of the phenomena or symptoms produced.—It is a matter of very great importance to ascertain how far certitude in diagnosis may be arrived at, and the seat of the disease ascertained. On this subject it may be 120 PRINCIPLES OF MEDICINE. affirmed that, although clinical observation combined with pathology has done much, more requires to be accomplished. As a general rule, it may be stated, that disease or injury of one side of the encephalon, especially influences the opposite side of the body. It is said that some verv striking exceptions have occurred to this rule, but these at any rate are remarkably rare. Besides, it has always appeared to me probable that, inasmuch as extensive organic disease, if occurring slowly, may exist without producing symptoms, whilst it is certain most important symp- toms may be occasioned without organic disease, even these few excep- tional cases are really not opposed to the general law. Then, as a general rule, it may be said that diseases of the brain proper are more especially connected with perversion and alteration of the intelligence;- whilst disease of the cranial portion of the spinal cord and base of the cranium, are more particularly evinced by alterations of sensation and motion. In the vertebral portion of the cord, the intensity of pain and of spasm, or else the want of conducting power, necessary to sensation and voluntary motion, indicates the amount to which the motor and sensitive fibres are affected. Further than this we can scarcely generalise with prudence, although there are some cases, as we shall subsequently see, where care- ful observation has enabled us to arrive at more positive results. The fatality of lesions affecting various parts of the nervous centres varies greatly. Thus the hemispheres may be extensively diseased, often without injury to life, or even permanent alteration of function. Convulsions and paralysis are the common results of disease of the ganglia, in the cranial portion of the cord. The same results from lesion of the pons varolii. But if the medulla oblongata, where the eighth pair originates, be affected, or injury to this centre itself occur, it is almost always immediately fatal. (4.) The rapidity or slowness with which the lesion occurs, influences the phenomena or symptoms produced.—It may be said as a general rule, that a small lesion (for instance, a small hemorrhagic extravasation), occurring suddenly, and with force, produces, even in the same situation, more violent effects than a very extensive organic disease which comes on slowly. This, however, will depend much upon the seat of the lesion. Very extraordinary cases are on record, where large portions of the nervous centres have been much disorganized, without producing any- thing like the violent symptoms which have been occasioned at other times by a small extravasation in the same place. Here, again, the nature of the circulation within the cranium offers the only explanation, for the encephalon must undergo a certain amount of pressure, if no time be allowed for it to adapt itself to a foreign body; whereas any lesion coming on slowly enables the amount of blood in the vessels to be diminished according to circumstances, whereby pressure is avoided. (5.) The various lesions and injuries of the nervous system produce phenomena similar in kind.—The injuries which may be inflicted on the nervous system, as well as the morbid appearances discovered after death, are various. For instance, there may be an extravasation of blood, exudation of lymph, a softening, a cancerous tumour, or tubercular deposit, and yet they give rise to the same nervous phenomena, and HEALTHY AND DISEASED INNERVATION. 121 are modified only by the circumstances formerly mentioned, of decree, seat, suddenness, etc. Certain nervous phenomena also are of a parox- ysmal character, whilst the lesions supposed to occasion them are sta- tionary or slowly increasing. It follows, that the effects cannot be explained by the nature of the lesions, but by something which they all have in common ; and this, it appears to me, may consist of—1st, Pressure with or without organic change ; 2d, more or less destruction or disorganization of nervous texture. Further, when we consider that the same nervous symptoms arise from irregularities in the circulation ; from increased as well as diminished action; sometimes when no appre- ciable change is found, as well as when disorganization has occurred— the theory of local congestions to explain functional alterations of the nervous centres seems to me the most consistent with known facts. That such local congestions do frequently occur during life, without leaving traces detectable after death, is certain; whilst the occurrence of mole- cular changes, or other hypothetical conditions which have been sup- posed to exist, has never yet been shown to take place under any circumstances. While such appear to me to be some of the generalizations which are important to the physician with regard to the nutritive and nervous functions, viewed separately, it should never be forgotten that he has constantly to do with their conjoint action. Indeed, the derangement of one order of functions exercises a constant influence over the other, so that in every disease the effects of disordered nutrition are visible in perverted innervation, and the converse. Thus an improper quantity or quality of food produces sometimes excitement, at others dulness of intellect. Various articles of diet have been known to cause violent headache, and different kinds of nervous phenomena; while starvation, if long continued; excites delirium, paroxysms of mania, and lastly, stupor. In children, derangement of the alimentary canal is the most common cause of spasm and convulsion, and in the aged it often leads to apo- plexies and palsy. Again, impeded respiration, poverty of the blood, accumulation of effete matters in the system, suppressed secretions and obstructed excretions, are all accompanied or followed b}7 disorders of innervation. On the other hand, the influence of the nervous system on nutrition is equally apparent. Syncope and even death itself have been occasioned by mental emotions. Anxiety and suppressed grief predispose to diseases of the stomach, and thereby to altered nutrition, terminating in various maladies. The reception of joyful or distressing intelligence, it is well known, invigorates or depresses the bodily energies. Various organs are excited to action by particular trains of thought or desires, and the countenance is reddened by modesty, and blanched by fear. As a general rule, it may be said, while slight emotions increase the secre- tions, very violent ones, particularly if suppressed, completely suspend them, and are most dangerous to life.* Direct mechanical injury to the large nervous trunks, in addition to causing paralysis, is now recognised in some cases to produce increased heat and redness in parts, often fol- * " Give sorrow words; the grief that will not speak, "Whispers the o'erfraught heart, and bids it break."—Shakspeare. 122 PRINCIPLES OF MEDICINE. -, i. a I,™ nnd ulceration In chronic cases, such paralysis lowed b7 eM.datlon/^Jrine'aof I limb, or some other portion of the Sof nuK^wlS Lpairnient of sensibility or motion, of wh.ch he mos^r narkable example I am acquainted with is recorded by Pro- feL Romber. 0f Berlin^ It was that of an unmarried woman aged o?1i "horn a'the result of extensive suppuration on the left side of the nek which burst through the tonsil, the features on the correspond- ng skde of the face gradually became atrophied, without any diminutum Fig. 99. of sensibility or motion. Looking at the two halves of the face sepa- rately, it appeared as if the one belonged to a young, and the other to an old woman. By some it was supposed that the diseased side was sound, and that the other was swollen. The hair, eyebrows, and eye- lashes were very thin on the affected side, and she was in the habit of dividing her hair towards the right, so as to equalize the quantity. Every feature, including the brow, eye, nostril, lips, cheek, and chin, as well as the left half of the tongue and left palatine arch, was smaller than those on the opposite one.* Further illustrations of the general principles now detailed will be constantly met with under the head of special diseases. * Klinische Ergebnisse. Berlin, 1846. Fig. 99. Remarkable atrophy on the left side of the face, in a woman aged 2: without loss of sensibility or motion in the affected parts.—(Romberg.) SIMPLE, CANCEROUS, AND TUBERCULAR EXUDATIONS. 123 SIMPLE, CANCEROUS, AND TUBERCULAR EXUDATIONS —THEIR PATHOLOGY AND GENERAL TREATMENT. There are three varieties of exudation, which, occurring as they do in one or other of the textures, occasion the great majority of those diseases we are called upon to treat. A knowledge of the manner in which these are produced, of the characters of each, of their specific differences and natural progress, constitutes the foundation of modern medicine. I propose, then, in the first place, to describe them to you generally, and then to direct your attention to the special peculiarities which they present in individual cases. The term exudation has been introduced into pathology, not only to express the act of the liquor sanguinis passing through the walls of the blood-vessels, but also to denominate the coagulation of the fibrinous portion of the liquor sanguinis itself, upon the surface, or in the substance of any tissue or organ of the body. The use of this term removes a difficulty* which morbid anatomists have long experienced; and hence it has of late years been extensively used to indicate various kinds of morbid deposits. Thus it has been applied to all those processes hitherto termed inflammatory, tubercular, and cancerous; it may be associated with every form of morbid growth ; it often gives rise to concretions, and frequently constitutes the soil in which grow those parasitic vegeta- tions or cryptogamic plants of a low type, which communicate essential characters to certain diseases. Under the head of exudation, indeed, considered as a morbid process, is comprised the greater part of organic as distinguished from functional diseases; of lesions of nutrition, as sepa- rated from lesions of innervation. I. Production of Exudation. Exudation is in every case preceded by a series of changes which have taken place in the capillary vessels, and in the blood contained in them. These changes, as we are enabled to follow them in the trans- parent parts of animals under the microscope, are seen to occur in the following order :—1st, The capillary vessels are narrowed, and the blood flows through them with greater rapidity. 2d, The same vessels become enlarged, and the current of blood is slower, although even. 3d, The * Of inflammation, Andral says, " created in the infancy of science, this expres- sion, altogether metapborical, wis destined to represent a morbid state, in which the parts appeared to burn, to be inflamed, etc. Received into general language without any precise idea having ever been attached to it, in the triple relation of symptoms which announce it, of the lesions which characterise it, and of its intimate nature, the expression inflammation is becoming so very vague, its interpretation is so very arbi- trary, that it has really lost its value ; it is like an old coin without an impression, which ought to be removed from circulation, as it only causes error and confusion." On the other hand, exudation of the liquor sanguinis is a demonstrative fact, and gives rise to a definite idea. Hence, for all scientific and practical purposes, the expression '• exudation '' may be substituted for that of inflammation. 124 PRINCIPLES OF MEDICINE. flow of blood becomes irregular. 4th, All motion of the blood ceases, and the vessel appears fully distended. 5th and lastly, The liquor san- guinis is exuded through the walls of the vessel; and sometimes there is extravasation of blood corpuscles, owing to rupture of the capillaries. The first step in the process, viz., narrowing of the capillaries, is readily demonstrated on the application of acetic acid to the web of the frog's'foot. If the acid be weak, the capillary contraction occurs more slowly and gradually. If it be very concentrated, the phenomenon is not observed, or it passes so quickly into complete stoppage of blood as to be imperceptible. Although we cannot see these changes in man under the microscope, certain facts indicate that the same phenomena occur. The operations of the mind, for instance,, as fear and fright, and the ap- plication of cold, produce paleness of the skin, an effect which can only arise from contraction of the capillaries, and a diminution of the quantity of blood they contain. In the majority of instances, also, this paleness is succeeded by increased redness, the same result as follows from direct experiment on the web of the frog's foot, and which constitutes the sec- ond step of the process. In other cases, the redness may arise primarily from certain mental emotions, or from the application of heat; and in both instances depends on the enlargement of the capillaries, and the greater quantity of blood which is thus admitted into them.* The variation in the size of the capillaries, and of the amount of blood in them, is conjoined with changes in the movement of that fluid. Whilst the vessels are contracted, the blood may be seen to flow with increased velocity. After a time the blood flows more and more slowly, without, however, the vessel being obstructed ; it then oscillates, that is, moves forwards and backwards, or makes a pause, which is evidently synchronous with the ventricular diastole of the heart. At length the vessel appears quite distended with yellow or coloured corpuscles, and all movement ceases. Again, these changes in the movement of the blood induce variations in the relations which the blood corpuscles bear to each other, and to the walls of the vessel. In the natural circulation of the frog's foot, the yellow corpuscles may be seen rolling forward in the centre of the tube, a clear space being left on each side, which is filled only with liquor * It has been asserted that instead of contraction of the capillaries, the first changes observable are enlargement with an increased flow of blood. To determine positively the question of contraction or dilatation, I have recently made a series of careful observations ou the web of a frogs foot. Having fixed the animal in such a way that it could not move, I carefully measured with Oberhaeuser's eye micrometer the diameter of various vessels bel'ore, during, and alter the application of .-timuli. The results were, that immediately hot water was applied, a vessel that measured 13 spaces of the eye micrometer contracted to 10 ; another that measured 10 contracted to / ; a third that' measured 7 contracted to 5; a fourth, which was a capillary carry- ing blocd globules in single file, and measured 5, was contracted to 4; and another one ot the smallest size which measured 4, was contracted to 3. With regard to the ultimate capillaries, it was frequently observed that if filled wi:h corpuscles, they contracted little, but if empty, the contraction took place from 4- to 2 so that no more corpuscles entered them, and they appeared obliterated. This was especially seen alter the addition of acetic acid. It was also observed that minute vessels that con- tracted from 4 to 3, afterwards became dilated to 6 before congestion and stagnation occurred. The smaller veins were seen to contract as much as the arteries of the same size. PRODUCTION OF EXUDATION. 125 sanguinis and a few lymph corpuscles. There are evidently two cur- rents, one at the centre, which is very rapid, and one at the sides (in the lymph spaces, as they are called), much slower. The coloured cor- puscles are hurried forward in the centre of the vessel, occasionally mixed with some lymph corpuscles. These latter, however, may fre- quently be seen clinging to the sides of the vessel, or slowly proceeding a short distance along it in the lymph space, and then again stopping. Occasionally the lymph corpuscles get into the central torrent, whence they are carried off with great velocity, and accompany the yellow corpuscles. It has been said that tliese corpuscles augment iu number, accumulate in the lymph spaces, and obstruct the flow of blood. In Fig. 100. young frogs their number is often very great; but then they constitute a normal part of the blood, and in no way impede the circulation. In old frogs, on the other hand, all these, and subsequent changes, may be ob- Fig. 100. An exact copy of a portion of the web in the foot of a young frog, after a drop of strong alcohol had been placed upon it. The view exhibits a deep-seated artery and vein, somewhat out of focus; the intermediate or capillary plexus run- ning over them, and pigment cells of various sizes scattered over the whole. On the left of the figure, the circulation is still active and natural. About the middle it is more slow, the column of blood is oscillating, and the corpuscles crowded together. On the right, congestion, followed by exudation, has taken place. a, A deep-seated vein, partially out of focus. The current of blood is of a deeper colour, and not so rapid as that in the artery. It is running iu the opposite direc- tion. The lymph space on each side, filled with slightly yellowish blood plasm, is very apparent, containing a number of colourless corpuscles, clinging to, or slowly moving along, the sides of the vessel. 6, A deep-seated artery, out of focus, the rapid current of blood allowing nothing to be perceived but a reddish yellow broad streak, with lighter spaces at the sides. Opposite c, laceration of a capillary vessel has produced an extravasation of blood, which resembles a brownish-red spot. At d, congestion has occurred, and the blood corpuscles are apparently merged into one semi-transparent, reddish mass, entirely filling the vessels. The spaces of the web, between the capillaries, are rendered thicker and less transparent, partly by the action of the alcohol, partly by the exudation. This latter entirely fills up the spaces, or only coats the vessel. 200 diam. 19(5 PRINCIPLES OF MEDICINE. served, without the presence of colourless corpuscles. When the capil- laries enlarge, however, the central coloured column in the smaller ves- sels maybe'~seen to enlarge also, and gradually approach the sides of the tube, thus encroaching on the lymph spaces. The slower the motion of the blood, the more the lymph spaces are encroached on, until at length the coloured corpuscles come in contact with the sides of the vessel, and are compressed and changed in form. The vessel is at length completely distended with colourless corpuscles, the original form of which can no longer be discovered, so that the tube appears to be filled with a homogeneous deep crimson fluid. This is congestion. If the morbid process continue, the vessel may burst, causing haemor- rhage, or the liquor sanguinis may transude through its walls, without rupture, into the surrounding texture. This last is exudation. II. Theory of Exudation. It is of the utmost importance in pathological inquiries to separate facts from theories. Our facts may be correct, although the conclusions derived from them are wrong. This proposition, however generally admitted, is seldom adhered to in practice ; for, in medical writings and statements, we frequently find fact and hypothesis so mingled together, that it often requires considerable critical and analytical power to sepa- rate the one from the other. We are, however, in all cases, insensibly led to theorise—that is, to attempt an explanation of the phenomena observed, in order that we may derive from them some general principle for our guidance. Such speculation is always legitimate, so long as we consider opinions to be mere generalizations of known facts, and are ready to abandon them the moment other facts point them out to be erroneous. The phenomena of exudation, previously described, may easily be demonstrated—they constitute the facts. Let us now examine how they have been attempted to be explained—in other words, what is the theory. 1. The contraction and dilatation of the capillaries are explicable, by supposing them to be endowed with a power of contractility analogous to that existing in non-voluntary muscles. John Hunter thought they were muscular, from the results of his observations and experiments; and they may be shown by the histologist to consist of a delicate mem- brane, in which permanent nuclei are imbedded. Mr. Lister has recent- ly shown that much of the contractility is dependent on fusiform cells, which have the property of shortening themselves, and which run trans- versely round the vessels. In structure, then, they possess elements closely resembling the muscular fibres of the intestine, and we know that like them, they may be contracted or dilated by emotions of the mind (that is, through the nerves), or by local applications, that is, di- rectly. The narrowing of these tubes, therefore, may be considered, as Cullen thought it was, analogous to spasm, while their dilatation may be referred either to the relaxation which follows such spasm, or to mus- cular paralysis. The recent observations of CI. Bernard and others as to the effects produced by dividing the large nervous trunk of the sym- pathetic in the neck, have singularly confirmed this theory THEORY OF EXUDATION. 127 2. The rapid and slow movement of the blood is explicable on the hydraulic principle, that when a certain quantity of fluid is driven for- ward with a certain force through a pervious tube, and the tube is nar- rowed or widened, while the propelling force remains the same, *he fluid must necessarily flow quicker in the first case and slower in the second. It has been supposed, from the throbbing of large vessels leading to con- gested parts, that they pump a larger quantity of blood than usual into them. This was called '' determination of blood " by the older pathol- ogists, and is now known not to be a cause, but a result, of the changes going on in the capillary vessels and tissues of the affected part. The oscillatory movement, seen later in the transparent parts of small ani- mals, has not been observed in man, and probably depends, in the for- mer, on a weakened power of the heart. 3. It is the stoppage of the blood and exudation of the liquor sangui- nis, however, which it is most difficult to explain ; for why, so long as there is no mechanical obstruction (and during this process none has ever been seen), should the circulation through the capillaries of apart cease ? It has been endeavoured, indeed, of late years, to account for this stoppage by referring it to a mechanical obstruction, which is sup- posed to result from the formation of colourless corpuscles, which cling in large numbers to the sides of the capillaries, and so cause interruption of the stream. But this hypothesis is negatived by the following facts : —1st, In young frogs, the vessels may be seen to be crowded with col- ourless corpuscles, while the circulation is in no way affected. 2d, In old frogs, oscillation and gradual stoppage of the stream may be seen, without any colourless corpuscles being present. 3d, The colourless corpuscles, as shown by Remak, are increased after large venesections, in the horse, without ever causing active congestion.* And, 4th, In Leucocythemia all the vessels are crowded with colourless corpuscles, and yet no active congestion in these vessels, nor exudation of any kind, takes place. (See Leucocythemia.) We cannot ascribe the stoppage of the circulation in the capillaries to venous obstruction, or to mechanical pressure of any kind, because all observation proves that such causes, while they induce effusion of serum, never occasion exudation of liquor sanguinis. Neither can we suppose it to depend on endosmose, nor on a vis a tergo, as such physical causes cannot be shewn to apply in all cases. We are compelled, there- fore, to attribute the vital force producing these changes, not to anything residing in the blood, or in the vessels, but to the tissues which lie out- side the vessels. That these do possess a power attractive and selective, whereby matters are drawn from the blood to carry on nutrition and secretion, is now generally admitted in physiology. A modification of this power, whereby the attractive property is augmented, and the se- lective one diminished, at least offers us an explanation consistent with all known facts, and seems to be the only active agency to which we can ascribe the approach of the coloured particles to the capillary walls, and the passage through them of the exudation. * Diagnostische und Pathognetische Untersuchungen, &c, 1845. He also found that in man the colourless corpuscles of the blood were few in number during inflam- mations, and were augmented during successive bleedings, so that he concluded the fewer there are of these the higher is the degree of inflammation. 128 PRINCIPLES OF MEDICINE. When the liquor sanguinis is exuded, it generally coagulates, and constitutes a foreign body in the texture of the parts affected ; and then it becomes the object of nature either to remove it from the system, or so to modify it that its presence may be rendered conducive to the wants of the economy. In order to accomplish this, two kinds of changes take place in it__1st, The exudation serves as a blastema, in which new vital structures originate and are developed; 2d, It exhibits no power of becoming organised, and the exuded matters, together with the textures involved in them, die. In the first case, corpuscles spring up in the ex- udation, which differ in form, size, constitution, and power of further development, and give rise to tliese various appearances and changes which, in some cases, have been denominated the results of inflammation, in others, various kinds of deposits. In the second case, death of the exudation takes place—slowly, constituting ulceration ; or rapidly, pro- ducing gangrene. III. Vital Transformations of the Exudation. We find that the peculiar constitution of the blood, or the general vital power of the organism, exercises a very powerful influence on the development of the exudation. This has long been recognised by pathol- ogists iu certain conditions, denominated respectively diathesis, dyscra- sia, or cachexia. I propose at present to direct your attention to some of the facts connected with exudation as it occurs in the body during health, as well as when connected with cancerous and scrofulous consti- tutions. I shall call the former simple exudation, to distinguish it from what may be denominated cancerous and tubercular exudation. Simple Exudation. Simple exudation presents four principal forms—1, As it occurs on serous membranes, where it exhibits a finely fibrous structure, and has a strong tendency to be developed into molecular fibres; 2, As it occurs on mucous membranes, or in areolar tissue, where it is generally converted into pus corpuscles; 3, When it occurs in dense parenchymatous organs, such as the brain, where it assumes a granular form, and is associated with numerous compound gran- ular corpuscles; 4, As it is poured out after wounds or injuries, and occurs on granulating sores. In this last case the superficial por- tion is transformed into pus corpuscles, while the deeper seated is converted, by means of nuclei and cells, into nucleus and cell fibres,which ultimately form the cicatrix. 1. On examining the minute structure of the exudation on a serous 101. Fig. surface. 101- iIolecular fiDres and plastic corpuscles, in simple exudation on a serous a, The latter after the addition of acetic acid. 250 diam. VITAL TRANSFORMATIONS OF THE EXUDATION. 129 surface when recently formed, and when it presents a gelatinous semi- trausparent appearance, it will be found to be made up of minute fila- ments mingled with corpuscles (Fig. 101). The filaments are not the result of the development of either a nucleus or a cell, but are formed by the simple precipitation of molecules, whicii arrange themselves in a linear manner, iu the same way as they may be seen to form in the buffy coat of the blood. As the exudation becomes firm, the filaments appear more distinct and consolidated, varying from TTi__th to ToJooul 0I" an inch in diameter. Boundless, or different layers of them, often cross each other; and as the lymph becomes older, they assume more and more the character of those in dense fibrous tissue. The corpuscles, when newly formed, are delicate and trans- parent, but in a short time become more distinct, and are then seen to be composed of a distinct cell-wall, enclosing from three to ei. Appearance of a thin section of the tumour. Fig. 150. Another section treated with acetic acid. 250 diam. Fig. IT)7. Soft polypi growing from the Schneiderian mucous membrane.—(Liston.) —Half natural size. 156 PRINCIPLES OF MEDICINE. structure at once becomes evident. These tumours are of a rounded or Fi2.159. Fig. 160. Fig. 161. Fig. 162. oval form, frequently embedded in a cyst, composed of the indurated structures in which they lie. They are of considerable density, varying from that of tendon to that of ligament or fibro-cartilage, and on section present numerous white glistening fibres, inti- mately interwoven together, or arranged in bundles constituting circles, or loops intercrossing with each other. Occa- sionally they have a calcareous centre or nucleus. Their colour is generally white, but sometimes they have a yellow- ish tinge. They are for the most part not very vascular, although there is great difference in this respect, some approaching the pinkish colour of sarcomatous growths, and others being of dead white and of extreme density, containing scarcely any ves- sels. They vary greatly in size, from that of a pin's head to a volume measuring several feet in circum- ference. These tumours may be situated in various tissues and organs, as in the subcutaneous and submucous cellular tissue, in the mamma, and uterus, in which last-named organ they are most common. When de- veloped in the uterus, they often push the mucous membrane before Fig. 158. Fibre cells and fibres from the pulpy interior of a polypus removed by Mr. Syme. Fig. 159. The same, after the addition of acetic acid. Fig. 160. Ciliated epithelial and pus cells from the exterior of the tumour. Fig. 161. The same, after the addition of the acetic acid. • # Fig. 162. Section of a dermoid fibrous tumour, embedded in the uterine walls. One-fourth of the entire growth is represented. Natural size. _ _ . Fig. 163. Section of a dermoid fibrous tissue from the uterus, after the addition ot acetic acid, showing the concentric direction of the fibres. 250 diam. Fig. 163. FIBROUS GROWTHS. 157 them. In thi3 way they grow outwards, forming what are called hard polypi. At other times they grow towards the serous or internal cavity, pushing the membrane before them in a similar manner, so that it ulti- mately constitutes a neck or pedicle, by which they are attached to the uterus. Such pedunculated fibrous tumours are sometimes found in the peritoneum, growing from the uterus. Occasionally the pedicle breaks across, and the tumour becomes free in the serous cavity. To the same cause are owing the small fibrous, oval or round bodies, called loose cartilages, found in the joints, more especially that of the knee, some of which are truly osteo-cartilaginous. Others are found in the veins, and denominated phlebolites. apparent (Fig. 163). Not Fis-m- unfrequently these latter are collected together in masses (Fig. 164), and sometimes they are isolated, as in the sarcomatous tumours; but then the proportion of them to the fibrous element is generally small. The bony nuclei of such tumours are composed of amorphous mineral matter, not of true bone (see Fig. 345), although Lebert says that on two occasions he has seen true bone produced. Wedl also has figured true bone in the inte- rior of these growths. (See Fig. 270.) The two forms of fibrous growth now spoken of may frequently be found associated together in one tumour. Some are composed of several rounded or oval masses varying in size, enclosed and separated from each other by a cyst, or layer of areolar tissue. The external surface, under such circuni- Fig. 164. Section of hard uterine polypus, which had been boiled in dilute acetic acid and dried ; a, groups of nuclei, surrounded by bundles of fusiform fibres—( Wedl). 250 diam. Fig. 165. Section of Neuroma connected with three nervous trunks.—Natural size.—(Smith.) 158 PRINCIPLES OF MEDICINE. stances, is more or less nodulated. It may frequently be observed that some of these nodules are soft and pulpy—semi-gelatinous, with a very sparing layer of fibrous tissue; whilst others may be seen more or less tough, gradually passing into a fibro-cartilaginous density, grating under the knife. Nay, even in the same nodule I have frequently observed some parts of it soft and others hard, and have shown that the softer parts are mostly cellular, and the harder fibrous, and that between the two there are many degrees of variation. Xeuromatous Fibrous Tumours.—This form of fibrous tumour is de- veloped in the nerves, sometimes spontaneously, at others as the result of injuries, and especially of amputation. In the museum of the Rich- mond Hospital, Dublin, I examined a most remarkable series of prepara- tions, taken from two individuals, in whom almost every nerve of the body presented knotty swellings. In some places these were developed into tumours, which varied in size from a pea to that of the human head.* A subcutaneous tumour, described by the late Mr. W. Wood of Edinburgh, must be referred to this class of tumours.f All these neuromata, on being minutely examined, are found to con- sist of fibrous texture, more or less dense, the filaments often arranged in wavy bundles running parallel to each other, but occasionally assum- ing a looped form, or intercrossing with each other, as in Fio-. 162. I have also found them to contain groups of cells, so that, on the addition of acetic acid, they closely resemble the structure represented in Fig. 164. Fig-166. Fig. 167. Not unfrequently they are fibro-cartilaginous, sometimes with the cells closely aggregated together, at others widely scattered (Fig. 166). In some of the neuromatous swellings described by Dr. Smith of Dublin,* I found the fibrous tissue to present wavy bundles, among which a few * See Smith's Treatise on Neuroma—Dublin, 1849. t Edin. Med. and Surg. Journal, 1812. Fig. 166. Thin section of a subcutaneous tubercle, composed of fibro-cartilage. Fig. 167. Fibrous structure of a neuromatous swelling, given to me by Dr. Smith, rom one of the cases he has described. 250 diam. FATTY GROWTHS 159 granule and cartilage cells were scattered and shrivelled, apparently from the action of spirit (Fig. 167.) Fatty Growths.—Lipoma. The morbid increase of fat is frequently so imperceptible, that it is impossible to separate the pathological from the physiological state. Obesity may gradually increase, either locally or generally, internally or externally, so as to cause, not only inconvenience, but actual disease. Some individuals have become celebrated from their excessive fatness. (See Polysarcia.) Fat sometimes occurs in masses being only an exaggeration of the normal texture of the part, as when it collects about the heart, in the omentum, or on the serous membranes, in which case it takes the exact form of the included viscera. Fat may also be aggregated in masses in unusual situations, and then form the so-called fatty tumour. Fatty tumours vary in size; they may reach a growth weighing upwards of 30 lbs. Sometimes their surface is lobulated, at others smooth. They are of a yellow colour, resembling adipose tissue, aud Fig. 168. Lobulated Lipoma of the nose.—(Bickersteth.) 5205 160 PRINCIPLES OF MEDICINE. are occasionally divided into bands by white fibrous tissue. The rela- tive amount of these two elements varies greatly in different specimens, some being soft, oily, containing few fibres, others being hard and dense, the areolar tissue preponderating. For the most part they are very sparingly supplied with blood-vessels ; the vessels abound most in the fibrous varieties. In the latter case they are liable to ulcerate, and, under such circumstances, have frequently been mistaken for cancer. _______ Some of tliese growths, indeed, may be con- Fig. 170. Fig. 171. matter is composed of vesicles of a round or oval form, more or less liable to undergo alterations in shape from pressure (Fig. 170). They vary Fig. 169. Smooth Lipoma, removed from under the tongue, one-half the natural size.—(Liston.) Fig. 170. Two layers of voluminous fat cells, varying in size, from a Lipoma. 200 ai. Fig. 171. Fat cells from the same Lipoma, dried, showing crystalline bundles ot Margaric acid. 250 diam. CYSTIC GROWTHS. 161 from the T-,r ^nth to ^|7th of an inch in diameter; are composed of a diaphanous cell-wall, which frequently includes a nucleus. The nucleus is generally round or oval, about the ^Voth or y^„th of an inch in diameter. Occasionally it is stellate or penniform, of a crystalline appearance, from the formation of crystals of margarine or margaric acid around it (Figs. 171, 172 a). On rupture of the cell-wall the oil may be made to flow out, and the cell-wall puckers or shrinks up. Such collapsed cells may frequently be seen among the more perfect formations, mixed with glo- bules of oil and fat granules. The fibrous tissue presents the usual appearance of are- olar texture runuing between groups of the adipose cells, being denser, and occupying greater space, according to the proportion in which it enters the tumour. Steatoma- tous and melicerous fatty matter may con- sist of the cells just described, mingled in various proportions with granular matter. In some melicerous encysted growths, we have found the whole to be composed of granular matter, in which faint traces of delicate cell-walls were seen more or less compressed together. In all such productions the relative amount of the vesicular and granular' elements varies greatly. An excess of fat may cause the entire disappearance of the usual structure of a part, and its conversion into adipose tissue. The muscular system is very liable to this fatty transformation or degeneration, which often occurs in the heart, aud in muscles which have not been much ex- ercised, owing to local disease or paralysis. In this case adipose tissue generally springs up in the cellular substance surrounding the muscular fasciculi, and by its increase and pressure upon them, causes the trans- verse striae to disappear, aud the whole to assume a granular appear- ance—(See Fatty Degeneration, Fig. 304). Fig. 172. Cystic Growths.— Cystoma. The different crypts and follicles of the skin and mucous membrane as well as several of the excretory ducts of internal organs, may become obstructed, and as a consequence enlarged and hypertrophied. It is true such growths usually consist of one or more elementary tissues, aud do not therefore properly constitute a class of themselves. Their im- portance iu a practical point of view, however, as well perhaps as the difficulty of knowing under what head to describe such compound growths, warrants our speaking of them separately. Eucysted growths arc composed of a cyst or envelope, enclosing various kinds of contents. They differ greatly in size, situation, and structure, which renders their arrangement somewhat difficult. By some Fig. 172. Structure of a Fibro-Lip ymatous tumour; a, isolated cells, showing stellate crystals of Margaric acid. 210 diam. 11 1(32 PRINCIPLES OF MEDICINE. they have been divided into simple and compound, according as the tu- mour is formed of one cyst, or is composed of several. By others they have been arranged, according to the nature of their contents, into h/gromatous, atheromatous, melicerous, and steatomatous growths. The latter mode of division is very faulty, as many of these varieties are only altered forms of one substance—fat; whilst some compound encysted tumours contain various kinds of contents in separate cysts. But as there can be no doubt that the peculiar contents give to these growths a distinctive character, we shall first speak of them as simple or com- pound, and then describe their different kinds of contents. Simple cystic growths.—These growths are formed of a cyst generally composed of fibrous tissue, lined by a smooth membrane. Sometimes the membrane is structureless, or only composed of areolar tissue. At other times it is covered with a distinct layer of epithelial cells the nuclei of which are very apparent on the addition of acetic acid. The former kind con- stitute the vesicles so fre- quently found in the plexus choroides, in the kidneys, ovaries, etc., and vary in size from a pin's head to that of a hazel nut, or even walnut, and usually have aqueous contents. The lat- Fi(r 173 ter kind constitute the cys- tic growths wdiich arise in the follicles of the skin, in the mamma, ova- ries, testicles, etc.; these frequently reach the size of an orange, and are sometimes much larger, and vary greatly as to the nature of their con- tents. For the most part they are only sparingly supplied with blood- vessels, and seldom cause inconvenience except from the deformity they occasion when situated externally. Compound cystic growths are of two kinds. 1st, The external sac may contain on its internal surface second- ary or even tertiary cysts, which may be sessile or pedunculated—or the growth may be divided into numerous compart- ments by divisions of the fibrous sac. v V \Y ) These are the true multilocular encysted Fig. 174. Fig. 175. tumours. The external cyst in every case is formed of fibrous tissue. The internal surface is smooth, sometimes with, at others without an epithelial layer. The primary, as well as the Fig. 173. Simple cyst of the broad ligament of the uterus, with very vascular walls, a, New vessels; b, broad ligament.—(Wedl.} 30 diam- Fig. 174. Diagram of compound cystic growth, containing secondary and tertiary cysts, developing themselves endogenously. Fig. 175. Diagram of compound cystic growth, in which the included cysts are formed by irregular divisions of the fibrous sac. CYSTIC GROWTHS. 163 secondary cysts, are for the most part richly supplied with blood-vessels, and hence they are peculiarly prone to contain exudation which may undergo various kinds of development. They may also ulcerate. In the ovary these growths frequently attain an enormous size, mea- suring several feet in circumference; the cystic internal membranes often secreting more or less rapidly even gallons of fluid. 2d, Numerous cysts may be pedunculated from one stock, and more or less crowded together, with a tendency to grow out- wards instead of inwards; as happens in the case of so-called uterine hydatids, Fig. 176. which is a cystic disease of the chorion, as described by Mittenheimer. taB-_:___ ■•■-. Section of the wall of the same cyst, showing the epithelial cells in situ. Fig. lt>4. Cells from the interior of a simple cyst, a, b, c, Cells developing endo- Renously, independent of the nucleus, which is embedded in the wall of the parent cell; d, e, the same, undergoing the fatty degeneration; f, g, cylindrical epithelium, seen sideways and from above ; h, polygonal epithelium cells; i, fibre cells.—( Wedl.) 250 diam. 166 PRINCIPLES OF MEDICINE. fibrinous exudation (Fig. 185,187). Such is the general structure of the atheromatous encysted growths of various authors. Fig. 1S5. Fig. 180. Again, the fatty matter may be more or less lardaceous in character, and consists of beautiful round or oval cells, some of which are distinctly Fig. 187. Fig. ISs. nucleated. Mixed with these may be a granular matter, combined with Fig. 185. Structure of cholesteatoma, consisting of disintegrated fat vesicles and epithelial scales, with numerous crystals of cholesterine.—(Beale.) 215 diajn. Fig. 186. Encysted tumour, with fatty steatomatous contents. Natural size— (Liston.) Fig. 187. Contents of a large atheromatous cyst, opened by Mr. Syme, consisting of numerous crystals of cholesterine, oily granules, granule and pus cells, with en- closed cysts containing oil granules.—(Murchison.) 200 diam. Fig. 188. Adipose cells embedded in a fatty granular matter, from a steatomatooi encysted tumour of the ovary. 250 diam. CYSTIC GROWTHS. 137 epithelial cells or their debris (Fig. 188). At other times no distinct cells can be observed, only a granular or amorphous mass, the greater part of which is soluble in ether. This constitutes the steatomatous encysted growth (Fig. 186). 6. Many encysted growths contain hair and teeth. The hair is occa- sionally inserted into the walls of the cyst, at other times lies loc^e in it, mixed with the fatty or other contents. The hair has exactly the same structure as the hairs in other parts of the body, having distinct bulbous roots. When attached they are surrounded by a follicle in the lining membrane; when loose they have been evidently grown in follicles, and been afterwards separated. Their apices are frequently split up into seve- ral fibres in the longitudinal direction. The teeth belong sometimes to the first, and sometimes to the second dentition. They present on section the usual structure of cavity, with ivory, enamel, and bone. Sometimes they are found embedded in a follicle of the lining membrane, at others, like the hairs, they are quite unattached. 7. Occasionally the cysts contain lymph, softened fibrin, and purulent matter, presenting the structure of molecules (Fig. 189), or of pus and granule cells—this is the result of exudation into their cavities. Occasionally there is a serous ; fluid more or less mixed up with extravasatcd blood, giving to the ^^^^^^^^^^^3pM!M^p^^| iMf* contained liquid various colours and appearances, according to the age of the extravasation. Thus it may be red, dark brown (re- sembling coffee), of a dark-green- ish tinge, etc. etc. Sometimes it is of a dark-bluish or blackish tint from excess of pigmentary deposit. 8. Sometimes the contents of a cystic growth are formed of a solid exudation, which has undergone the sarcomatous transformation as previously described, and wholly consists of fusiform cells (Fig. 190). The exuda- tion poured into such cysts may pass into the can- ; cerous formation, aud then the characters we have •' described will be associated with those which dis- y tinguish cancer. •-*! 9. Some cysts contain the peculiar secretion of ':::^.~-\f.£$$lfs the organ in which they are found. Thus cysts iu F. ]go the liver may be full of bile, and those in the kid- ney of urine. 10. Lastly, cysts may contain a greater or smaller amount of mineral matter. Fig. 1S9. ;••:■.■-.'ii ■; 111! The mode in which encysted growths are developed is—1st, By the hypertrophy of pre-existing tissues, whereby, from the accumulation of lig. 189. Cysts in cystic-sarcoma of the mamma, filled with molecular matter. lig. 190. Fibrous tissue composed of fusiform corpuscles, from a sarcomatous encysted growth in the kidney. 250 diam. 168 PRINCIPLES OF MEDICINE. materials within, canals are distended, follicles or vesicles enlarged, and their walls thickened. Thus the simple cysts in the plexus choroides are owing to effusion of serum into the areolar spaces in the villi of the membrane, and their subsequent distension. Those in the kidney may be owing to the dilatation of uriniferous tubes above an accidental obstruction in the same manner that the whole kidney may become encysted from obstruction of the ureter. The Malpighian capsules, also, or the shut sacs of the thyroid, may be distended with fluid, which thus forms cysts. I like manner the crypts of the skin, the blind sacs of conglobate glands, or of the follicles of mucous membranes, become obstructed at their orifice; and their contents gradually accumulating, distend the walls, which become enlarged and thickened. Simple cysts in"the ovary become dilated by enlargement of isolated Graafian vesicles, either deep in the stroma of the organ, or on the surface, when they grow outwards, and become pedunculated. This mode of cystic formation, from distension by material that cannot readily find an cs-ape, is remarkably well observed in bones, in which cysts are some- times produced in conse- quence of accumulated pus. In the Edinburgh University Museum is a remarkable pre- paration, in which a large osseous cyst has been deve- loped in this manner, at the lower end of the Femur (Fig. 191); and in the Edinburgh College of Surgeons' Mu- seum, is another, which has formed in a similar manner in the head of the tibia (Fig. 192). In the first spe- cimen the osseous cystic walls are thin, in the second they are greatly thickened. In this respect they resemble the cranial bones, which in some cases are expanded and rendered thin, and under other circumstances become preternaturally thick through disease. 2d. The origin of compound encysted tumours is not so well de- termined. It is very probable, however, that in most cases they consist of clusters of simple cysts, which become compressed together, assume an increased power of growth, and are at length surrounded by a cap- sule. They are most common in the ovary; and here we can readily understand how successive growths of Graafian vesicles may give rise Fisr. 191. Fig. 191 Cystic-osteoma of the femur. One-eighth the natural size.—iMt'l"') Fig. 192. Cystic-osteoma of the tibia. One-eighth the natural size.—(Miller, cop'I from the preparations above referred to.) CYSTIC GROWTHS. 169 cither to the appearance of secondary or tertiary cysts, or to the mul- tilocular form we have described. Once produced, the compound cyst enlarges, the individual ones grow sometimes inwards and sometimes outwards, according as there is more room for expansion in the one direction or the other. In the former case they open into each other by ulceration. Hence, in very old compound cystic growths,'we find one large cavity with the traces on its internal wall of previously existing cysts, or bands and divisions with pouches between them. In the latter ease they grow outwards, forming clusters of cysts more or less pe- dunculated, as in the so-called hydatid moles of the chorion (Fig. 177, a). These endogenous and exogenous modes of growth are sometimes found in the same specimen. 3d, Another mode in which compound cysts are formed is by the gradual enlargement of the areolae in newly-formed fibrous tissue. On examining thin sections of sarcomatous growths, we observe the fila- Fig. 193. Fig. 194. mentous tissue arranged in a circular form, enclosing spaces varying in size. These spaces are often lined by a distinct epithelial membrane, and sometimes contain serum, blood, or exudation, either in a granular or fibrous state. Such growths have long been known under the name of cystic sarcoma (Figs. 193, 194, and also Fig*. 170, 189). 4th, The glandular or epithelial cells of an organ assume an increased power of development, and become scattered through its tissue in great numbers. In the kidney especially, a cystic disease is not unfrequently met with, in which the cysts vary from the size of a pea down to the TnV.rth of an inch in diameter, as may be accurately traced with the aid of the microscope. The diagnosis and treatment of encysted growths belongs to the spe- cial pathology of each organ affected by them. It need only be men- tioned here that a knowledge of the structure of these tumours is not unimportant, as an examination of the fluids discharged from them fre- quently enables us to speak with certainty regarding their nature. Fig. 193. Cy.-ts in cystic-sarcoma of the mamma, crowded with cells; a, the cells ufter the addition of acetic acid. Fig. 191. Fibrous stroma from another part of the same tumour, with commen- cing enlargement of the areolar spaces, after the addition of acetic acid. 250 diam. 170 PRINCIPLES OF MEDICINE. Glandular Growths.—Adenoma. Glandular growths are essentially hypertrophies of gland texture, in the same manner that fibrous or fatty growths are an increase of fibrous or fatty tissues. But the structure of a gland is compound, and cm- braces two kinds of growth. Strictly speaking, the growths are fibro- epithelial, but of a kind so peculiar as to warrant Lebert and Birkettin constituting them into separate groups. Glandular growths may be regular or irregular, that is, they may involve the entire gland or only a portion of it, and in the latter case they may assume the form of tumour. They may also be perfect or imperfect, in the first case closely resembling the gland structure, in the second differing from it in various degrees, and passing into fibrous, cystic, fatty, and other forms of growth. It is not our intention to enter Fig. 195. into minute descriptions of the various appearances and modifications of structure they present in the several glands. Under the names of chro- nic mammary tumour, bronchocele, enlarged prostate, and hypertro- phied, indurated, or swollen glands, their existence was recognised be- fore their structure was known. While now it has become apparent that growths, which are truly glandular in their nature, have frequently been mistaken for fibrous and even for cancerous formations. These growths are sometimes lobulated, with the lobes more or less compressed, and the interlobular fibrous tissue varying in density and amount. They may reach a considerable size. One, removed from the female breast by Mr. Syme, which I carefully examined, was larger than Fig. 195. Structure of a cystic glandular tumour of the neck, in the neighbour- hood of the thyroid gland, a, Appearance of a portion slightly separated and viewed by a simple lens,presenting a grape-like bunch of lobules; b, c, d, ultimate lobules, composed of single or branched ca?cal tubes, distended with epithelial cells; e, dis- tended condition of these on the addition of water; f, alteration of their shape on pressure; g, fusiform cells found in small numbers.—(Redfern.) 250 diam. GLANDULAR GROWTHS. 171 the human adult head, and weighed upwards of eight pounds. To the feel they vary in density, are lobular or smooth externally, and in the latter case are not unfrequently surrounded by a fibrous capsule. On section they are sometimes smooth and glistening, at others somewhat granular and dull. The cut surface varies in colour, sometimes being almost white, at others of a pale yellow, pink, or fawn colour, apparently from the greater or less amount of vascularity of the particular speci- men. Their mode of growth is by no means uniform. Sometimes they remain indolent and stationary, then again they increase steadily in size, slowly at one time and rapidly at another. Occasionally, after giving rise to much anxiety, they gradually disappear, but not unfrequently they present all the external characters and symptoms of fibrous or sar- comatous tumours, and now and then those of true cancer. In structure, glandular tumours consists of gland elements—that is to say, of a basement membrane, urnished with blood-vessels on one side, and nucleated cells or nuclei on the other. Their firmness, softness, and friability, depend upon the amount of fibrous tissue in them, and upon the number of cells. The follicles are frequently much distended, pre- senting blind sacs apparently without ducts, and are crowded with epi- thelial cells, more or less compressed together. If ducts do communi- cate with them, these are similarly distended, as seen in Fig. 198. The thyroid gland is especially liable to a new formation of tissue, first described by Rokitansky, in which embedded in a lax fibrous stroma and rounded vesicles, surrounded by a layer of delicate pavement epithe- Figs. 196, 197, and 198. Structure of a glandular tumour, surrounded by a fibrous cyst, removed from the female mamma. Fig. 196. Thin section transverse to the glandular lobules, after the addition of acetic acid, shewing the condensed epithelial lining membrane and enclosed epithelium cells. Fig. 197. a, Mass of epithelium separated from the cut lobule ; l>, cellular contents ; c, the same, after the addition of acetic acid. Fig. 198. Longitudinal section of one of the ducts leading from the lobules, after the addition of acetic acid. 250 diam. !72 PRINCIPLES OF MEDICINE. Hum and containing colloid substance, which escapes when one of these is ruptured, rig. 199, a, B.* Whether the remarkable structure denominated by M. Robin, " Tumeur Hete- radenique,"f iu any way re- sembles this, it is difficult for me to say, never having had an opportunity of examining a specimen. Lymphatic glands are very liable to enlarge through lo- cal irritation, arising from a neighbouring ulcer or injury; O™ v and the mesenteric glands are (~) I N. ' x especially f-o, in consequence of the various ulcers which form in the intestines. In typoid fever they are fre- quently found swollen as large as hens' eggs, present- ing a reddish or purple hue externally, soft and spongy to the feel, on section exhi- biting a granular texture and greyish hue, and on pressure yielding a dirty white juice. This juice Fig. 199. or "cA0 0 Fig. 200. . Fig. 201. Fig. 202. abounds in the cell elements ot the gland, which exhibit an increased * Zur Anatomie des Kropfes, Wien, 1S49. \ Lebert's Anatomie Patholo.irique Generate et Speciale, Liv. 10, 11. Fig. 199. New formed tissue in a follicle of the thyroid gland. A, Areolar fibrous tissue surrounding the epithelial-like lining of the areolae. Many of these have been removed to show the glandular formations within. These vary in shape, some, 6, a, being constricted, others round or oval—a, c. B, colloid masses of various shapes from the interior of a a. g, Epithelium, with commencing fatty degeneration, seen also at d, e, and/, h, Blood-vessels containing colourless corpuscles of the gland.— (Wedl.) Fig. 2 jO. Cells in fluid, squeezed from a mesenteric gland, in a case of typhoid fever. Fig. 201. The same in another case. Fig. 202. The same cells, after the addition of acetic acid. 250 diam. EPITHELIAL GROWTHS. 173 power of development. The cells enlarge, their nuclei divide into two, these increase by division into four, or a multiple of two, and often form a cluster in the centre of the cell, as seen in the accompanying fio-ures (Figs. 200, 201.) The causes whicii excite glandular growths are not always apparent. They may be constitutional and local, and in the latter case the irrita- tion exciting them may be direct, as from a blow; indirect, as from a neighbouring sore ; or reflex, as when uterine diseases affects the mamma. Sometimes when the apparent cause is removed, the glandular growth disappears, but at others it continues to grow independently of any- such cause. The laws, which regulate the occasional persistence or disappearance of these growths, have not yet been determined, but one essential and hitherto unrecognised condition, with regard to their inde- pendent growth, admits of being explained in the following manner : At first the irritation, however communicated to the gland, whether direct or reflex, operates by stimulating it to increased cell-growth, and by augmenting the flow of blood. Hence ensue turgescence and en- largement, with the formation of cells, often in such numbers that they cannot readily escape. This is especially the case in the female mamma of young women not pregnant, in whom, while this morbid action is progressing, the proper function of the organ is in abeyance. Hence the follicles enlarge more or less rapidly, and according to the amount of irritation and increased nutrition which results, is the consequent amount of growth. It frequently happen*, however, that if the increased amount i>f cell elements can find a ready exit, they retain their normal type for a certain time, and on the cessation of the cause, they cease to be formed or accumulated, and the growth disappears. But when they assume a power of independent development, this is not so readily accomplished. In this case they continue, and, by the permanent stimulation to growth, form persistent tumours. Again, the enlargement of glands in the neighborhood of canceroui and scrofulous ulcers or growths is not necessarily caused by the pre- sence of cancer, or tubercle in them. I have frequently examined en- larged axillary glands, which have been removed with cancerous breasts, and found nothing but simple hypertrophy of those glands. Iu the case of an extensive epithelioma of the thigh, for which amputation was performed by the late Mr. R. Mackenzie, the inguinal glands on the affected side were greatly enlarged. After the death of the individual, I found no epithelioma in those glands, but again only simply hyper- trophy. But if this condition be allowed to remain for auy length of time, epithelioma as well as cancer does form in them, or simple aud tubercular exudations are thrown out, which assume the character of pus or tubercle. It follows that enlarged glands are not a necessary proof of the extension of certain growths secondarily, and that, as we shall subsequently see, their commencement, instead of discouraging, ought perhaps in certain circumstances to lead the surgeon to an early excision of the tumour. Epithelial Growths.—Epithelioma. The epidermic and epithelial cells are continually thrown off from the 174 PRINCIPLES OF MEDICINE, skin and mucous membranes, and new ones are as constantly formed. Numerous circumstances may arise, which induce their production in greater numbers, or their accumulation in particular parts. In this case they may soften and give a morbid character to fluids, as that of the urine, or they may become indurated, causing thickenings or swellings on.the mucous surfaces, callosities, or tumours of the skin. Structures composed of epidermic growths, as hair or horn, may become excessive, or arise in parts which are unusual. Lepcrt was the first to point out that many of the tumours hitherto called cystic, fibrous, and even can- cerous, belong to this class of growths. In all cases, they consist of an increased number of epidermic or epithelial cells, more or less com- pressed together, frequently united by filaments of fibrous tissue, and supplied by blood-vessels. The term epithelioma, first introduced by Hannover, may be appropriately applied to the entire group. The following are the principal forms assumed by this kind of growth:— 1. Corns and Callosities consist of a local hypertrophy of the epider- mis, and arc composed of numerous epidermic scales condensed into an indurated mass. The corn is a distinct rounded or acuminated tumour, varying in size from a barley-corn to that of a pea, more commonly surrounded by indurated epidermis. On examining a vertical section under high magnifying powers, it appears irregularly fibrous, but on making a horizontal section these are shown to be the edges of epider- mic scales, each of which has its distinct nucleus. Occasionally these cells soften and separate from each other, constituting the soft corn. Callosities of the skin exactly resemble corns in structure, but are dif- fused over a greater surface. Both corns and callosities are occasioned by interrupted pressure upon any part of the skin. To a certain extent they protect the delicate nervous filaments below. At other times, from their bulk or hardness, they cause increased pain whenever the pressure is modified or increased. Corns are common on the feet from undue pressure of the shoe; callos- ities occur on the knees of housemaids, on the hands of handicraftsmen, sempstresses, etc., or in any other portion of the surface exposed to pressure. The cure consists in removing the cause. We have fre- quently observed, that during an attack of fever and the subsequent con- valescence, the corns and callosities on the feet of patients have disap- peared, having "grown out," as it is called. Changing the shoe or bootmaker, or obtaining another last, has been known to remove them. 2. The scaly skin diseases must be classified among epidermic growths. Accumulations of epidermic scales, upon a reddened and indurated sur- face, constitute their characteristic features. In psoriasis they are gath- ered together in considerable masses. In pityriasis the scales are smaller, are more easily separated from the surface, and frequently asso- ciated with minute cryptogamic vegetations. The flattened and im- bricated form of ichthyosis is also composed of similar accumulations of epidermic scales, but without the reddened surface. (Fig. 85.) 3. Warts and Condylomata are also, for the most part, composed of epidermic cells condensed together. The wart consists of projections of a papillary form, varying in size, and occurs under circumstances where pressure does not take place. These growths appear to be constitutional, EPITHELIAL GROWTHS. 175 or associated with peculiar states of the body. Thus condylomata and SS^-. ■.:,-'.'• > Fig. 203. Fig. 204. warts are frequently found round the margins of the anus, vulva, and- perns, in syphilitic individuals. Warts, assuming the form of cauliflower excrescence, often arrive at a large size in such situations, weighing even several pounds. They frequently form on the hands of vouiTg persons and are sometimes found in other parts of the body, coming and goino- without any obvious cause. Condylomata, when closely examined, seem to be made up of a con- geries of papillae (papilloma), sometimes flattened at the top, so that they cannot be separated ; at others, presenting fissures or sulci which lead down to a common stalk. Sometimes the papilla? are small and rounded; at others, elongated and en- larged at their extremities. The tumours thus formed may be only the size of a pin's head, or may be so large as to weigh several pounds. In the latter case the central portious seem to consist of a fi- brous structure, probably an hypertrophy of the dermis, which is supplied with blood-vessels (Fig. 20G). Their surface sometimes is smooth, resembling thick- ened epidermis ; at others it is lobulated, composed of rounded groups of papillae, resembling externally a cauliflower. flii^ tumours, when small, are almost wholly composed of epithelial scales, which assume a square or elongated form, their nuclei being for the most part very distinct. In the larger growths the sur- face is similarly composed, but internal- ly we find more or less areolar tissue, supplied with blood-vessels. On 1 ig. 203. Warts on the penis. One-fourth the natural size.—(Acton.) rig. 2o-t. Summit of a papilla from a wart. *!ij—l)5' ^erPencJicular section of a papilla from an acuminate condyloma, after the addition of acetic acid, a, Vascular loop—internal to whicii is fibrous tissue form- ing the axis of the papilla—outside are nuclei, b, b, Basement membrane, c, c, Lpidermic ee\U.-{Wedl.) 250 diam. 176 PRINCIPLES OF MEDICINE. ^fe Fig. 200. snipping off a small isolated papilla from such a tumour, and examining it entire, it presents a couical or round projection, covered with epider- mic scales, as in Fig. 204. When a vertical section of it is made, we ob- serve a vascular loop, surrounded by basement membrane, external to which are layers of epithelial cells varying in thickness (Fig. 2();">). The Ver- ruca Achrocorclon is a peculiar epi- dermic tumour, furnished with a cen- tral canal, through which blood-vessels ramify abundantly to all parts of the tumour. The central parts of such tumours are composed of fibrous structure (Fig. 200) ; externally they consist of epidermic scales, arranged concentrically round the central vascular part, which, if cut into, gives rise to great haemorrhage. (Vogel.) All these tumours may soften and ulcerate on the surface, and, under such circumstances, give rise to purulent and ichorous discharges. 4. Another form of epithelioma is one whicii frequently commences as an ulcer, although sometimes it is preceded by slight induration of or a small wart on the part affected. It is common in the under lip, in the tongue, and in the cervix uteri. In the lip there may often be observed a furrow or groove in the indurated spot or wart, in which the ulceration com- mences. This slowly extends, with indurated, thickened, and raised margins, is cir- cular and cup-shaped, its sur- face sometimes covered with a white cheesy matter, at others with a thick crust or scab (Fig. 207). It slowly extends, until it involves a greater or less portion of the lip and neighbouring parts, pouring forth a foul ichorous discharge. In the tongue, the disease follows a similar Fig. 207. course ; the base of the sore, however, is generally more fungoid or papillated on the surface, and ex- ceedingly dense, owing to the close impaction and compression together of laminae of epithelium. These on section present a mass having a white sur- Fig. 206. Transverse section of the base of a condyloma. The dark shading in the centre and radiating lines, represent dense fibrous vascular tissue.—( Wedl.) ■ Fig. 2o7. Ulcerated epithelioma of the lip.—(Liston.) EPITHELIAL GROWTHS. 177 face, with a tendency to split up and separate, are dense to the feel, and do not yield on pressure a milky juice (Fig. 20sj. On the cervix uteri similar ul- cers are very common, with hard irregular edges, yield- ing a copious ichorous dis- charge, and causing more or less thickening of the neigh- bouring textures. The so- called cauliflower excres- cence is a form of epithelioma ; so also are the cancer of the scrotum of the chimney sweeper, certain forms of rodent ulcer, and of noli me tangere. An epithelioma of the hand is well figured by Mr. Paget,* and so also is a remarkable one in the interior of the stomach by Professor A. Kctzius.f In all these cases, the ulcers, when examined microscopically, present -.-*V on the surface masses of epithelial cells in all stages of their develop- ment. Some spherical aud nucleated are about the tttVo tQ 0I> an iQeQ in diameter, others are much larger; both often resembling cancer-cells when isolated or viewed alone, but associated with flattened scales, varying in shape and size, sometimes occurring in groups adherent at their edges, at others mingled together in a confused mass. Many of the cells and scales often reach an enormous size (Fig. 210), and as they become old, split up into fibres. These elements are commonly mingled with numerous molecules and granules, naked nuclei, fusiform, granular, aud pus cells. Below the surface the epithelial cells may be seen more * Surgical Pathology, vol. ii. p.417. f Museum Anatomicurn Holmiense. Sect. Path. Tab. 7. 1855. Fig. l'i 'S. Section of an ulcerated epithelioma of the tongue. Natural size. Fig. 20!). Epithelial cells compressed together, immediately below the surface 0- the ulcer, Fig. 208. Fig. 210. Epithelial cell*, one of them very large, in white curdy matter squeezed from the duct, seen Fig. 208. Fig. 211. The same, seen in mass. 250 diam. 12 178 PRINCIPLES OF MEDICINE or less compressed and condensed together, and when the epithelioma is Fig. 212. Fig. 213.] chronic, and the structure dense, these present concentric laminae sur- rounding a hollow space or loculus, evidently owing to the compression Fig.'214. Fig. 215. Fig. 216. together of numerous epithelial scales. This peculiar appearance, some- times called " cell nests," is characteristic of this form of epithelioma Fig. 212. Concentric laminae of condensed epithelial scales, from the lower portion of the white matter seen Fig. 208, with epithelial cells, and fragments of muscular fasciculi. Fig. 213. Muscular tissue immediately below the white mass, Fig. 208. Fig. 214. Epidermic scales, in mass and isolated, from the surface of an epithelioma of the scrotum, in a chimney-sweep. Fig. 215. Group of deep-seated cells, in the same case. Fig. 216. The same, after the addition of acetic acid. 250 diam. EPITHELIAL GROWTHS. 179 (Fig. 212). On breaking them up, they exhibit a variety of forms, iu whicii their epithelial character is visible on the one hand, and the fragments of concentric circles are seen on the other. The lymphatic glands in the neighbourhood of such ulcers have a great tendency to be secondarily affected, in which case they enlarge, soften, and easily break down under the finger. Not unfrequently thev contain a yellow cheesy-looking substance, which, under such circum- stances, represents fatty degeneration, analogous to the reticulum of cancerous formations. On crushing a portion of the altered glandular substance between glasses, it presents the appearances represented Fig. 217. If the concentric masses are broken down, the individual epithelial M ^vi^Srftt; Fig. 218. cells are rhere also seen to be of various fantastic shapes, in which fragmentary portions of circles are detectable (Fig. 217). In the yellowish portions the nuclei are composed of fatty granules, and the cells themselves are molecular, and mingled with numerous oily particles (Fig. 21S, also Fig. 02). A modification of this form of epithelioma occurs on mucous surfaces, especially in the urinary bladder, and has been variously called villous cancer, dendritic vegetation (Zottenkrebs of Rokitansky). It forms a fungous projection, having a fibrous basis which is elongated into branched stems, supporting villi, more or less aggregated together, and covered with a layer of epithelial cells. It is soft, and readily breaks down under the finger, the pulpy matter exhi- ''%eW Fig. 219. Fig. 22" biting under the microscope numerous irregularly-shaped cells, partly Fig. 217. Fragments of the concentric masses figured, Fig. 212, from a lymphatic gland. Fig. 218. Epithelial cells, in yellow cheesy matter, of the same gland. Fig. 21!>. Culls in pultaceous white matter, from a fungoid epithelioma of the urinary bladder. Fig. 220. The same, after the addition of acetic acid. 250 diam. 180 PRINCIPLES OF MEDICINE. fibrous, and partly epithelial, in various stages of development (Fig. 219). 5. Hairy formations.—Great varieties exist in different individuals regarding the amount of hair on their body. Some men have been known to be as hairy as certain of the lower animals. Patches or groups of hair, seated on a somewhat indurated base, may frequently be seen scattered over the surface in parts usually smooth ; these constitute a form of so-called mole on the skin. Hair has been found on the surface of the mucous membrane, and even in the lungs ; and is common in encysted tumours, especially of the ovary and testis. In several such cases I have found the root of the hair implanted in a follicle, at other times loose, with the roots of a bulbous form exactly resembling those on other parts of the body. The point of the hair is generally somewhat truncated, presenting at its extremity two or more fibres, produced by the longitudinal splitting up of the hair. In lengtn they vary from one quar- ter of an inch to several inches. 0. Horny productions.— Under this head may be classed the prominent growths in some forms of ichthyosis; tumours re- sembling warts, but so in- durated as to resemble horn, and true horny ex- crescences growing from the surface. In some forms of ich- thyosis, the growths stand out as distinct spines, broad on the surface, nar- row at their insertions, like columns of many sides accurately fitting to their neighbours. Horny tu- mours occasionally occur, varying in size from a bean, or extending over a space the size of half- a crown. Many cases are on record of true horn Fig. 221 having grown from the surface, especially from the head, originatnig in some sebaceous follicle. Fig. 221. From an old preparation in the Edinburgh University Museum. The medal attached to it bears the following quaint inscription—" This horn was cut by Arthur Semplc, chirurgeon, out of the head of Elizabeth Low, being three inches above the right ear, before these witnesses, Andrew Temple,, Thomas Burne, George Smith, John Smytone, and James Tweedie, the 14th of May, 1671.—It was growing seven years ; her age, 50 years." Natural size. VASCULAR GROWTHS. 181 They have grown several inches long, as seen in Fig. 221. On making a section of these productions, they are found to be identical with the structure of true horn in the lower animals, or with that of the nails on the hands and toes. They consist of condensed epidermic scales, which, on the addition of acetic acid, assume all the characters of such structures. Vascular Growths.—Anyionoma. Vascular growths are formed by an increase in the dimensions or number of the arterial, capillary, or venous vessels. Several growths already described, as well as such as are of a cancerous nature, are very vascular; indeed, so much so, that in some cases the slightest touch causes alarming haemorrhage, as in the case of so-called uterine polypi, and fungus hmmatodes. No doubt there is considerable increase of vas- cular growth in such tumours, but their basis is formed of other mate- rial,—they are not wholly vascular. This term is more properly applied to those diseases which have hitherto been denominated aneurism, erectile tumours, and vttrix 1. Aneurism is an arterial swelling, which may vary in size from the slightest possible dilatation of the calibre of the vessel, either wholly or partially, to the formation of enor- mous tumours, larger than the human head. Fig. 222. In such cases, we find the growth to consist externally of the dilated and hypertrophied structures of the vessel itself, or of the tissues in its immediate neighbourhood, and of lay- ers of blood,more or less coagulated within it. The varieties of Aneurism are numerous, but the principal are—1. Aneurism by dila- tation, in which the whole circumference of the vessel is dilated. 2. lis;. 222. True saccular aneurism of the aorta, nearly filled with coagulated clot.— One-third the real size.—(After Hodgson, slightly modified.) 1 ig. 22,'?. Remarkable spontaneous varicose aneurism, formed by communication between the vena cava and the aorta at its bifurcation. A, Aorta ; B, Vena cava; C, Aneurism; D, Situation of a round aperture somewhat larger than a sixpence, through which the communication between vein and artery was kept up.—(Syme.) 182 PRINCIPLES OF MEDICINE. Saccular, also called true Aneurism, in which one portion or side of the vessel is dilated into a sac. 3. False Aneurism, in which the coats of a vessel have been ruptured. It has been called primitive when all the coats are divided, as by a wound, and consecutive, when it is consequent on ulceration or rupture of the internal and middle coats. 4. Mixed Aneurism, in which, after dilatation, general or partial, of all the coats of a vessel, the internal and middle ones burst, and a false aneurism is superadded. 5. Dissecting Aneurism, in which there is laceration of the internal and middle coats, so that the blood becomes infiltrated between the coats of the vessel, separates them for a greater or less dis- tance, and bursts externally at some distance from the internal lesion. 6. Hernial Aneurism, in which the external and middle coats are lace- rated, and the internal protrudes through them, forming a hernial aneu- rismal sac. 7. Aneurism by anastomosis, in which an artery, by an unnatural communication with a vein, causes a pulsating tumour in the latter. The tendency of these growths is to burst externally or internally into spaces where least resistance is offered, but occasionally the clot of blood in the interior coagulates to such an ex- tent as to close up the cavity, prevent influx of fluid, and cause spontaneous cure—a result which is observable in the figure of a very rare specimen of aneurism of the left coronary artery described by Dr. Peacock.* The special Fig. 225. pathology of these growths, however, is far too extensive a subject to be entered upon in this place. * Monthly Journal of Medical Science, March, 1849. Fig. 22-i. Aneurism of the coronary artery, completely filled with coagulated clot. Natural size.—{Peacock.) Fig. 225. Section of erectile tumour.—(Miller, after ?) VASCULAR GROWTHS. 183 2. Erectile growths are generally soft; for the most part situated in the subcutaneous tissue, the skin covering them being of unusual deli- cacy. When compressed, they may be gradually emptied of blood, which returns like water into a sponge on removing the pressure. For the most part they are congenital. When the arteries are numerous in them, they have a brownish or reddish colour, and pulsate during life. When the veins abound, they are of a blue or purple colour. Their texture consists of numerous capillaries, more or less distended, mixed with arteries and veins, the interstices of which are filled up by areolar tissue. A section presents a spongy texture, composed of fibrous bands closely resembling the appearance of the corpus cavernosum penis, with areolae or spaces into which the blood enters (Fig. 225). The section of a fresh tumour is not unlike that of a sponge soaked in blood. In structure it is composed of vessels of all sizes, abounding in capillaries, which are more or less sacculated or aneurismal, and anastomose freely with each other. In one case of erectile growth in the liver, I found Fig. 226. the intervascular structure to consist of caudate and branched cells, and Fig. 22T. in another in the brain, I found it loaded with earthy salts. Fig. 226. Varicose cutaneous vessels of the anus in the subcutaneous cellular tissue. Fig. 227. Dilated papilla? of the skin, cut horizontally, the light-coloured papillary structure containing dilated vessels.—(Wedl.) 60 diam. 184 PRINCIPLES OF MEDICINE. Varix is a permanently enlarged and tortuous vessel. Swellings from this cause are for the most part venous, and may exist in various parts of the body, but are frequent in the saphena veins of the inferior extre- mities the* spermatic veins (varicocele), and haemorrhoidal veins (hemor- rhoids). In all these cases the veins gradually enlarge, and then be- come distended, tortuous, and coiled up. Several of these, accumulated together, may produce knotty swellings in the legs, cause the testicle to assume an unusual size, or produce tumours, which, during defalcation, are protruded beyond the margin of the anus. Such growths may ulcer- ate, and cause death by haemorrhage, or they may be spontaneously obliterated by the formation of clots within them. An artery rarely becomes varicose. The enlargement of vascular growths, for the most part arises through dilatation of the vessels ; no new materials are produced in them, with the occasional exception of such as arise in the clot of blood within them, viz. fibrous or albuminous laminae, or calcareous masses. Through the presence of these, the vessel becomes obliterated, and gradually assumes the density and appearance of ligament. Fisr. 229. Fig. 230. Fig. 231. Fig. 232 Fig. 233. Xcw vessels constitute one of the most common pathological forma- Fig. 228. Varicose vessels in the caput triqonum resicee.—(Wedl.) Fig. 229. Inner layer of umbilical artery of calf, eight inches long.—(Drummond.) Fig. 230. Succeeding layer in the same vessel, composed of spindle-shaped cor- puscles.—(Drummond.) Figs. 231 and 232. Layers more external in the same vessel, in different stages of development into fibres.—(Drummond.) Fig. 233. Common carotid artery of an embryo calf two inches in length, showing different directions of the fibre cells.—(Drummond.) 200 diam. ^ VASCULAR GROWTHS. 185 tions. In the embryo the capillaries originate iu independent cells, which throw out arms or prolongations that unite with one another (Figs. 234 and 23")). The larger vessels originate in globular cells which become fusiform, and arrange themselves, some longitudinally and others trans- versely, to constitute the different coats of the vascular wall (Figs. 229 to 233). In the adult the ob- servations which have been made in connection with this subject, have led to three theo- ries. 1st, That new vessels are of independent origin, and that it) If A they, as well as the blood they i '/ contain, spring up in a blastema U$y according to the general laws of VM. cell formation. 2d, That the |-|i:7 globules of the blood, escaping (fay from the vessels, channel a way through the surrounding exuda- tion, and thus form new vessels. 3d, That the walls of the old f g. 234. vessels themselves at particular places present bulgings and irregularities which become pushed out more and more by the vis a tergo, and so form new channels. An inquiry into this subject is surrounded with difficulties, but all the results of modern research tend to the conclusion, that in exudations new vessels for the most part have an independent Fig. 235. Fig. 207. origin, being formed as in the embryo ; although old vessels may occa- sionally send out off-shoots or prolongations. Thus in lymph we some- times observe cells in all stages of development, of the spindle-shaped and branched forms, which, according to the observations of Drum- mond,* and more recently of Billroth,! by their fusion, or by their * Monthly Journal of Medical Science, November, 1854. + Billroth Ueber die Entwicklung der Blutgefiisse, Berlin, 1856. Fig. 231. Stellate cells in the tail of the tadpole, developing into capillary vessels. lig. 235. Capillary vessels in different stages of formation from stellate cells, in the eye of the foetal calf.—(Drummond.) rig. 230. Branched cells in lymph exuded on the peritoneum. 1 ig. 237. Vessels in an early stage of formation, from a colloid tumour of the back. 250 diam. 186 PRINCIPLES OF MEDICINE. arrangement side by side, form capillaries of various magnitudes. These capillaries afterwards unite themselves with the pre-existing vessels. Cartilaginous Growths.—Enchondroma. Cartilaginous growths were first described by Miiller, under the name of Enchondroma (Osteochondrophites of Cruveil- hier). In the soft parts they are surrounded by an envelope of cellular tissue, and in the bones by a bony capsule. In the first case they occur, although very rarely, in the glands, as in the parotid or mamma. In the second case they are most common in the bones of the extremities. The tumours may be round and smooth, or rouo-h and nodulated from several of them being accu- mulated together. Though hard to the feel, they often present a peculiar elasticity. They crunch when cut with the knife, usually present a smooth, glistening surface, and are not unfrequently more or less soft, pulpy, gelatinous, and even diffluent in some parts of their substance. They are rarely Fig. 238. met with. In structure, enchondroma presents all the characters of cartilage— ^ 1 f\ft -^v^k , Fig- m Fig. 240. Fig. 241. that i°, nucleated cells varying in size, isolated or in groups, situated in a hyaline substance. A network of filamentous tissue runs through the substance of the tumour, forming areoke, in which blood-vessels ramify. VVuhin the areolae so formed the cartilage is found. These two ele- ments vary as regards amount in different tumours. Sometimes the cartilage is in excess, resembling that in young animals, or that in the , f'g- 238\ Enchondroma of the hand and fingers. The tumour, of which a section fU11S 6. °Se,A' It*fiT >°f aJim- P°rtion of the same tum°nr. Fig! m. hZt^et^ VfeTlaX:ed theCells' these ^ving been washed out. anencLndLaTthSur at 1 0. Diseased human articular cartilage, from a scrofulous joint, showing the enlar^iih'nt of the corpuscles, the increase of the nuclei within them, and their escape into the intercorpuscular softened substance—[Redfn-n.) lig. 2.)1. Similar alteration in costal cartilage of the donf, caused by the passage of a seton thirty-four days before death.—(Redferu.) rigs. L'.»2 and 253. Different appearances of enlarged cells in diseased human ar- ticular cartilage.— (Redfern.) 190 PRINCIPLES OF MEDICINE. the same results, showing that to**^*™^**^* cell nutrition and growth (Figs. 250 to -5/, and ZiO). Fi£?. 255. Fig. 256. Fig. 25T. Osseous Growths.—Osteoma. We have seen that in many cartilaginous growths deposit of J™e m? take place to a greater or less extent. In such casesjthej^cartilaginous Fi<* 054 Vertical section of cartilage from the surface of the patella, showing the ""SK ttU£ wdc^.i^r^fr'dis.ased »,.icul„ «*»> "•'^r/^Sf "Tiofibrou, paction,, ta. the teu.en. -*»£* eased human semilunar cartilage.— (Redfern.) OSSEOUS GROWTHS. 191 tissue undergoes the true bony transformation, in the same manner that Fig. 258. Nodulnted exostosis attached by an osseous pedicle to the inferior and inner portion of the femur of a woman, set. 23. It had been growing from her ear- liest youth, was accidentally broken off by a blow, and shortly after excised by Mr. St/iiic Natural size. Fig. 259. Lateral view of an exostosis, removed from the posterior and inner sur- face of the humerus, two inches from its head, by Mi-. Syme. At a, a piece of the tumour has been broken off, showing the cancellated structure of the interior.—(Lister.) Real size. Fig. 260. Part of a section through one of the prominences of the tumour, a, Superficial cartilage ; <■, a portion of deep-seated cartilage, surrounded by dense bone ; 6, and d, e, calcified cartilage not so dense as the more superficial portions.—(Lister.) Real size. Fig. 201. Section of a portion of the tumour at the line of junction of the calcified cartilage, and the cancellous structure of the interior, the earthy matter having been removed by dilute hydrochloric acid, a, Cartilage, with its cells changed by the pro- cess of calcification; b, c, is true bone, containing laminae, lining the excavations in the calcified cartilage ; d, part of a spiculum of the cancellous structure; e and f. (paces formerly occupied by medullary substance.—(Lister.) 200 diam. 192 PRINCIPLES OF MEDICINE. normal cartilage becomes os.sified in passing from the foetal state through the periods of youth, manhood, aud old age. This we must separate from the numerous forms of calcareous concretions so frequently met with. True bone may be at once recognised by its osseous lacunae and canaliculi. Earthy concretions only consist of an amorphous mass of mineral material. (Compare Figs. 265 and 345). Osseous growths may affect the external surface, the substance, or the internal surface of bone. In the first case they are denominated exosto- ses. They form prominences on the surface of the bone varying in size from a small point to that of a cccoa-nut. There is no part of the osse- ous frame free from them, but they are very common in the bones of the extremities. They may arise as the result of direct local injury, as from a blow or fall, or they may be connected with peculiar constitutional diseases. In syphilitic constitutions, exostoses more especially arise on the shafts of the long bones; in rheumatic persons they surround the joints. Many of these growths on the surface of bones have not been shewn to originate in cartilage as the bones themselves do. But in others there can be no doubt that such is their mode of growth, viz. matter is thrown out from the blood, which is converted first into cartilage and then into bone (Fig. 261). In this manner enchondroma may be con- verted into osteoma. The growths in-which this, change is observable generally present roundish masses. They may be intensely hard or eburnated, or comparatively soft and cancellated. This is owing to the bone texture being more compact in the one case, and more spongy in the other. Externally they may be covered with a layer of cartilage, and a smooth membrane (Fig. 258). Bony growths may more especially affect the substance of bones, and this in two ways. An exudation may be poured into the cancelli of the osseous texture, whicii is gradually transformed into perfect bone. From this cause its substance becomes much indurated aud of great density, and the cancelli and medullary cavity are more or less obliterated. We frequently observe this in the long bones of the inferior extremity as well as in the flat bones of the cranium. Some of the latter have thus become upwards of an inch in thickness, and on section presented the close texture and density, although not the structure, of ivory. Some- times, however, the bones, instead of being condensed aud thickened, become spongy, the cancelli enlarge, and the whole assumes unusual lightness. Iu this case, the exudation poured into the cancelli is trans- formed into pus, and acts as a distending power, and sometimes collects in a central cavity, causing at the same time expansion and hypertrophy of the surrounding osseous tissue (Figs. 191, 192). On other occasions the new osseous growth assumes the form of spicula, radiating from the shaft, a result most common in cases where the bone is the seat of sar- comatous or cancerous formations, through which they ramify (Fig. 262). ° Bony growths are sometimes thrown out on the internal surface of the cranial bones. This occurs in a peculiar disease first described by Ro- kitansky in puerperal women. I saw this formation frequently in Berlin, on the internal surface of the cranial boues, in the numerous dissectious. which occurred in the Maternity Hospital of that city during an epide- OSSEOUS GROWTHS. 193 mic puerperal fever which raged there in 1840. Unfortunately, they were not examined microscopi- cally. The internal table of the skull in all these cases was so soft, that the knife could rea- dily penetrate if. These de- posits, when dry, assume a gra- nular laminated aspect, more or less curled up and separated from the internal lamina of the cranial bones. Very fine spe- cimens of this lesion are to be found in the pathological mu- seums of Prague and Vienna. There is a form of growth generally originating in bone, which is soft, easily breaking down under the finger like rice- pudding or marrow (hence called myeloid by Mr. Paget). It has frequently been con- founded with soft cancers, as pointed out by Lebert, and, in addition to fibrous and fusiform cells, contains others of a round or oval form, varying in size from the T^oth to the 7£oth °f an inch in diameter, having in their interior from two to twenty nuclei. These growths occur in various situations, but Fig. 202. are most common in bones, especially of the jaw, constituting certain forms of epulis (Figs. 263, 264). The large cells often contained in the friable matter of such growths (Fig. 264), closely correspond to the many nucleated corpuscles described by Kolliker, as, occurring in the marrow of foetal bones.* A remarkable example of it is figured by Mr. Paget, occurring in the bones of the cranium, and in the brain.f The growth of new bone, after fractures or injuries, takes place in the following manner: An exudation is poured out from the vessels in the neighbourhood, which at first unites the lacerated edges of ruptured * Manual of Human Histology, vol. i. fig. 7. t Surgical Pathology, vol. ii. p. 222. The peculiar character and structure of these growths may ultimately warrant their being classified among the primary division of tumours, under the name of myeloma. But at present our acquaintance with them is limited, and the many-nucleated cells, which is their chief characteristic, I have seen in growths presenting all the characters of sarcoma, adenoma, epithelioma, and enchondroma. r ig. 262. Spicular growth of bone, in an osteo-carcinomatous tumour of the tibia. One-fourth the natural size.—{ Syme.) 13 ) 194 PRINCIPLES OF MEDICINE. Fist 2G4. periosteum, muscle, and cellular tissue, so as to form a capsule around the whole of the denuded and injured bone. This exuda- tion, at first granular, is partly transformed into fibrous tis- sue, and partly into com- pound granular corpuscles, which may be observed to form an internal coating tu the capsule just alluded to. The blood extravasated is rapidly absorbed, and a gela- tinous exudation, which is poured out from the neigh- bouring capillaries, collects between the capsule and denuded bone. This, at first yellowish, becomes gradually lactescent and white, and assumes __. „ ^-^~. all the characters of fibro-carti- lage. (Fig. 265, a.) This car- tilage, in its turn, is transformed into bone, by exactly the same process as the one structure passes into the other in the normal state. As solidification takes place, the soft parts are absorbed and contracted, whilst the bony growth, in the form of spicula, forming the boun- \ daries of large cancelli (Fig. 205, b), insinuates itself between and around the fractured bones, producing complete union. Certain textures have been occasionally transformed into true bone. I examined the preparation of an eye at Munich, in the possession of Professor Forg, which contained an osse- ous mass, attached internally to the choroid and fibrous structure of the sclerotic, and encroachiug considerably on the space usually occupied by the vitreous humour. A thin section of it exhibited numerous bony corpuscles. A similar osseous transformation of the choroid membrane and lens has been described and figured by Dr. Kirk,* in a diseased eye of thirty years' standing (Figs. 267, 268, 269). I have seen true bone formed in the substance of the dura mater, where it has been exposed * Monthly Journal of Medical Science, November, 1853. Fig. 2C5. Fig. 263. Epulis removed fro n the upper jaw. Natural size.—(Syme.) Fig. 26-t. Cells with many nuclei in epulis. , Fig. 265. a, Fibro-cartilage formed between the separated portions of a fractured cervix femoris; b, new csseous structure, in the form of a bony spiculum or trabe- cula between the large cancelli, from the same fracture.—( Wedl.) 25u diam. OSSEOUS GROWTHS. 195 after removal of a portion of the cranium by the trepan. The osseous laminae, sometimes found on the surface of the spinal arachnoid, also Fig. 266. Fig. 267. Fig. 268. possess the true bony structure (Fig. 269). Ligaments have occasionally been transformed into osseous texture (Henle); the calcareous concretions Fig. 261). Fig. 270. occasionally found in the centre of fibrous tumours, though generally com- posed of amorphous mineral matter, are sometimes formed of true bone Fielf been able to do this through the kindness of Drs. Van der Byl and Handfield Jones. T Journal of Practical Medicine and Surgery, March 1858, p. 485. 14 210 PRINCIPLES OF MEDICINE. Constitutional Treatment.—We are altogether unacquainted with any means of counteracting the tendency which predisposes to morbid growths. But considering that for the most part the constitutional change is connected with excess of nutrition, and in this respect is alto- gether opposed to what we observe in cases of scrofula and tubercle, we may infer that lowering the nutritive processes, while we yet allow the general tissues to be supported, should be the rule of practice. In car- cinoma, and rapidly formed growths, the body (unless it produce emacia- tion by attacking the chylopoietic viscera) is for the most part fatty, and diminution of this element in the food should be aimed at. But at a later period, when exhaustion makes its appearance, nutrients and stimu- lants will be required to prolong life. MORBID DEGENERATIONS OF TEXTURE. In the same manner that there may be hypertrophy or increase, so there may be, although from exactly opposite causes, atrophy or diminu- tion of texture. Atrophy may consist in simple decrease of bulk, the organ or tissue otherwise retaining its usual structure and function. There may be less work to do, and less force consequently -required; and for the same reason that the legs of a dancer become larger, those of a bed- ridden individual become smaller. So also as there may be increased bulk with alteration of texture, so there may be diminished size with change of tissue. These latter atrophies, as they constitute true organic diseases, especially merit our attention ; and they may be arranged in four groups, viz.—1st, albuminous; 2d, fatty; 3d, pigmentary; and 4th, mineral degenerations. Albuminous Degeneration. AVe have already seen how essential albumen is to nutrition ; and that to be made assimilable in various forms to the tissues of the body it must be .subjected to certain processes. Under other circumstances it may be effused, or collect in particular parts of the system, constituting organic diseases. If transuded through the vessels in a fluid form, that is, dissolved in water, as we find it in the serum of the blood, it produces what is called dropsy. If precipitated from its solution in a solid form, it may constitute a variety of inorganizable deposits presenting various kinds of ultimate structure. Lastly, tissues composed of various proxi- mate principles may be wholly converted into an albuminous substance, and thereby have their vital properties impaired or lost. We shall notice these shortly in succession. Albumen in solution is frequently effused from the blood-vessels as serum, constituting dropsy. It is distinguished from an exudation by containing no fibrin. There is not, therefore, that disposition to rapid coagulation and formation of an organizable blastema, although there is often a precipitation of matter, capable of assuming various forms. ^e ALBUMINOUS DEGENERATION. 211 have seen that an exudation depends on an alteration of the vital force which governs the attraction and selection of nutritive materials from the blood. Serous effusion or dropsy, on the other hand, is always indi- cative of mechanical obstruction to the return of blood from the capilla- ries through the veins. Thus, pressure of a tumour on the large venous trunks, disease of the heart and liver rendering the circulation difficult, or of the kidneys and skin diminishing the secretion or exhalation of fluid, are its most common precursors. In Bright's disease of the kid- ney, conjoined with various changes in the texture of the organ, serum containing albumen passes off in the urine. Membranous Albumen.—Albumen, in solution, if it exist in tolerable Fig. 2S6. quantity, is very apt to be precipitated in flakes or membranes. At the onset of vesicular diseases, as pemphigus, the fluid effused has been observed on being heated to contain smooth or folded laminae (Fig. 2S0). The same lamina? may be produced artificially by bringing oil of chloroform in contact with serum. Hence they are not fibrinous but albuminous. The mere shaking of white of egg, or manipulating serum in various ways, will often cause these laminae to form and constitute shreds, which resemble fibres, but are truly membranous (Panuni, Melsens). Sometimes such membranes, if produced slowly, collect round a central nucleus and ultimately form a concretion. The same has been observed by Wedl in the scrotum where the skin was converted into a tough substance like caoutchouc (Fig. 287). The con- centric laminae which form the interior of aneurisms present a similar structure, and are probably albuminous. (See Concretions.) r ig. 286. Structureless membrane formed by heating the clear fluid of pemphigus. On the left hand the membrane is folded together.—( Wedl.) 800 diam. 212 PRINCIPLES OF MEDICINE. Fibroid Albumen.—Many tissues, especially fibrous ones, when exposed 1_ .. ___j. •„ _______*. „f-------- 1_____ . Cells of the liver, in waxy degeneration of that organ. 250 diam. ALBUMINOUS DEGENERATION. 215 the Malpighian bodies, being compressed together, shrivelled, and pre- senting a similar pale, translucent appearance. 4th, I have seen the same tran>f< >rmation in the placenta as well as in simple chronic cancer- ous, and tubercular exudations. This lesion is not unfrequently associated with the fatty degeneration, next to be spoken of, especially in the liver and kidney, when in a cirrhosed state. (See Fig. of Cirrhosed Liver.) It would appear from analyses of the liver, mostly made by Dr. Drummond, and collected by Dr. W. G-airdner,* that the human liver, when affected with the waxy degeneration, contains less water, considerably less fat, and a greater amount of solid constituents than natural. Colloid Degeneration.— We have previously seen that there is a pecu- liar form of cancer called colloid, in which glue-like matter is associated with cancer cells. Dut colloid occurs independently of cancer, consti- tuting the sole contents of certain cysts (see Cystoma). It would appear to vary in chemical composition, as I have observed that specimens of it sometimes coagulate into a solid mass, whilst at others they are unaf- fected by the action of spirits. If not identical, it is at least allied to the albuminous degeneration. The enlargement of the thyroid gland in bronchocele, and the contents of compound ovarian cysts, are generally Fie. 296. Fig. 297. owing to the formation of colloid matter (Fig. 29G). Not unfrequently colloid masses become indurated, and assume a radiating striated appear- ance (Fig. 297). ^r • * Monthly Journal of Medical Science. May 1854. withcoiloiTm?uC*i0l^the-thyr0id b°dj' W'th S°me °f US Slandular sacs> distended Hg. 207. Radiated colloid masses from a cvst in an atrophied kidney, a, Lines r »' fj a central P°int>* &. radiated mass surrounded with a .dear border; '™7 ma^with a central granular substance and radiated border c; d, the centre _J\S/Ttemal ^^ b°rder'' e' a mass with two gra^ar globules in the ^ "' 250 diam. 216 PRINCIPLES OF MEDICINE. General Pathology and Treatment of the Albuminous Degeneration. It has been previously pointed out that albumen is essential to nutri- tion, and that it forms the basis of the blood and of the tissues. The flesh which constitutes the food of carnivora, and the albumen which comprises so large a portion of the fodder of graminivora, are alike, by the solvent action of the digestive juices, reduced to a fluid state. In this condition it passes into the blood, forming the walls of the blood- corpuscles, besides entering largely into the constitution of the liquor sanguinis, as serum, that is, albumen dissolved in water. During the building-up process it undergoes various transformations, among which those of its conversion into the fibrin of flesh, and the gelatine of bones, are perhaps the most important. By its association with the other prox- imate principles, also, it enters into the composition of every texture and organ in the body, and again joins the blood as albumen, mixed with a minute portion of effete matter as fibrin. There can be no doubt, as we shall subsequently see, that under certain circumstances it may he changed into fat also, so that from multitudinous transformations this important element is susceptible of undergoing, it well merits the term which, in its pure state, Mulder bestowed upon it, namely, that of " pro- teine." As albumen, we have seen how it may produce abnormal conditions of the tissues in various forms. The essential conditions for this kind of degeneration appear to be—1st, Extreme slowness of effusion from the blood-vessels, as in cases of chronic tubercle and fibroid transforma- tion ; and 2dly, Mechanical obstruction of the veins, in some part of the circulation, giving rise to dropsy. In the former case, it is favoured by excess of acidity in the primae viae, which, by its power of dissolving the albuminous compounds, must assist in adding this element to the blood in undue proportion. Why, on the other hand, muscles, cartilage, and the exudations, should sometimes pass into the albuminous fibroid degeneration, under much the same circumstances that at others they become fatty, is a point in pathology which is still involved in obscurity. The treatment will depend on the cause, nature, and seat of the dege- neration, but these in the living body are so obscure and deceptive as frequently to afford no indication for remedies. In the albuminous tubercular exudations, correcting excess of acidity in the stomach and bowels tends to check its excess, whilst the administration of animal oils favours its transformation into the nutritive molecular basis of the chyle. Wherever mechanical causes, or interruptions of the venous circulation, give rise to dropsy, recovery will depend on the means at our disposal for their removal. Fatty Degeneration. I have previously described fatty growths (see Lipoma), which, by encroaching on neighbouring tissues, and especially muscles, cause their atrophy. I have also shown how fatty matter accumulated within cysts, undergoes various transformations, both histological and chemical, at one time presenting a granular form, and at another a crystalline one, com- FATTY DEGENERATION. 217 posed of cholesterine or margerine (see Cystoma). It is now ascer- tained that there is no kind of tissue, whether healthy or morbid, that may not undergo a fatty degeneration. Such alteration frequently causes one of the mo-4 formidable organic diseases which the physician is called upon to treat. Reposition of Fatty Molecules and Granules.—Fat is as necessary a constituent of the food and of the tissues as albumen, and its universal presence in the organs, texture, and fluids of the body, renders it easily capable of precipitation and accumulation, if in excess. The moment the smallest particle of oil is formed, and comes in contact with an albu- minnus fluid, a membranous precipitation of the latter takes place around it, whicii tends to keep the various fatty molecules distinct and separate from each other. No doubt, under the action of heat, trituration, pres- sure, or the action of acids, which dissolves the albuminous envelope, the molecules are sometimes fused together, and constitute smaller or larger globules. The great predominance of the molecular form of fatty depo- sition, however, is evident in all morbid alterations of texture. In this state we find it constituting the substance of the atrophied supra-renal and thymus glands in the adult; the exudation in chronic softening of the brain, and other parenchymatous organs; accumulated within cysts, the result of trans- formation of their contents; in the centre of colloid masses; in chronic exudations, and extra- vasations of blood, presenting a milky, yellow, or fawn-coloured hue; or in the blood, urine, Fis- 298' and other fluids, giving them a chylous character. Indeed, the presence of fatty molecules may be said to be almost constant in morbid products; aud, when collected together in masses, they constitute organic lesions of the greatest gravity. Fatty Degeneration of Cells.—It was shown by Reinhardt, that all kinds of cell formation, under certain circumstances, undergo the fatty degeneration. The manner in which this is accomplished is in all cases the same. A few fatty molecules first form between the nucleus and cell-wall. These increase in number, and some of them apparently are fused together to produce larger ones. This process goes on until at length the whole couteuts of the cell consist of fatty molecules and abedefgh i k Fig. 299. granules. The nucleus is now no longer visible, and in many cases Fig. 298. Fatty molecules in groups, from the opalescent or white opaque centres of large colloid masses in the ovary. rig. 299. Granular corpuscles and masses from cerebral softening, a, Nucleated cell with a few granules; b, granule.- within the cell, partly obscuring the nucleus ; c, granules over the nucleus; d, granules within the cell, no nucleus visible; e, cell nearly filled with granules ; f, cell completely filled with granules; g, cell contracted m its middle; A, granular mass, the cell-wall having dissolved; i and k, granular masses peeled off from the vessels. 218 PRINCIPLES OF MEDICINE. wastes away, as if from pressure. Occasionally, this fatty deposition of molecules takes place within the nucleus in the first instance. (Fig. 92.) In either case the cell-wall, distended by the accumulation of fatty par- ticles, at length gives way, and the included oil granules either separate or for a time adhere together in granular masses. Sometimes tliese bodies are easily ruptured by external violence; at others they are more a bed e Fig. 300. resistant, and the oily matter is forced through the cell-wall, and collects outside, whilst the cell itself is more or less collapsed. In this way, col- lections of fatty granules and granular cells take place in the ducts of all glands whicii are lined by epithelium ; in the air vesicles of the lung and in the bronchi; in the cells of the liver, causing fatty degeneration of that organ ; in the shut sacs of vascular glands, as the spleen, and in all cell formations in exudation, especially those of pus and cancer. In stall-fed animals, a moderate accumulation of fatty granules in the interior of the hepatic cells is a normal condition; and the amount of fat in various tissues, which separates health from disease, is, under a variety of circumstances, impossible to determine with exactitude. Fatty Degeneration of Muscle.—There can be no doubt that the fibro- albuminous substance constituting flesh is capable of undergoing a trans- formation into fat. Of the exact chemical nature of that transformation we have yet to be informed; but it may not only be observed in the dead body, but may be produced artificially, by exposing muscle to a running stream of water, whereby it is changed into adipocere. In Fig. 300. Granular corpuscles acted upon by pressure, a, Some of the oily gra- nules made to coalesce ; b, oil forced through the cell-wall; c, the same with collapse of the cell-wall; d, rupture of the cell-wall; e, dislocation of the nucleus. 250 diam. Fig. 301. Early stage of fatty degeneration of voluntary muscle, a, The muscle breaking across; b, the fibrillar easily separated. In both specimens the tissue is soft, although the transverse strife are still visible.—(Wed'.) Fig. 302. Advanced stage of fatty degeneration in the muscular fasciculi of the heart. The transverse ttriae have disappeared, and the fasciculi are wholly composed of oil granules and globules more or less aggregated together.—(Wedl.) . Fig. 303. Another example of advanced fatty degeneration of voluntary muscle, the fasciculi presenting various degrees of the alteration. 250 diam. FATTY DEGENERATION. 219 voluntary muscle, we observe that the degeneration commences with diminished distinctness of the transverse striae, especially at the circum- ference of the fasciculus. As this extends inwards, minute molecules of fat occupy the position of the striae, and at length obliterate them; gradually these coalesce, globules of various sizes are formed within the sarcolemma, and the normal structure of voluntary muscle disappears. During the early changes the fasciculus becomes soft, exhibits a tendency to crack crossways, and ultimately is so pulpy as to be capable of being squeezed easily into an amorphous mass, from which large oily drops exude. To the naked eye, the muscular substance becomes paler, and more fawn-coloured, and at length yellow, and its normal density is greatly diminished. These changes are easily observed in the heart, in which organ they have been made the subject of special research by Ormerod, Paget, Quain, and others. The histological and clinical researches of Dr. 11. Quain* on this subject are of the greatest importance. All the voluntary muscles, however, are susceptible of undergoing a similar lesion, and it not unfrequently occurs in those of the lower extremity after long continued paralysis, disease of the hip joint, or other lesions which necessitate immobility of the parts. In this case, and occasionally in the heart itself, in addition to the transformation of the muscular fasciculi above described, adipose tissue accumulates between them, and by compressing their substance adds to the rapidity and com- pleteness of the transformation. In such cases the muscles are of a pale yellow colour, yielding on section large quantities of oil, while they pre- serve their usual form and fibrous look. I have seen all the muscles of * Med. Chir. Trans, vol. xxiii. Fig. 3ii4. Fatty degeneration of the psoas magnus muscle of a lad, who died with morbus coxarius. a, Muscular fasciculi in which no traces of transverse stripe are perceivable. The longitudinal striae are still not quite obliterated, although mingled with numerous fatty granules, b, Muscular fasciculi, wholly composed of minute molecules and granules, with no traces of either transverse or longitudinal striae. '•, tat cells of various sizes, running between and encroaching upon the fasciculi. fig. 305. Other fasciculi from another portion of the same muscle, after the addi- tion ot «ther. The adipose cells have been made round and somewhat flaccid; the nucleus consists of a congeries of brownish granules. 250 diam. 220 PRINCIPLES OF MEDICINE. the lower extremities so affected. Occasionally, while some muscles exhibit this transformation in its most advanced stage, others close beside them present their normal red colour, so that the limb on dissection resembles the alternate red and fatty streaks of bacon. In this case the degenerated muscle has the whole of its fasciculi transformed into adi- pose cells, with nuclei, as seen in Fig. 305. In involuntary muscles fatty degeneration may also be observed, although it is by no means so common as in voluntary ones. In this case oily molecules are deposited in the elongated fusiform cells compos- ing the texture, aud by their pressure on the nucleus cause its disap- ° pearance. AN hether the distended pregnant uterus shrinks to its nor- mal proportions after delivery wholly in consequence of such a degeneration (Heschl) is a point not yet determined. But there can be no doubt that many of the greatly enlarged fusiform cells of the organ (Fig. 141), do become more or less crowded with fatty granules (Fig. 306.) Fatty Degeneration of Blood-vessels.—-The larger blood-vessels, espe- Fig. 306. Fit Fig. 309. daily the arteries, are very commonly the seat of a fatty degeneration, generally called atheroma. It presents the appearance of a whitish or yellowish cheesy, but sometimes indurated and brittle substance, de- posited between the coats of the vessel, and often protruding on its inner surface. This deposit consists of numerous fatty granules, min"p Fig. 306. Enlarged fusiform cells of the pregnant uterus, after delivery, filled with fatty granules. 250 diam- Fig. 307. Atheroma of a blood-vessel. Natural size. Fig. 308. Fatty granules, oil drops and granule cells, with crystals of cholesterine from broken down atheroma of an artery. Fiff. 301). a and b. Two groups of fatty molecules from atheroma of artery. ° b i j 250 diam. FATTY DEGENERATION. 221 with crystals of cholesterine (Gulliver), to which, when hard and brittle, infiltrate the neighbouring tissue. The various appearances of these were carefully described and figured by me in 1842,* and attributed to exudations thrown out from the vessel. In 1849 Mr. Pagetf also described the same facts, and attributed them to fatty degeneration of the vessels themselves. Now, without denying the occasional fatty transformation of the walls of minute vessels, and the accumulation Fig. 811. Fig. 312. of fatty molecules within the nuclei, it may readily be seen that for the most part the fatty granules are outside the vessels. Indeed, the " Edin. Med. and Surg. Journal, vols, lviii. and lis. f Medical Gazette. Fig. 310. Transverse section through the coats of the popliteal artery of an aged woman who had gangrene of the feet, a. Inner coat; b, longitudinal fibre; c, cir- cular fibres; d, fimbriated and elastic coats loaded with fatty granules; e, external areolar tissue.—( Wedl) 200 diam. rig. 311. Cerebral vessels of an aged individual who died of apoplexy, a, Ulti- mate capillaries: b, larger vessel; c. small arterv, with fatty granules scattered over its surface —( Wedl.) Th*. 312. Yc^cls from softening of the corpus striatum, coated with granules and granular masses.—( Wedl.) 250 diam. 222 PRINCIPLES OF MEDICINE. extreme tenuity of the capillary wall does not permit of their forma- tion in its substance, as it is much thinner than the granules themselves. Besides, it may frequently be observed that the large amount of fatty granules outside the vessels is enormously disproportioned to the bulk of the latter, and altogether inexplicable by supposing them to be formed in and given off by "the vascular walls themselves, which for that purpose must assume a secretive fuuction. I have also seen and figured cell- formations in every stage in the granular fatty matter, constituting soft- ening of the brain. (See Fig. 113.) Of these Mr. Paget wrote in 185o,*__" Produced as they are in parts of the brain and cord in which no cell structures naturally exist (for they may be as abundant in the white substance as in the gray), we have yet, I believe, to trace the source and method of their formation." This admission appears to me altogether hostile to the idea of their originating in a degeneration of the vessels, whilst their formation in .an exudation", as I have previously described (p. 131), is consonant with every known fact. The true soft- ening of the brain from deficiency of nutrition frequently exhibits struc- tural changes altogether different, as I shall subsequently demonstrate. (See Diseases of the Nervous System—Softening.) Fatty Degeneration of the Placenta.—The lesion which has received this name from Dr. Barnes and others, was figured by me in 1844+ and likened to that whicii occurs in certain softenings of the brain. I still hold the same opinion with regard to it, and consider the fatty molecules and granule cells not to be formed by a transformation of placental tissue itself, but of the exudation or extravasation of blood which is poured out from its vessels. The yellowish or fawn-coloured deposits Fitr. 313. may be infiltrated throughout the tissue of the placenta over a greater or less space, or they may occur in isolated spots forming nodules. Thev * Surgical Pathology, vol. i. p. 1-16. \ Treatise on Inflammation. Plate—Fig. 10. Fig. 313. Villi from the placenta of a six months' foetus, a and 6, The vessels coated with molecular fatty matter; c, exudation from the vessel, nearly occupying the whole substance of the' villus; d, chronic exudation outside the vessel, converted into brown pigment.—( Wedl.) FATTY DEGENERATION. 223 are generally somewhat indurated, and give rise to the idea that they arc coagulated fibrin. I have frequently examined them and traced all the changes intermediate between a coagulated exudation or extravasa- tion of blood, and the ultimate conversion of the foreign matter into a mass of molecules filling up the intervascular spaces. Similar observa- tions have been more recently made by Drs. Handfield Jones* and Cowan.f In many cases the fatty material may be seen forming a layer separate from the vessel and inside the limitary membrane of the villus. In most cases, also, the texture of the placenta is pale from compression, or Fig. 314. Fiff. 315. Fig. 316. shrunken, but still intact, and the vessels, though coated externally with oil granules, are themselves quite healthy. Occasionally, in atrophied placenta, a quantity of brownish pigment is deposited between the vascu- lar wall and limitary mem- brane of the villus, which is probably owing to a modi- fication of the fatty matter or of the colouring material of the blood (Fig. 329, a). (See Pigmentary Degene- ration.) Fatty Degeneration of Cartilage.—The cells of car- tilage are liable to undergo the same fatty degeneration as is observable in other cells. The molecules * British and Foreign Med.-Chir. Rev. vol. ii. p. 354. t Edin. Med. and Surgical Journal, April, 1854. Fig. 817. Fig. 314. Fatty granules coating the blood-vessels, within the placental villi — (Cowan.) r ™-n Flg' /I15, GrouPs of fattv granules scattered through the substance of a placental villus.—(Cowan.) *ig. 316. Fatty granules both coating the vessels, and scattered through the vil- lous substance.—(Cowan.) ° m,l« g" j'I* Cells in fa"v trachealcartilage. They are filled with fatty brown mole- cules, and the secondary cells contain oil globules.—(Wedl.) 250 diam. 224 PRINCIPLES OF MEDICINE. at first formed, however, are exceedingly minute, thus communicating a brownish opaque aspect to the interior of the cell (Fig. 317). Subse- quently they coalesce and form larger granules, which again unite to produce drops of oil of considerable size. During this change the nucleus disappears, and sometimes the hyaline intercellular substance presents a multitude of brownish points, which communicate to it a marked opacity (Fig. 328). At others it undergoes the fibroid transfor- mation formerly described (Figs. 254 to 257, and 290). Fatty Degeneration of Bone.—Wedl has described the cancelli of bone in syphilitic caries as being dilated and filled with fat, owing to the exu- Fig. 319. a be Fig. 31S. Fig. 320. Fi-. 321. dation poured into them having undergone the fatty degeneration (Fig, 320), and in most cases of ulcerated bone a large formation of oily mole- cules and loose globules of oil may frequently be observed. Virchow has detected similar molecules in the lacunae and canaliculi. The molli- fies ossium, or malacosteon of adults, is also a form of fatty degeneration of bones (Paget), in which the cancelli are loaded with large oil drops, often tinted red. Combined with these, there is a formation of numerous cells, whicii vary in size from the y^„th to the jl„th of an inch in diameter, and contain a round nucleus, also varying much in size, and occasionally showiug various stages of division and of endogenous deve- lopment (Fig. 321). This, like so many other of the so-called fatty degenerations of texture, is probably owing to an exudation from the blood-vessels, mingled with more or less extravasation of the coloured Fig. 318. Horizontal section of the occipital bone in a case of syphilis, o, Dense external table, the internal composed of dilated cancelli filled with fat, seen by re- flected light.—( Wedl.) 3 diam. Fig. 319. Thin section of the same bone showing one of the cancelli enlarged and filled with fat globules, surrounded by empty lacunae.—( Wedl.) Fig. 320. Thin section of the outer table of the same bone.—(Wedl.) Fig. 321. New cells formed in malacosteon. a, From the marrow of the femur; b, others with developing nuclei; c, from a rib in another case, in which some organs were cancerous.—( Wedl.) 250 diam. FATTY DEGENERATION. ■225 corpuscles, in which we find new cells developed, combined with fatty transformations of the albuminous and fibrinous materials. In this re- spect it differs from the softening of bone in rachitis, which may be regarded as arrested development of bone with increased growth of car- tilage cells (Kolliker). Fatty Degeneration of other Textures.—It would occupy too much space for us to describe or even particularise every tissue, that is now known to undergo a fatty degeneration. All the glands may undergo this change. Nervous texture may soften, break up, its fatty material be liberated, and accumulate in oil drops of greater or less size. In em- physema, the pulmonary texture is sometimes fatty. (Rainey.) The cornea (Canton) and the lens (Dalrymple, Lebert), also may be similarly affected, forming soft cataract. Indeed, under various circumstances, it may be said that there is no organ or texture of the body, which in some form or other may not undergo this degeneration. Fatl>/ Degeneration of (he Exudations.—We have already seen that what has often been called fatty transformation of tissue is, in fact, fatty transformation of the constituents of the blood, which have been exuded or extravasated. Simple exudation is constantly undergoing fatty degeneration. I have seen the false membrane of pleurisy con- verted into a creamy substance, composed of innumerable fatty molecules, granular masses, and granule cells. Pus cells may frequently be observed to contain fatty granules, and to present all the intermediate stages of conversion into the granule cell, and the same may be observed in the pus and fibre cells of granulating sores. In Cancerous exudation, the fatty degeneration is so common, as to have attracted peculiar attention, uikLt the name of " Reticulum." This occurs in two forms. In one Fig. 324. it is seen on a fresh cut surface, scattered throughout the growth to a greater or les-s extent, as a network, more thick and abundant, however, in some places than in others. In the other it exists in masses of a bright yellow or orange colour; sometimes closely resembling tubercle, for Hg. 322. Retrograde cancer-cells, granules and granular masses, with crystals of cholesterine, from the reticulum of cancer of a lymphatic gland. lig. 323. Fatty and broken-down cancer-cells, with crystals of margarine, from the reticulum of cancer of the liver. Fig. 324. Fatty granular matter from the softened reticulum of a cancer of the hreast. tig. 325. Liberated and altered nuclei, with fatty molecules from the reticulum of a cancer of the testicle. 250 diam. 15 226 PRINCIPLES OF MEDICINE. I which it has often been mistaken. In the first form, granule cells, loose oil granules more or less mingled with decayed and broken down cancer- cells, are common. In the second, irregular bodies, resembling tubercle corpuscles, resulting from alteration in the form of the nucleus, after the cell-wall has been broken down, are numerous (Fig. 325). In some retrograde cancers I have seen large portions of the growth entirely composed of such corpuscles, and not unfrequently these, as well as can- cer-cells in all stages of decay, are associated with crystals of chole-te- rine or margarine (Figs. 322, 323). Tubercular exudation may always be observed to contain a greater or less number of fatty granules em- bedded in it, as well as contained in the tubercle corpuscles. What is called the softening of tubercle is owing to an increase of these, by the gradual transformation of the albuminous part of the exudation into fatty molecules, whereby the whole is rendered soft and pulpy. (See Fig. 133.) Fatty Degeneration of Morbid Growths.—All these are susceptible of becoming fatty, and consequently soft and pultaceous ; the transforma- tion is accomplished in a manner exactly similar to what we have de- scribed as occurring in the tissues of which they are composed, or of the exudations wdiich are conjoined with them. General Pathology and Treatment of Fatty Degeneration. The causes of fatty degeneration are to be sought in all those cir- cumstances which weaken the vital action of a part, but do not interfere materially with the assimilation of hydro-carburets. The disease, how- ever, is not purely local, as it may frequently be observed that the kid- neys, liver, heart, and other textures, are prone to undergo the fatty change in the same person. Hence everything that increases fatty mat- ter in the blood, such as its introduction by means of assimilation, or its not passing off in consequence of diminished excretion, tends to its deposition. Thus indulgence in rich food, and alcoholic liquors abound- ing in carbon, especially if there be little exercise, occasions it. Whether the fatty matter be deposited directly from the blood, or whether it be the subsequent result of a chemical transformation of tissue or exudation, has excited discussion. Dr. Quain supports the latter view, and has per- formed experiments, whereby it would seem that healthy muscular fibriu may be rendered fatty artificially, by digesting it for a fortnight in water. I have repeatedly seen muscles aud bones converted into adipocere, during the maceration in water necessary to clean the latter, and have frequently examined the former during the process, so as to satisfy myself that the fibrinous material of flesh undergoes a chemical transformation into fat. I believe with Dr. Quain that the same thing occurs in the living body, not only when dead tissues are enclosed in it, as in the experiments of Wagner, but slowly in living texture, until its vigour is at length so impaired that it is incapable of performing its function. This view in no way excludes the probability of the fact that in certain cases fatty matter may transude through the vessels in a fluid state, and collect outside, or be infiltrated to a certain extent among neighbouring textures in a molecular form. Further, we have seen that fat may occur within cells as a secretion, and by its accumulation cause not only atrophy PIGMENTARY DEGENERATION. 227 of the nucleus, but also obstruction of tubes and an endless variety of organic and functional derangement in the economy, according to the extent and seat of the degeneration. The treatment of this lesion is a field of inquiry which as yet has scarcely been entered upon. In most cases, indeed, its diagnosis in the living subject is very uncertain. But the cultivation of histology, by gradually enlightening us concerning those degenerations which are essentially fatty, and enabling physicians to recognize them as the cause of symptoms with which he has been long familiar, will assuredly at no distant day lead to more correct principles of practice. Already we begin to see indications of this in our notions regarding Bright's disease, and in the results of organic chemistry applied to clinical medicine. At present it would be premature to speculate on this subject, and what lit- tle there is to be said will be found under the head of special diseases. Pigmentary Degeneration. The formation of pigment in plants and animals is essentially connect- ed with that of fat, most colours either being different kinds of tinted oil, or secreted in cells at the expense of carbonaceous products, which are readily transformed into fatty compounds. In mor- bid conditions we find several of the textures of a different tints, but more especially red, yellow, brown, green, or black, from chemical alteration in the col- ouring matter, of blood or bile. Sometimes the change of colour is the result of peculiar secretions; at others, of the deposition of carbon. Red Pigments.—All red colouration iu the human body is owing to the presence of blood, the colour- ing principle of which has been called hematine. When observed in an isolated blood corpuscle, in ^^ which it is secreted, the real colour is seen by trans- ^"B ^1 mitted light to be yellow, although, as occurs with a strong infusion or tincture of saffron, it looks red to , the naked eye when concentrated. Unless, how- ° ever, it were known that the real colour of the blood <^ ** 0 is yellow, it would be impossible to understand the ^^ v£> presence of this latter tint around ecchymotic spots, ^ and in other situations. Virchow first described in ^ extravasations of blood prismatic crystals, with Fig. 326. rhomboidal bases, often approaching a needle shape, of a yellowish or deep ruby colour, which he denominated hematoidine. They are most frequently found in the sanguineous extravasations of the brain, in the corpora lutea of the ovaries, and in chronic haemorrhages of the liver, of hydatid cysts, and of other textures, but rarely in pulmonary or cancer- ous extravasations. In size, they vary from the 3^Votn to tne Jo oth of an inch in their long diameter (Fig. 326.) They are transparent, and _ Fig. 326. Crystals of hematoidine. a, Large oblique rhombic prisms ; at +, oblique six-sided prism ; b, smaller forms.—( Wedl.) 250 diam. 228 PRINCIPLES OF MEDICINE. strongly refractive, insoluble in alcohol, aether, dilute mineral acids and alkalies. Concentrated mineral acids cause them to assume the shades of green, blue, rose-tint, and finally a. dirty yellow. Yellow Pigment.—The real colour of the blood corpuscles is yellow, and so is the liquor sanguinis in which they are dissolved, and conse- quently all recent exudations of lymph, as well as most kinds of pus and tubercle. Blood, after being extravasated, is broken down and absorbed ; and as the colouring matter becomes less intense, it generally assumes a yellowish tint, as around ecchymotic spots, and old extravasations. Hence, also, the colour of the corpora lutea, and the yellow softenings of the brain, as well as the deep orange tint occasionally observed an the result of haemorrhages. The adipose texture, as well as the morbid accumulations of fatty matter, assumes a yellow tint, as when muscle undergoes the fatty degeneration, and the reticulum previously described forms in cancer. There is, however, another source of this colour in the bile, as it con- tains a deep yellow pigment, which, when absorbed into the blood, tinges all the textures, and passes off in large quantities by the skin and kidneys. The urine, when impregnated with it in considerable quantity, has the colour of porter to the naked eye. When bile, diluted with water, is treated with nitric acid, a marked series of changes in colour ensue. A little acid renders it green, a larger quantity blue, purple, violet, and lastly, a dull red or brown yellow. These chauges are sup- posed to be owing to the existence of three colouring matters in the bile, one brown, the cholepyrrhin, another yellow, the bilifulvin, both disco- vered by Berzelius, a third the biliphcein of Simon. Whether these pig- ments are derived from, or convert- ed into hematine, has not yet been ascertained, though Virchow suspects that they are the same, from the similar changes produced in crystals of hematoidine by the action of acids. Brown Pigments.—During the de- composition of extravasated blood, it has often been observed tnat the tints it sometimes presents are of a reddish, and sometimes of a bistre brown. Bile, also, when in mass, and inspissated, often assumes this colour. Different ganglia scattered through the nervous system owe their colour to the formation of brown pigment molecules, which are deposited in the nerve cells. The skin, in some races, is naturally brown or swarthy: the areolae round the nipples as- Fig. 327. Wartlike brown navus maternus of the female mamma, a, Epidermic cells, with their nuclei concealed by a dark brown pigment; 6, the nuclei surrounded with a similar pigment; c, cells without pigment; d, reddish-brown pigment, in the substance of an hypertrophied papilla: e, nucki in fibrous texture ; /, vascular loop -(Wedl.) PIGMENTARY DEGENERATION. 229 sume this tint during pregnancy; exposure to the sun induces this colouration of the skin, and causes freckles, and often large brown patches to appear on it in the fairest women; many warts and nam are also of this colour. In all these cases the colour arises from the deposi- tion of a brown molecular pigment, in the deeper cells of the epidermis and sometimes, as in warty naevi, from accumulation of dark pigment in minute sacs (Fig. 327). Not unfrequently brown pigment may be observed collected within cartilage cells, when that texture is diseased in the neighbourhood of necrosed bone, or in death of cartilage itself (Fig. 328). Occasionally, also, it is found covering placental villi, or situated betweeu the vessel and limitary membrane of the tuft, evidently the result of changes oc- curring in extravasated blood (Fig. 329). Dr. Addison has described a form of anaemia, in which the skin as- sumes a peculiar colouration, in connection with a diseased condition of Fig. 328. Fig. 329. the supra-renal capsules. It presents " a dingy or smoky appearance, or various tints or shades of deep amber or chestnut colour ; and in one in- stance the skin was so universally and so deeply darkened, that, but for the features, the patient might have been mistaken for a mulatto."* Eleven cases have been published by Dr. Addison, and several others sub- sequently by Mr. Hutchison,! where, co-incident with more or less of this bronzing of the skin, the supra-renal capsules were indurated, cancerous, or otherwise diseased. The presumed connection between the functions of these glands, aud the secretion of pigment in the integuments, has excited the attention of physiologists and pathologists. The experiments of the former and observations of the latter have recently shown that * On the constitutional and local effects of disease of the supra-renal capsules. 1855. f Medical Times and Gazette. Fig. 328. Atrophied bronchial cartilage, with deposition of brown pigment, a, Cells containing brown granular pigments ; b, cells containing large fat globules ; e. secondary cells with fatty granules. The intercellular substance is loaded with and obscured by brown pigment granules.—( Wedl.) Hg. 329. Placental villi, containing brown pigment from an aborted foetus, IS inches long, a, Villus, at its termination loaded with brown pigment; b, one only partially so filled at its summit, but with molecular pigment scattered through its sub- stance.-^ Wedl.) 250 diam. 230 PRINCIPLES OF MEDICINE. there is no real relation between disease of these glands and the amount of pigment in the skin. Dr. Ilarley,* more especially, has demonstrated that their excision iu white and piebald rats, causes no alteration in the health or external appearance of the animals. Numerous cases also are now on record of bronzed skin without alteration in the supra-renal cap- sules, and of extensive lesion of these glands without bronzed skin. Green Piqment.—The cause of green pigment has not yet been deter- mined. We have seen that nitric acid produces a grass-green colour when added to bile, and it is possible that the addition of some acid mat- ter to hematine in certain states of combination may produce a similar result. Abscesses of the brain not unfrequently contain pus of a decided green colour, and vomited matters occasionally present the same hue. The foeces in young children are sometimes of a spinach green, which is supposed to result from an altered condition of bile, or from the presence of blood. The contents of cysts frequently contain fluid of different shades of green. In mortification and putrefaction after death, the inte- guments frequently assume a greenish' hue. Lastly, morbid growths, especially in the bones of the cranium, have been described and figured of a decidedly green colour (Chloroma) by Balfour,f King,! and Lebert.$ Black Pigment.—Black pigment is by far the most common degene- ration met with, and is found in various situations. Thus ecchymotic extravasations generally assume a dark purple or black colour. Vomitings of blood in yellow fever and gastric cancer are frequently dark brown or black ; .so also are the foeces after blood has been mixed with them (Mehcna), or after taking fer- ruginous medicines; certain softenings of the stomach itself, of the intestinal glands, and of the entire mucous membrane iu cases of dysentery; Fig. 330. the contents of ovarian cysts and other encysted tumours; intestinal and ovarian cicatrices; the sordes on the teeth and gums in cases of fever; and mortified or dead parts. When morbid growths are black they have received the name of Melanoma, and the black colouration of the collier's lung and bronchial glands has been called False Melanosis or Black Phthisis. Nothing is more common than to see chronic tubercle surrounded by black pigmentary deposit. Scattered tubercles on the peritoneum are often surrounded by a black ring, which, when magnified, presents the appearance represented (Fig. 330). Black patches have occasionally been produced on the skin, appa- rently from the secretion of pigmentary matter on the surface, which is capable of being washed off. A case of this kind is recorded by Mr. * Brit, and For. Med. Chir. Review, vol. xxi. 1858. \ Edin. Med. and Surg. Journal, vol. xliii. p. 319. X Monthly Journal of Medical Science. Aug. 1853. § Anatomie Pathologique, Planche xlv. Fig. 330. Ring of black pigment masses (a) and molecules (b) round a tubercle of the peritoneum. The black tint disappeared after some days' immersion in alcohol. 250 diam. PIGMENTARY DEGENERATION. 231 Teevan,* in the person of a young girl, aged 15, the upper part of whose face was covered with a black discolouration. The colouring matter was analysed by Dr. Rees, who found in it carbon, associated under the microscope with short hairs, epithelial scales, and granules, and globules of fat. Portions of necrosed bones are often of a black colour, a change which according to Wedl commences at the external portion of the systems of bone corpuscles, disposed round the Haversian canals. The blackening is probably owing to a chemical change of the osseous tex- ture, similar to what occurs in caries of teeth from the action of acid Fig. 332. Fig. 333. Fig. 334. Fig. 335. Baliva. It is not dependent on an exudation, which in sections of a bone so affected is nowhere visible (Fig. 331). Black pigment may exist in the form of minute granules (Fig. 332), or of irregular masses scattered throughout a texture (Fig. 333). Some- times the former are found within cells which may be round, flattened, many-sided, or have irregular prolongations (Figs. 334, 33G). This occurs in the choroid membrane of the eye; in the skin of men and animals during health; in the melanotic growths so common in grey horses (Fig. 335), in the epithelial cells of the collier's lung, and in certain forms of cancer (Figs. 336, 337). In all these cases the nucleus is some- times clear and colourless, and at other times obscured by the black pig- ment. Black pigment may also occur in the crystalline form, associated with hematoidine, in old sanguineous extravasations. It has been called melanin. * London Medico-Chir. Transactions, vol. xxviii. Fig. 331. Transverse section of a necrosed Tibia, a, Medullary canals divided transversely; b, pigment, formed at the junctions of the concentric bone systems; c, radiating bone canaliculi —( Wedl.) 90 diam. Fig. 332. Black pigment molecules from the lung. Fig. 333. Black pigment irregular masses semi-crystalline, from an intestinal aggre- gate gland. Fig. 334. Polygonal cells loaded with pigment, from the surface of the pericardium. Fig. 335. Cells loaded with pigment, having clear nuclei, from a melanotic tumour i >f the horse. 250 diam. Kig. 331. 232 PRINCIPLES OF MEDICINE. It may be easily shown that the black pigment granules, cells, and crystals, found in morbid products, although they may closely resemble each other to the naked eye, and even under the microscope, are different in their chemical compositions. Thus one kind of black pigment loses colour on the addition of nitro-muriatic acid or chlorine water, whilst another resists not only these agents, but even the action of the blow- pipe. It follows that the latter consists of carbon, while the former is a peculiar secretion formed within cells, or a transformation of the colouring matter of the blood. Blue, purple, and other pigments.—Blue pigment has been described as occasionally occurring in urine. This was first ascertained by Prout to be due to blue indigo, and it appears probable from the researches of Schunk and others, that all the blue and purple colourations which have been seen in urine, are due to the decon,position of Indican (a normal constituent of this execretion) and the formation of blue and red indigo. The addition of strong sulphuric acid to an equal quantity of urine, at once produces these colourations.—(Carter.) General Pathology and Treatment of Pigmentary Degeneration. The formation and modifications of pigment, as observed in plants and animals, is a subject which has been little studied, and opens up a wide field of inquiry for the chemical histologist. In endeavouring to ascertain the causes whicii give rise to change of colour in the textures, we must attend to the following circumstances :— 1st. Colouring matter bears a certain relation to the non-nitrogenous and oily constituents both of plants and animals. Thus, vegetable oils and resins are seen to form in plants where starch or chloropbyle is col- lected, the latter substances disappearing in the cells, as the quantity of oil increases in them. In animals we almost always find pigment asso- Fig. 336. Cells in a melanotic cancer of the cheek, the black pigment in which disappeared on the addition of hydrochloric acid. Fig. 337. Cells in the black sputum of the collier, the pigment of which is per- sistent under the action of every known chemical agent. 250 diam. PIGMENTARY DEGENERATION. 233 ciated with fat. The brilliant colours of the invertebrata are so many coloured fats, and the pink fat of the salmon, and green fat of the turtle, indicate the same relation in animals higher in the scale. The epidermic appendages, which are generally coloured, are always covered with fat, secreted by a special apparatus—the sebaceous glands. The blood corpuscles are intimately associated with the chyle, which is an oily emulsion, and the bile is rich in fat. In diseased conditions of the liver, the hepatic cells often contain oil to the exclusion of the yellow pigment. 2d. It would appear, that light, heat, and exposure to atmospheric air, are connected with the production of pigment. The young leaves of plants are much lighter in colour than those which are older, and the hair of young animals is not so dark as that of the adult. In autumn the leaves fade, and become brown, reddish, or yellow, and in man we observe that the pigment of the hair ceases to be formed in advanced age, which at length becomes white. Young fruit is green, and as it ripens, the part exposed to the sun is most coloured. Exposure of the skin of man, as is well known, renders it darker, and the fairest skin- ned individuals (whose integuments are well loaded with fat) are those who are most subject to freckles. Then it must be remembered, that while light evolves colour in living, it destroys pigment iu dead textures. Now the decomposition of the atmosphere is carried on in vege- tables by the leaves, under the stimulus of light, and in animals by the lungs and skin. In plants the leaves fix the carbon and give off the oxygen ; in animals the lungs receive oxj'gen, while carbon is separated iu the form of carbonic acid by the same organs, and oxygen in combi- nation with water, in the form of exhalation, is given off both by the lungs and skin. That the skin is connected with respiration is proved by the fact, that if its functions are interrupted, pulmonary diseases aud even asphyxia are the common results. Carbon is also separated in the form of oily matter largely by the skin and by the liver, an organ also connected with respiration. Hence why Europeans in tropical climates, by breathing a rare atmosphere, eating much, and taking little exercise, are liable to hepatic diseases. Thus the lungs, skin, and liver are inti- mately associated, in the function of excreting carbon, and it is curious that these are the three organs in which pigment is formed. 3d. There seems to be a certain connection between the materials introduced into the structure of the plant or animal by means of the soil and of food. Some plants are rich in acids, others in alkalies, or various salts originally derived from the soil, and we have seen that these re-agents operate on colouring matter. Although this subject has been very slightly investigated, we can still perceive how, by the evolution of chemical products, acting on different pigments, the various shades of colour may be occasioned, which we observe in most plants and some animals at certain seasons. Thus green chlorophyle may be changed in one place into a yellow resin, and in another, by the forma ■ tiou of ulmic or other acids, be transformed reddish or brown. In animals the influence of nutrition is traced with more difficulty, but even here we may discern that at certain seasons (such as that of breed- ing) new products are evolved, which, by operating on the blood or the 234 PRINCIPLES OF MEDICINE. vital properties of cells, may eliminate more or less colour. Accord- ing to Heusinger, carbonaceous food used in excess tends to the pro- duction of pigment, and hence he explains how the Greenlanders, not- withstanding the cold, are dark coloured, from their constant consump- tion of fat. For the pathology of carbonaceous deposit in the lungs of the collier, I must refer to the special diseases of the respiratory system. (See Carbonaceous Lungs.) The treatment of pigmentary degenerations is most uncertain, but if the preceding observations are in any way well founded, it must be clear that the management of this lesion must be directed to removing the physiological conditions on which it depends. Mineral Degeneration. By this term is understood the infiltration or deposition of mineral matter into a texture, in such a way that it is no longer capable of per- forming its functions. We have already seen that sometimes this takes place in such a regular manner as to form bone, which replaces the pre- existing texture, as in muscle, membrane, or certain exudations and tumours. But at others it enters into the constitution of a texture dis- solved in fluid, and is thus deposited in or throughout its substance, changing its physical and destroying its vital characters. In this way we separate miueral degenerations from concretions, which are acci- Fig. 338. dental collections in hollow viscera, although undoubtedly they insensibly pass into one another. There is scarcely perhaps any tissue, whether elementary or compound, that may not undergo the mineral degenera- tion. But it is frequently observed in the coats of blood-vessels more or Fig. 338. Structure of mineral degeneration of the walls of an aneurism, a, The internal membrane with groups of fatty granules; 6, horizontal section of the creta- ceous middle coats, presenting irregular spaces, of various dimensions, filled with car- bonate of lime; c, globular masses of mineral matter, in the lighter portions of the section &.—(Wedl.) 250 diam. MINERAL DEGENERATION. 235 less associated with atheroma; in exudations ; in certain morbid growths —rarely in nervous texture. Mineral Degeneration of Blood-Vessels.—Nothing is more common than to find the large arteries brittle from the deposit of mineral matter in their coats,-often associated with fatty degeneration or atheroma- sometimes the one lesion and sometimes the other having the predomi- nance. Plates and patches of mineral matter may in this way often be observed, which' on stripping off the inter- nal membrane (Fig. 338, a) may be seen em- bedded in the middle coat, b. These never present the structure of bone, but either an amorphous conglomera- tion of mineral mat- ter, or an amalgama- tion of round globules, similar to those which Czermak has described as sometimes occur- ring in dentine (Fig. 338, c). Occasionally though more rarely, the smaller vessels undergo a similar degeneration. In this case mineral matter is deposited in their coats, which when widely scattered also presents a globular form, closely resembling drops of oil, for which they are apt to be mistaken, unless mineral acids are added, when they dissolve with effervescence. Fig. 339 represents this de- generation in the small vessels of the brain as de- scribed by Dr. Bristowe and Mr. Rainey.* Mineral Degeneration of Xervous Texture.— ■"•" JF a nx^. Deposition of mineral jsjr. ^|f| ^^jpl \ matter in the tubes or ganglionic cells of nervous substance is a rare occur- -a » rence in man, although ^ u more common in sheep Fig. 840. and other of the inferior animals. Foerster, however, has recorded the * London Pathological Transactions, vol. iv. p. 118. 839. Fig. 339. Incrustation of the small vessels of the brain, with carbonate and phos- phate of lime, in the form of globules, some masses of which are separated, whilst others are aggregated together outside the vascular wall.—(Bristowe and Rainey.) Fig. 340. Mineral degeneration of the nerve-cells and tubes of the spinal cord.— (Foerster.) 250 diam. 236 PRINCIPLES OF MEDICINE. case of a boy who had paralysis of the lower extremities, and in whose spinal cord after death, the nerve cells and tubes were found encrusted with mineral deposits, as seen in Fig. 340. In this case, also, the creta- ceous closely resembled fatty matter; but on the addition of hydrochloric acid, the granules were dissolved with effervescence.^ In other Textures mineral matter may be deposited occasionally in their interstices, but if, as in muscular tissue, it does not assume the form of a bony growth to which we have previously alluded (p. 194), it is usually the result of an exudation. The fibrous membranes of the brain not unfrequently in this way contain calcareous laminated depositions. In certain parts of the pia mater, and the choroid plexus especially, we often find mineral bodies of a rouud or oval form resembling starch cor- puscles. (See Amyloid Concretions.) Mineral Degeneration of the Exudations.—All the forms of exudation after their soft parts are absorbed, may occasionally leave behind them a greater or less quantity of mineral matter. Thus, on serous membranes, in areolar textures, in the sinuses leading from chronic abscesses and so on, masses of earthy matter are met with, formed of amorphous mineral Fig. 341. Fig. 342 Fig. substances, composed of phosphate and carbonate of lime. These are evidently the result of a simple exudation, the animal matter of which has been absorbed, whilst the mineral constituents in excess are aggre- gated together, and form laminae on membranes, or nodules in parenchy- matous organs. I have seen the gall-bladder in this way converted into a calcareous shell, and the pericardium into an unyielding mineral box, inclosing the heart. The cardiac valves are also especially liable to these mineral incrustations. A cancerous exudation in the same manner under- goes the calcareous transformation. The mesenteric glands may not unfrequently be observed to be partly cancerous and partly cretaceous. On one occasion I examined a large cancerous growth of the omentum and peritoneum, which was so loaded with phosphatic salts, that slices of it when dried lost little of their bulk. The juice squeezed from this tumour, besides masses of mineral matter, was seen to contain cancer- cells in various stages of disintegration, naked nuclei, fusiform cells, and a multitude of molecules, some fatty and some mineral (Fig. 341). On * Mikroskopischen Pathologischen Anatomie, Taf. xv, Fig. 341. Mineral masses in a degenerated cancerous tumour of the omentum. Fig. 342. The same, in a degenerated cancerous mass in the liver. Fig. 313. Cancer-cells infiltrated with cretaceous molecules, in a mesenteric gl CONCRETIONS. 237 another occasion I found the cancer-cells embedded in and infiltrated throughout with minute cretaceous molecules (Fig. 343). In cancer, as in atheroma of arteries, the mineral is often associated with the fatty degeneration. A Tubercular Exudation passes more readily into creta- ceous and calcareous transformation than either the simple or cancerous forms. Indeed, it may be said that the natural mode of arresting the advance of tubercle is by converting it into mineral matter. I possess specimens of miliary as well as of infiltrated tubercle, arrested in all Fig. 344. Fig. 345. stages of their progress, by cretaceous transformation, in which case, on microscopic examination, it is seen to consist of mineral masses associated with a few tubercle corpuscles, debris of the tissue in which it occurs, and occasionally a few crystals of cholesterine (Fig. 344). Mineral Degeneration of Morbid Growths.—Mineral deposition may occur in all kinds of morbid growths, but is most common in fibroma and cystoma. In enchondroma the tendency is to form bone. The white fibrous tumours of the uterus, we have previously seen, may undergo the osseous transformation (Fig. 270); but this is an occurrence of extreme rarity. Far more commonly the centres of such growths are composed of amorphous mineral depositions (Fig. 345), which frequently increase, and invade their whole substance, causing arrest of their pro- gress. I have often found imbedded in the uterine walls, mineral masses, varying in size from a hen's egg to that of a cocoa-nut, formed in this manner. Fine preparations, showing the same fact, may be seen in the Edinburgh University Museum. CONCRETIONS. By concretions are understood non-organized and non-vascular pro- ductions, formed by the mechanical aggregation of various kinds of matter, generally in the ducts or cavities of the hollow viscera. It has already been pointed out, that although they pass gradually into the class of degenerations, several of which closely resemble concretions, still they are distinguished from them by their never having been organized, or Fig. 344. Mineral masses in a cretaceous tubercle of the lung. Fig. 345. Section of an amorphous mineral mass forming a calcareous nucleus of a uterine fibrous tumour.—(Wedl.) 250 diam. 238 PRINCIPLES OF MEDICINE. Fi-. 346. formed out of an organic structure. They possess a remarkable sition, however, to collect round a central nucleus, which may be organic or non-organic, and often present as the result of pure accident. Hence they generally exhibit a tendency to assume the globular or oval shope. Albuminous Concretions.—It has al- ready been explained that albumen may be precipitated from its solutions in the form of membrane (p. 211). This is sometimes so effected as to produce con- cretions, of which I have long possessed a remarkable specimen, found loose in the cavity of the abdomen. Mr. Shaw has described a similar specimen, about one-half the size of mine, con- taining a nucleus of fat—also formed in the peritoneal cavity* It was excised from a hernial sac, and consisted of aggregated layers of albuminous substance, as seen in Figs. 346, 349, 350. The con- centric layers of aneurismal co- agula, and some so-called fibrin- ous depositions on the valves of the heart, whicii subsequently be- come white and indurated, are of a similar character. The sec- tions of the nucleus in my speci- men (Fig. 347) is represented magnified fifty diameters, Fig. 348, showing the adipose cells of the structure, loaded round the circumference with mineral mat- ter. In all other respects it re- sembled Mr. Shaw's specimen. Fatty Concretions.—These constitute gall stones, which for the most part are formed of laminae of cholesterine, associated with inspissated bile. They are found in the gall ducts or bladder, and vary in colour, size, form, and number. They may be perfectly white, and then they consist almost wholly of pure cholesterine. Sometimes they are brown, and at others jet black, approaching carbon in chemical composition. There may be only one large gall stone, nearly filling the gall bladder. When there is only one, it is oval in form, and when there are several stones present, they take a many-sided form, in consequence of pressure Fig. 347. Fig. 348. London Pathological Trans, vol. vi. p. 205. Fig. 346. Longitudinal section of the albuminous concretion referred to, and its encysted nucleus of fat.—(Shaw.)—Natural size. Fig. 347. Section of the nucleus of an albuminous concretion.—Natural size. Fig. 348. Section of the nucleus of an albuminous concretion, showing the circum- ference loaded with mineral matter, and the cell structure of the interior. 50 diam. CONCRETIONS. 239 on each other. ^ In one case, as many as 2000 minute biliary concretions were counted in the gall bladder. The black gall stones are often rough, round, and spiculated. On section they generally present a nu- cleus which is composed of inspissated bile, and mucus, surrounded by concentric rings. Occasionally, the centre of the stone is hollow, and the substance lining the cavity crystalline. The tough white masses occasionally found in cystic tumours (cholesteatoma) are also fatty concre- tions. Sometimes also fatty masses have been passed by stool, more especially when the pancreas has been diseased. Pigmentary Concretions.—These are most common in the lun^s and bronchial glands of colliers, from which I have often dug out masses varying in size from a millet seed to that of a pea, with shiny smooth frac- tured surfaces, composed of pure carbon. Occasionally I have seen a bronchial gland converted into a cyst, filled with a thick black fluid, like inspissated paint, principally composed of carbonaceous matter, which would doubtless in time also have formed an indurated concretion. Fig. 349. Fig. 850. Mineral Concretions.—This is by far the most common form of con- cretion found in the body, and usually results from the deposition of various salts from their solutions, often round a nucleus of foreign mat- ter, so as to form solid mascs varying in size, form, and general arrange- ment of parts. Not unfrequently the nucleus may be a portion of coa- gulated blood or inspissated mucus, so that mineral concretions are sometimes found in the veins (phlebolites) and in all mucous passages, such as the salivary, bronchial, pancreatic, hepatic, renal, etc. Frag- ments of degenerated mineral texture may also be pushed out from the walls of such passages and constitute a nucleus, which collects mineral matter around it. In almost all such cases, the mineral is composed of phosphate, with varying proportions of carbonate of lime, and the form of the concretion will be influenced by the size and shape of the cavity in which it is found. An excellent example of this may be seen by exa- mining the grains of sand in the pineal gland, which will be found to Fig. 349. Portion of one of the concentric lamellae, of the same concretion. Fig. 350. Transverse section of the edges of the concentric lamella?.—(Shaw.)— 250 diam. 240 PRINCIPLES OF MEDICINE. consist of botryoidal masses varying in size, but constituting mineral moulds of the glandular shut sacs in which they were produced. Fig. 35i. Urinary Concretions.—-Mineral concretions, however, are by far most common in the urinary apparatus, and may be formed in the tubules or pelvis of the kidney, in the ureter, or in the urinary- bladder. In the tubules of the kidney they usually assume the character of amorphous deposits, filling up and distending the tube, and presenting radiating white lines in the secreting cones. They may be composed of phosphate of lime or urate of ammonia (Fig. 352). Occasionally masses of a putty- like substance are formed in the substance of the kidney by the accumulation of such deposits, which in time would have consoli- dated into calculi. More rarely the entire kidney is so infiltrated with mineral mat- ter, that its functions are destroyed. I possess a specimen of this kind, where the organ might be supposed to be petrified, and others exist in the Edin- burgh University Museum. i •••.».#► dr Fig. 352. Fig. 351. Various forms of biliary concretions. /, White biliary concretions, com- posed chiefly of cholesterine. c, Irregular biliary concretions of inspissated bile. 6, Black biliary concretions, chiefly carbonaceous, d, Yellow biliary concretions with spicula formed in the ducts of the liver, e, Section of a dark-brown biliary calculus, so indurated as to be capable of receiving a polish, showing the concentric arrange- ment of its substance. /, Section of a large white biliary concretion, showmg the radiated as well as concentric arrangement.—Natural size. Fig. 352. Vertical section of the kidney, a, Some of the tubules filled with urate of ammonia, and presenting irregular black streaks, with lateral branches ana twig?, 6, The molecules of mate of ammonia aggregated together in masses. 60 di. 250 diam. CONCRETIONS. 241 When calculi form in the pelvis of the kidney, they assume the form of the cavity, which varies, however, in different cases, being contracted in some and dilated in others. The accompa- nying figure of a renal ■ ^ -»* calculus exhibits regu- lar protuberances, jut- ting out between the urinary cones from a mass formed in the pelvic cavity (Fig. 353). Renal calculi Fig. 353. Fig. 354. generally give rise to constant irritation and surrounding suppuration, constituting what Rayer has called calculous pyelitis. Their chemical constitution is usually uric acid, or phosphate of lime, alone or united in various proportions. Fig. 355. Tig. 356. The most frequent seat of urinary calculi is in the bladder, whence, from the circumstance of their giving occasion for one of the most im- portant operations in surgery, they have been made the subject of care- ful study. Here they vary in size, general appearance, and chemical constitution. In size they range from that of a millet-seed or grains (known under the name of gravel), which may pass along the urethra, to that of a body weighing several ounces, and occupying nearly the whole bladder. In form they may be round, oval, flattened, irregular, or nodulated, and in chemical constitution may consist of phosphate of lime, triple phosphate of ammonia and magnesia, uric acid, oxalate of lime, or xanthic oxide. Not unfrequently in one calculus may be ob- served deposits of varying chemical compositions, round a central 353. External view of a remarkable renal calculus, with projections on all it but one, impacted in the pelvis of the kidney.—Real size. 354. Section of the same calculus, with nucleus of uric acid and oxalate of Fig. sides of Fig. hmc Fig. covered Fig. nucleus 355. Calculus with lithic acid nucleus, surrounded by oxalate of lime, and externally with lamina? of lithic acid.—(Syme.) 356. Triangular formed calculus of lithic acid deposited round a phosphatic at one corner.—(Syme.) 16 242 PRINCIPLES OF MEDICINE. nucleus, indicating the salts predominant in the urine during the period of its formation (Figs. 355 to 361). Fig. 360. Fig. 361. One of the most remarkable circumstances connected with vesical cal^li is, that the nucleus may be composed, not only of various kinds of salts or of fragments of other calculi, but even of foreign substances which have been introduced from without. Thus various rounded bodies thrust down the urethra may form the cen- tres of these concretions. Fig. 362 represents a piece of slate pencil as the nucleus of a phosphatic concre- te- 362- tion. Mr. Syme removed it by the ope- ration of lithotomy, and the man confessed he had introduced the foreign body himself, which had slipped from his fingers, and entered the bladder Fig. 357. Oval calculus of lithic acid, having a lithic acid nucleus, surrounded by oxalate of lime.—(Liston.) Fig. 358. Oval calculus of uric acid.—(Liston.) Fig. 359. The triple phosphate surrounding a mulberry concretion of oxalate o lime.—(Liston.) ., Fig. 360. Nodulated mulberry calculus composed of oxalate of lime.—(a. Ma Fig. 361. Phosphatic calculus formed round a fragment of uric acid calculus, pre- viously broken up bv lithotrity.—(Syme.)—Real size. • ,, Fig. 362. Phosphatic calculus formed round a piece of slate-pencil, which had Dee introduced into the bladder through the urethra.—(Syme.)—Real Size. CONCRETIONS. 243 two years previously. One of the most extraordinary cases of this kind in which a man in a state Fig. 36*. is that recorded by the late l>r. R. Mackenzie of intoxication was, during a quarrel, knocked down by his comrades, who cruelly thrust several horse beans into his urethra. Six months subse- quently he was operated upon for stone, and five calculi re- moved, each of which on being cut open was found to contain a bean, surrounded by a shell of triple phosphate* (Fig. 363). Dr. Dunsmure has also related a case of lithotomy, where the nucleus of the stone originated in the man's falling with violence across the gun- nel of a boat in such a way as to lacerate the perineum, and force a portion of his woollen trousers into the bladder. I examined the nucleus of the Fig. 36i calculus after removal, and found the fibrous substance it was composed of to consist of wool.* Monthly Journal of Medical Science. January, 1852. Fig. 3G3. Sections and external appearance of the calculi in Mr. Mackenzie's case formed round horse beans, introduced into the bladder in the manner described.—(R. Maeken-ie.)—Rial size. Fig. 3G1. Prostatic calculi exhibiting the concentric lamina?, and nuclei of these bodies.—( Wedl.) 250 diam. 244 PRINCIPLES OF MEDICINE. Prostatic Concretions.—The adult prostate gland almost invariably will be found to contain a number of calculi, which increase in number with the age of the individual, and are often very numerous when the o-land is enlarged. They are of a yellowish colour, vary in size from -i-th to the -i°-th of an inch in diameter, and are characterised by their concentric lamina?, surrounding a single or double nucleus, which also varies greatly in size. Dilute mineral acids cause the calcareous matter to be dissolved, leaving, however, the structural appearance unaffected, and rendering them occasionally soft and compressible. Iu this respect they resemble the amyloid bodies which occur in the arachnoid, and like them they may possibly be colloid masses, throughout wbich mineral mat- ter is imbibed in a fluid state, so as gradually to convert them into calculi. J [airy Concretions.—Balls composed of hair are not unfreqiicntlv Fig. 365. Mass of hair found in the human stomach, as described above. Infe- riorly it was encrusted with a layer of altered food, a fragment of which has been removed towards the left, showing the hair beneath.—(Ritchie.)—Three-fourths the real size. CONCRETIONS. 245 found in the stomach and alimentary canal of the inferior animals es- pecially such as are in the habit of licking their hairy coats. Rare c'ases have been recorded where similar masses have been found in the stomach of the human subject. One of these has been published by Dr. Ritchie of Glasgow.* It was that of a factory girl, aged 21, who had contracted the habit of pulling hair from her head, while employed at work, and swallowing it. She had ileus, followed by symptoms of rupture of the intestine. On dissection, the mass here figured, forming a mould of the stomach, composed of moist female hair, was discovered,'and two smaller ones were found in the intestines (Fig. 365). Similar cases with hairv concretions are recorded by Pollockf and May.| Veyetable Fibrous Concretions.—Tliese are only found in the alimentary canal, and in man are most common in the intestines. The largest collection of them extant is in the Edinburgh Uni- versity Museum, which was made by the second Monro. An admirable dissertation regarding them was published by his son, Monro tertius.§ Wollaston first demon- strated that they were principally compos- ed of the fibrous matter of the oat seed, a earches and published figures of Dr. Doug- * Monthly Journal of Medical Science, July, 1849. T Pathological Transactions of London, 1851-2. X Association Journal, No. 156, 1856. § Morbid Anatomy of the Human Gullet, Stomach, and Intestines, Edinburgh, 1811. Fig. 366. Section of a remarkably-shaped intestinal concretion, a, Nucleus of extravasated blood; b, b, b, concentric laminae. It weighed 14] ounces, measured 7 inches in length, and was evacuated by the rectum.—(Husx and Mosander.)—Half the real size. r ig. 367. Section of an intestinal concretion, with a plum stone for its nucleus, in the Monro collection of the Edinburgh University Museum.—Real size. Fig. 366. fact confirmed by the careful r< 246 PRINCIPLES OF MEDICINE. las Maclagan.* These concretions vary in size from a pea to that of an orange. They are round or oval in shape if isolated, but are frequently compressed or flattened at the sides, and occasionally of very irregular shapes, according to the amount of pressure or impaction to which they have been subjected. In colour they are of a yellowish brown, but are much lighter if infiltrated with earthy salts to any unusual extent. They easily crumble down under firm pressure, and present a short fibrous tex- ture, like the felt of a hat. On section with a sharp instrument, thev present on the cut surface a series of concentric lines, which are often of a lighter colour and harder consistence than the general substance of the concretion. In the centre may frequently be observed a nucleus composed of some foreign body, such as a plum or cherry stone, a piece of bone, etc. Chemically, they consist principally of fibrous vegetable matter and phosphate of lime, mingled with small proportions of water, soluble vegetable matter, fat, foeces, and a little silica derived from the structure of the oat—(Maclagan). On examining a small fragment of these concretions under a power of 200 diameters linear, they are seen to be made up of an aggregation and mingling together of vegetable fibres, principally derived from the cary- opsis of the oat, mingled in recent specimens with numerous irregular crystals and amorphous precipitate of the phosphate of lime. The fibres vary greatly in length and diameter, but in form are pointed at one extremity, truncated at the other, with a central canal, which gradually diminishes to- wards the pointed extremity, The accompanying figure repre- sents a fragment taken from the concretion represented Fig. 308, from the Monro collection, in which, besides the vegetable fibres alluded to, masses of mo- lecular mineral matter may be Fi£. 36S. observed soluble in dilute nitric acid, of which the white concentric lines were principally composed (Fig. 373). As regards the manner in which these concretions are formed, it is to be observed, that the fibres of the caryopsis of the oat possess, in a remarkable degree, the property of felting, which, as pointed out by Dr. Carmichael of Buckie,t is prevented by oil, and favoured by the use of dry substances, as fuller's earth. Both these substances are used largely in wool manufactories, the one for carding and the other for felt- ing. I am indebted to that gentleman for some specimens of concre- tions, formed of oat dust (that is, the hairy covering of the oat), simply by the rotatory or oscillatory motion of the wirecloth sieve of a mill. From thence may always be collected soft concretions of various sizes, "- Monthly Journal of Medical Science, Sept. 6, 1841. t Ibid. June, 1848. Fig. 308. Hairs from the caryopsis of the oat, felted together, and mingled with granular masses of the phosphate and carbonate of lime. 250 diam. CONCRETIONS. 247 formed round pieces of thread, or other foreign bodies. The same thing appears to result in the animal body, from the peristaltic action of the intestines, when the fibrous dust is imperfectly separated from the meal, as was formerly the case in the oatmeal used largely as food for man in Scotland. Since the employment of winnowing machines, and greater consumption of meat and oleaginous substances, the formation of these concretions has become very rare. In horses, however, they are still common, and it is remarkable that in remote districts, where meal is still imperfectly prepared, cases still occasionally occur, such as the one recorded by Dr. Turner of Keith,* of a man who, in 1841, passed fourteen, and in 1*45-0, other eighteen of these concretions. Amyloid and Amylaceous Concretions.—Valentin,! Lebert,^ Grluge,§ aud others, have figured rounded mineral bodies with concentric circles, frequently present in the brain's substance, and more or less soluble in mineral acids. In April, 1847,|| I "presented a portion of a tumour to the Pathological Society of London, which was attached to the tento- rium, and crowded with similar bodies. They are evidently mineral concretions, formed, however, on an organic base, varying in size from Fi2. 309 Fig. 372. the T^o(Tth t0 tbe 2oVoth of an inca in diameter. Their fracture was exactly like that of starch corpuscles, but they were not rendered blue » Monthly Journal of Medical Science, Sept. 1841, and January, 1848. \ Handwbrterbuch der Physiologie, Taf. 1, Fig. 2. j Physiologie Pathologique, PI. xi. Fig. 10. jj Pathologische Anatomie, Liv. 16, Taf. 2. || Proceedings of Pathological Society of London, 1846-7, p. 17. Fig. 369. Amyloid bodies embedded in a seemingly amorphous matter. Fig. 370. The same, after dilution with water, now seen to be invested with a fibrous sheath, and surrounded by fusiform cells and naked nuclei. Fig. 371. The same, after the addition of acetic acid. Fig. 372. The same, after the addition of nitric acid, a, One of these bodies with a thick investing capsule ; 6, c, and d, others showing the various ways in which they crack on pressure; e, cvlindrical form produced by rolling them between glasses. " 25°diam' 243 PRINCIPLES OF MEDICINE. Fig. 373. Fig. S74. these bodies were optically as well as chemically identical with starcb, and that they were true corpora amylacea. They have been found in various tissues and fluids by subsequent observers, and have been made the special subject of research by Dr. Carter,^ who has demonstrated their existence in almost every tissue and fluid of the human body, and in every kind of morbid product. They are of two varieties, the one (described by Mr. Busk) resembling wheat starch, the other and rarer kind corresponding in every particular with that derived from the potato. It follows that there exist concretions, some of which resemble while others really are starch corpuscles. The former are amyloid, and the latter amylaceous concretions. Both these bodies, without the action of re-agents, are not only liable to be coufounded with each other, but with colloid and fat masses. It is questionable, indeed, whether the amyloid concretions are colloid bodies, which have subsequently become impreg- nated with mineral matter, or whether they are starch corpuscles that have undergone a mineral degeneration. But the relation of these two kinds of concretions to one another, to fat and colloid masses, are points * Archives, Band vi. s. 125. 1854. \ Quarterly Journal of Microscop. Science, vol. ii. p. 106. 1854. \ Edinburgh Medical Journal, August, 1855, and Graduation Thesis, 1856. Fig. 373. Small corpora amylacea, in the auditory nerve of a deaf individual, with several granule cells.—(Foerster.) Fig. 374. Variously-shaped and sized corpora amylacea, from the human pancreas. a, Nucleated ; 6, c, d, variously-shaped ; e, seen edgeways.—(Carter.) 250 diam. CONCRETIONS. 249 which have not yet been investigated. The presence of sugar, which has recently been shown to be always a constituent of normal blood, in that part of the circulation which lies between the hepatic and pulmo- nary veins, may also be connected with the formation of one or more of these non-nitrogenous substances. All speculation on this subject, however, is at present highly hypothetical, and it is only from the pro- gress of organic chemistry that we can hope to derive a satisfactory ex- planation of these transformations which go on in the blood tissues, so that we may determine the laws regulating the production of the amy- laceous and amyloid concretions. SECTION III. ON THE RECENT CHANGES IN THERAPEUTICS, OCCA- " SIONED BY AX ADVANCED KNOWLEDGE OF DIAG- NOSIS AND PATHOLOGY. In the previous two sections I have endeavoured to give a condensed account of the present state of diagnosis, and of the pathology of organic diseases. A practical knowledge of the one, and a better appreciation of the other, have been very widely diffused within the last sixteen years. In consequence a change almost amounting to a complete revolution in our treatment of disease, has taken place within that short period. It is true that this change is not yet reflected in our systematic works, although clinically it is everywhere recognized. When we compare the actual°practice of medicine with what it was, or with what it is repre- sented to be, even in modern books on the theory and practice of physic, the discrepancy must strike even the least observant. It seems to me that the time has now arrived for calling the attention of the profession, and more especially of its youthful members, to the causes which have produced so important a result, and for pointing out some of those prin- ciples on which an improved medical art for the future must necessarily be based. I have already alluded to the general treatment required in diseases of nutrition (p. 107), and have endeavoured to show that a knowledge of the various processes, of which that function is made up, is a necessary preliminary step to correct medical practice. Our agents for combating this class of disorders, are nutrients, hematics, eliminatives, astringents, etc. Diseases of innervation require for their proper management the same previous knowledge, and demand as remedies stimulants, sedatives, narcotics, etc. The mode of applying these can only be learnt by treat- ing maladies in detail, whilst for what is known of the general principles of their action 1 must refer to special works on this subject.* Remedies have hitherto been employed too much in reference to symptoms, and with too little regard to the pathological states which produce those symptoms, or to the intimate relations which exist between the nutritive * See especially Headlam on the Action of Medicines. FALLACIOUS CHARACTER OF PAST EXPERIENCE. 251 and nervous functions. Thus, for instance, impaired digestion may cause headache and sleeplessness. Now, we can relieve the latter symptoms by morphia; but if this remedy increase the want of appetite, as it really does, what have we gained ? The urgent symptoms are temporarily pal- liated, but their cause, so far from being removed, is actually intensified. This distinction between a palliative and a curative treatment has been too much overlooked in medical practice. Drugs have been given to relieve symptoms, while the causes producing them have not been sufficiently attended to. Need it then excite surprise that as our knowledge of pathology has advanced, and our means of diagnosis have improved, this discrepancy has become more apparent, and that we now direct atten- tion more to the causes and less to the effects of disease ? The changes which have recently taken place in medical practice, as a result of this mode of viewing diseases, will be referred to in the spe- ■ cial part of the work. Two great facts, however, seem to me, from their especial importance, to demand attention here. These are—1st, The diminished employment of blood-letting and other antiphlogistic reme- dies in the treatment of acute exudations, or so-called inflammations; and 2d, The power which it has been demonstrated may be exercised over certain diseases of innervation, through the influence of suggestion or strong impressions made upon the mind. Both these facts have re- cently excited great attention and discussion; their influence on medical theory and practice has already been great, and their explanation on scientific grounds seems to be called for, with the view of establishing correct principles for our future guidance. THE DIMINISHED EMPLOYMENT OF BLOOD-LETTING AND OTHER ANTIPHLOGISTIC REMEDIES IN THE TREATMENT OF ACTTE INFLAMMATIONS. It must be admitted by all who contemplate the actual state of medi- cal practice in this country, that the use of blood-letting, and of other antiphlogistic remedies, has within a recent period greatly declined. According to Dr. Alison,* such remedies, and more especially blood- letting, were formerly highly successful in arresting the disease, but fail to do so now, and are even injurious; and the inference he draws from these supposed facts is that inflammation itself is no longer the same, that its type, and more especially the febrile symptoms accompanying it, have altered from an inflammatory to a typhoid character. In short, it seems to be Dr. Alison's opinion, that our advanced knowledge of diagno- sis and pathology has had little influence in producing this great revo- lution in our treatment, but that the human constitution (in a manner whicii is not explained) is fundamentally altered, and that medical men were as right in bleeding twenty years ago as they are correct in now abstaining from it. In opposition to these views, it will be my endeavour to show—1st, That little reliance can be placed on the experience of those who, like Cullen and Gregory, were unacquainted with the nature * Edinburgh Medical Journal, March, 1856. 252 PRINCIPLES OF MEDICINE. of, and mode of detecting, internal inflammations. 2d, That inflammation is the same now as it has ever been, and that the analogy, sought to be established between it and the varying types of essential fevers, is falla- cious. 3d, That the principles on which blood-letting and antiphlogistic remedies have hitherto been practised are opposed to pathology. 4th, That an inflammation once established cannot be cut short, and that the object of judicious medical practice is to conduct it to a favourable ter- mination. 5th, That all positive knowledge of the experience of the past, as well as the more exact observation of the present day, alike establish the truth of the preceding propositions as guides for the future. Proposition 1.—That little reliance can be placed on the experience of those who, like Cullen and Gregory, were unacquainted with the nature of, and the mode of detecting, internal inflammations. Inflammation for many years was generally recognised, especially in external parts, by the existence of pain, heat, redness, and swelling, and in internal parts by fever, accompanied by pain, and impeded function of the organ affected. In short, groups of symptoms, in accordance with the nosological systems of the day, constituted inflammation. But the school of morbid anatomy, by showing that inflammation was a diseased condition of a part, entirely overthrew the errors and confusion inherent in all such nosological systems. Clinical observation, based on a more correct diagnosis and pathology, has since demonstrated that artificial nosological groups of symptoms bear no relation whatever to the inter- nal inflammations they were formerly supposed to indicate, and has led to a mass of information, connected with internal disease, which, up to this time, has never been correctly systematised. Again, more recent histological research, by exhibiting to us that inflammation is in truth a disease of nutrition, governed by the same laws that determine the growth and functions of cells, as they exist in the embryo and in healthy tissues, has united physiology and pathology into one science, and has removed our present knowledge still further from the traditional errors of the past. Why, then, should we on our onward course be governed by the opinions of Cullen and Gregory, of Gaubius and Sydenham, of Aretaeus and Hippocrates? These distinguished men all advanced medicine in their day, as far as they were enabled to do so by the then state of science and the means within their reach; but the principles which guided them ought no more to be considered laws to be followed now by practical physicians, than should the exploded astronomical doc- trines of Copernicus and Tycho-Brahe be acted on by practical naviga- tors. It is not my intention, therefore, to enter into a lengthened refutation of the opinions of former writers, or even of many modern ones, in determining what pathologists now understand by the term inflammation. What I mean by it in the following remarks, is an exu- dation of the normal liquor sanguinis; and Dr. Alison evidently means the same thing, when he acknowledges " that exudation of lymph is essential to almost all changes of structure produced by inflammation " Whatever, then, may have been formerly understood by this word in- flammation—in whatever way it may be now applied—whether to the THE UNCHANGEABLE NATURE OF INFLAMMATION. 253 congestion of the blood-vessels, the exudation of liquor sanguinis, or to the change in the texture causing these phenomena—it is important to remember that in speaking of it both Dr. Alison and myself mean an alteration in a part characterised by the exudation of lymph through the walls of the minute vessels, resulting from changes more or less well marked in the nervous, vascular, sanguineous, and parenchymatous ele- ments of that part. (See p. 123, et seq., also Dr. Alison's observations in the Note to this subject, at p. 279.) As regards diagnosis, it must be acknowledged by all parties that, up to a recent period, internal inflammations were sought to be recognised only by symptoms. But medical men, who have of late years studied these inflammations by physical signs as well as by symptoms, must have come to the conclusion, that symptoms alone are altogether insuffi- cient to enable us to determine the existence of internal inflammations. This is a point which, if necessary, could be established by innumerable facts, which show, 1st, That all the symptoms of inflammation may be present, and yet post-mortem examination demonstrate the absence of lesion; and, 2dly, That inflammation has been the cause of numerous deaths, without one of the symptoms generally supposed to be its accompaniments having been present. But here, also, it is unnecessary for me to enter at any length into this question, because it is admitted by Dr. Alison that we can now detect inflammation of the lungs " in cases where there is so little of pain, or cough, or dyspnoea, or inflammatory fever, that we should not in former times have given them the name of pneumonia." But when he goes on to say that " the cases of pneumonia thus overlooked were attended with little or no immediate danger," I am constrained to dissent from this opinion, for it appears to me that many of these cases, especially such as are complicated and occur in old age (so-called latent pneumonia), are, at this moment, the most fatal, and that they always must have been so. On the other hand, the symptoms which formerly were supposed to indicate pneumonia, viz., pain, cough, dyspnoea, rusty sputa, and fever, we now know are met with in a variety of lesions, independent of pneumonia, especially in certain cases of bronchitis in young subjects, or engorgements and apoplexy of the lung, associated with fever or heart disease in older persons. Hence, formerly, bleeding was not practised iu many cases where pneumonia was present, whilst it was largely resorted to in others where that dis- ease never existed at all. Other writers besides Dr. Alison have endeavoured to show, and not unsuccessfully, that what was formerly understood by pneumonia or peri-pneumonia, is altogether different from what we now mean by these tonus. But they have not been so successful in deducing from the experience possessed by former physicians in treating symptoms, what ought to be the rule of practice for those iu modern times who recognise the anatomical lesions of organs. If, indeed, it could be shown that the group of symptoms formerly called inflammatory always indicated the same morbid lesion, former experience might still be useful to us. But we contend that this is what clinical observation proves to be im- possible. Such are the contradictory statements and the confusion resulting from the unacquaintance of the past race of practitioners with a correct diagnosis and pathology, that no confidence whatever can be 254 PRINCIPLES OF MEDICINE. placed in their impressions, as to what cases were or were not benefited by bleeding. Hence, although I am far from repudiating experience in cases which in the present day are clearly recognizable as true inflammations, it is surelv unreasonable to bo guided by that experience in cases where it is acknowledged that the observations are imperi'ect and vague, and which, even aniono- those who desire to take advantage of it, causes endless differences of opinion as to what was meant or intended. .Medicine is not a scientific art whicii is dependent for its principles on the study of, and cooimentary on, the older writers. What they thought and what theq said, are not, and ought not, in a question of this kind, to be our guide, as to what was or is. On the contrary, it is the book of nature, which is open to all, that we ought to peruse aud study, and why should we read it through the eyes of past sages, when the light of science was comparatively feeble and imperfect, instead of bringing all the advanced knowledge of the present time to elucidate her meaning ? The lesson, which a careful study of the history of medicine has forced upon me, is the necessity of re-investigating, with all our improved modern appli- ances, the correctness or incorrectness of existing dogmas, in order to establish an improved practice for the future. Proposition 2.—That inflammation is the same now as it has ever been, and that the analogy sought to be established between it and the varying types of fevers is fallacious. The essential nature of inflammation has been already alluded to, viz., a series of changes in the nervous, sanguineous, vascular, and parenchymatous functions of a part terminating in exudation of the liquor sanguinis, or what some call effusion of lymph. Now what proof is there that any of these necessary changes have of late years undergone modifications ? If a healthy man receive a blow, or any other injury on his person, are the resulting phenomena in these days in any way different from those which took place in the days of Cullen and Gregory ? Were the effects which followed wounds received at the battle of the Alma different from those which resulted from similar injuries at the battle of Waterloo ? This has not yet been shown. Do we observe any essential difference in our civil hospitals in the effects of injuries, or in the process of healing, after wouuds and operations? This also has not been shown. Again, if a healthy individual nowa- days be exposed to cold or wet, and be seized with an inflammation of the lungs or pleura, is not the lung hepatized in the one case, and do not layers of organizable lymph form in the other, in exactly the same way as formerly V If so, is not hepatization removed, and does not the lymph contract adhesions in the same manner now, as in the days of Cullen and Gregory ? If these changes have been materially modified in recent times, I again urge that such modifications have not been shown ; and if they have not, in what can it be said that inflammation and its results have changed within the last twenty years ? To this question, notwithstanding repeated careful perusal of Dr. Alison's paper, I am obliged to say I can find no answer. It is true he THE UNCHANGEABLE NATURE OF INFLAMMATION. 255 points out that the symptoms of pneumonia of Cullen differ from those of the pneumonia of Gri:57 1st Oct. 1841 to Lst July 1842 42 23 3 16 ;) Dr. T. Pea- 2,7GO " 1842 " 1843 41 26 0 15 ) cock. 7,204 " 1843 " 1844 31 16 4 11 ~ 3,252 " 1844 " 1845 50 33 i 13 Dr. Hughes Bennett. 3,638 " 1845 " 1846 61 40 6 15 7,435 1846 " 1847 93 47 5 41 7,446 " 1847 " 1848 103 52 6 45 3,724+ " 1848 " 1849 88 66 5 17 Mr.M'Dougall. 46,965 648 388 38 222 My former resident clerk, Dr. Thorburn, was kind enough, at my request, to go over 208 case-books of the Infirmary, dated between the years 1812 and 1837, and belonging to twelve physicians, all of whom practised an antiphlogistic treatment. He found that of 103 cases of pneumonia, 55 were cured, 41 died, and 7 were relieved. Dr. Thorburn then carefully read over these 103 cases, and rejected all those that were incomplete, or which presented no evidence of having been pneumonia. The remainder were tabulated, and it may safely be said that they were all cases of pneumonia, or of acute inflammations of the chest closely allied to that disease, and the result was:—Number of cases, 50 ; died, 19 ; cured or relieved, 31. The total number of cases recorded by M. Louis, was 107.| Of these 32 died, or 1 in 3|. In 78 of those cases which occurred at La Charite, bleeding was performed, from the first to the ninth day, and the deaths were 28, or 1 in 3J-. The duration of the disease in the cases which recovered, was 15^ days. Of the remaining 29 cases, which occurred at La Pitie, the bleeding was performed earlier, that is during the first four days, and of these only four died, that is, 1 in 1}. The duration of the disease, however, in the cases that recovered, was 18¥ days. This diminished mortality, but greater length in the time of recovery, M. Louis attributes to the bleedings not having been so large, and the greater amount of tartar emetic employed. Hence, the proposition he sought to establish, that although bleeding has a very limited influence on pneumonia, it should be practised early. With regard to 31. Louis's results, it should be remembered, that all these patients enjoyed excel- lent health when they were attacked, and that the duration of the disease * At these periods there were great epidemics of fever. f At this period considerable changes took place among the medical staff of the Infirmary. t Recherches sur les effets de la Saignee. Paris. 1835. 272 PRINCIPLES OF MEDICINE. was estimated from the occurrence of febrile symptoms, up to the time when light food could be taken, which was generally three days after the fever had ceased. . . That the result of an active antiphlogistic treatment was the pro- duction of a mortality of about 1 in 3 cases, seems to me further esta- blished by the account of Rasori* who, in the great hospital of Milan, treated G48 cases by large doses of tartar emetic, of which 555 were cured, and 143 died, that is, 1 in 4^. In publishing this statement, Rasori gives the result as one more favourable than the practice of blood- letting, which of course he would not have done unless the latter treat- ment was well known to have been attended with a greater mortality than that by tartar emetic, or 1 death in 4£ cases. M. G-risollet advocated more moderate bleedings than those so fre- quently had recourse to, his conscience preventing the abandonment of venesection altogether (p. 561). He analyses the 75 cases of Bouillaud, pointing out that only 49 were treated by the coup sur coup mode of bleeding, of whom G died, or 1 in 8 cases, a favourable result which he attributes to the youth of the patients treated. Of his own cases one group of 50 cases were bled only in the first stage of the disease; of these 5 died, or 1 in 10. Those cases that died were bled most, each losing about 4 lb. 4 oz. of blood in successive bleedings. All the cases in this group were uncomplicated, and of the average age of 40 years. Of 182 cases that were bled in the second stage, 32 died, or more than 1 in 6. Here also those who died were bled most. Of the whole 232 cases, o7 died, that is about 1 in 6i, as the general result of M. Grisolle's hospital practice, a mortality only one-half that of M. Louis's cases, although the circumstances under which they occurred were the same, with the excep- tion of not being so heroically treated. Laennec also, who only bled moderately at the commencement of the disease, regarded the mortality as one death in 6 or 8 cases4 Dr. Glen, my late resident clerk, was so good as to tabulate for me all the cases of pneumonia given in the army returns, and reported by Colonel Tulloch.§ Nothing can be more unsatisfactory than the nature of these returns, as we have no information as to the exactitude with which they were made, how the diagnosis was determined, or what was the treatment. The favourable mortality, as it has been supposed, of 1 death in 13 cases, which, according to Dr. Glen, is the general result, is of little or no service to the present inquiry. Treatment by Diet.—This treatment essentially consists in allowing the disease to go through its natural course. During the stage of fever the diet is light, and cold water allowed for drink; subsequently more generous diet is allowed, with wine, according to the nature of the symptoms. Sometimes a dietetic is converted into an expectant^ treat- ment, when remedies are given to meet occasional symptoms, as in the practice of Skoda, in the Charity Hospital of Vienna. An account of * From an Analysis of Rasori's Practice—Annales de Therapeutique. Janvier, 1847. f Traite pratique de la Pneumonie. Paris. 1841. X Forbes' Translation. Fourth Edition. P. 237. § Government Statistical Reports on Mortality among the Troops. 1853. THE AUTHOR'S TREATMENT OF PNEUMONIA. 273 this has been given to us by Dr. George Balfour of Cramond, who found from the books of the hospital, that during a period of three years and five months, commencing 1843, 392 patients were treated, of whom 45 died, or 1 in 7£. Occasionally opium was given in small doses if there was much pain. Venesection was also practised early if there was much dyspnoea, and emetics given if the expectoration consisted of tough mucus. Dr. Balfour has also given some statistics of the Homoeopathic Hos- pital of Vienna, accompanied, however, with statements which render it doubtful whether every case that applied was admitted, and consequently not fairly comparable with other hospital statistics. There can be no doubt, however, that many severe cases of pneumonia recovered under a system of treatment, which, it appears to me, most medical men must consider to be essentially a dietetic one. Dr. Dietl treated 380 cases of primary pneumonia, in the Charity Hospital of Vienna; 85 by venesection, 106 by large doses of tartar emetic, and 189 by diet only, with the following result: Vene- Tartar Diet. section. Emetic. Cured.................. 68 .................. 84 .................. 175 Died..................... '17 .................. 22 .................. 14 85................. 106 .................. 189 Percent..................20.4 .................. 20.7.................. 7.4 Deaths....................1 in 5.................1 in 5.22....................1 in 13i It was further observable that of the 85 cases treated by blood-letting, 7 of the fatal cases were uncomplicated ; whilst of the 189 cases treated by diet, not one of the deaths was an uncomplicated one. Treatment directed to further the natural proyress of the disease.— The treatment I have pursued in pneumonia is founded on the patholo- gical principles formerly given, viz., never to attempt cutting the disease short, or to weaken the pulse or vital powers, but on the contrary to further the necessary changes which the exudation must undergo, in order to be fully excreted from the economy. To this end, during the period of febrile excitement, I content myself with giving salines in small doses, with a view of diminishing the viscosity of the blood. As soon as the pulse becomes soft, I order good beef tea and nutrients; and if there be weakness, from 4 to 8 ounces of wine daily. As the period of crisis approaches I give a diuretic, generally consisting of half a drachm of nitric aether, sometimes combined with ten minims of colchicum wine, three times daily, to favour the excretion of urates. But if crisis occurs by sweat or stool, I take care not to check it in any way. On examining into the results of this practice, which has been publicly carried on by me in the clinical wards of the Royal infirmary during the last eight years, and which has been carefully recorded by the clinical clerks, I find the total number of cases to be 78*; the average age, 30|. Of these, 75 were dismissed cured, and 3 died, that is, 1 in 26. Of the 75 cases cured, 65 were uncomplicated, and 10 complicated. * In the former edition the number stated was C5. Since then, 13 cases of pneu- monia have been treated by me in the infirmary. 18 274 PRINCIPLES OF MEDICINE. Of the 65 uncomplicated cases, I find that the clerk has omitted to state either the exact day of rigor, or of convalescence, in 5, so that no deduc- tion can be derived from them as to the duration of the disease. Of the re- maining 60 uncomplicated cases, 47 were single and 13 double pneumonia. The duration of the 47 cases of single pneumonia was as follows, viz.—1 case recovered in 5 days; 3 cases in 7 days ; 2 cases in S days • 4 cases in 10 days; 2 cases in 11 days; 3 cases in 12 days; 2 cases in 13 days; 12 cases in 14 days; 2 cases in 15 days; 3 cases in 16 days; 2 cases in 17 days; 3cases in 18 days; 1 case in 19 days ; 2 cases in20 days; 2 cases in 21 days ; 1 case in 22 days; 1 case in 23 days; and 1 case in 26 days. Average duration of single uncomplicated pneumonia, 14^ days. The duration of the 13 uncomplicated cases of double pneumonia was as follows :—1 case recovered in 9 days ; 1 case in 13 days; 2 cases in 14 days; 1 case in 16 days; 2 cases in 18 days; 1 case in 19 days; 1 case in 20 days; 3 cases in 21 days; and 1 case in 55 days. Average duration of double uncomplicated pneumonia, 20 days. Of the 65 uncomplicated cases, 7 were bled, and were subjected to an antiphlogistic treatment before admission. Of these 1 case recovered in 7 days; 2 cases in 14 days; 1 case in 16 days; 1 case in 17 days; 1 case in 20 days; and 1 case (a severe double one) in 55 days. Average duration of cases bled, 20 days. Of the ten complicated cases of pneumonia which recovered, the 1st case supervened on chronic asthma, bronchitis, and emphysema, and recovered in 14 days; the 2d case supervened on typhus fever, and reco- vered in 16 days; the 3d case supervened on chronic asthma, bronchitis, and pleurisy, and recovered in 48 days; the 4th case supervened on typhus fever, and recovered in 18 days; the 5th case supervened on pleurisy on one side, with pleural exudation existing 8 weeks before admission, and recovered in 19 days; the 6th case supervened on rheumatism with heart disease, and recovered in 19 days; the 7th case supervened on very severe rheumatism, with endocarditis and pericarditis, but recovered in 15 days ; the 8th case was complicated with pleurisy, which continued long after the pneumonia disappeared, and recovered in ten days; the 9th case was complicated with chronic tubercular condensation at the apex of the right lung, and was double, but recovered in 9 days; and the 10th case was complicated with bronchitis and phthisis, but recovered on the 9th day. The average duration of the pneumonia in the 10 com- plicated cases was 17f days. Of these 7 were single and 3 double pneu- monia, the latter recovering respectively in 18, 15, and 9 days. Of the 65 uncomplicated cases of pneumonia, including the 13 double cases, I find that the exact day of dismission is omitted from the register in 4 cases. But the average residence in the hospital of the remaining 61 cases was 24f days. This average is undoubtedly too high, as I find that several cases had been allowed to linger in the house, in conse- quence of supposed chronic pains, or trifling skin eruptions, in no way connected with the pneumonia. The three fatal cases were all complicated. The first with uncon- trollable diarrhoea, and on dissection, conjoined with pneumonia, there was found extensive follicular disease of the mucous membrane of the duodenum, jejunum, but chiefly of the ileum. The second case was THE AUTHOR'S TREATMENT OF PNEUMONIA. 275 complicated with persistent albuminuria and anasarca. No post mortem examination could be obtained. The third case, that of a drunkard, was complicated with delirium tremens, and latterly violent convulsions. On dissection, in addition to the pneumonia, there was found universal cere- bral meningitis, with exudation, at the base, as well as over both hemi- spheres of the brain. (See Cerebral Meningitis. Case of David Murray.) In addition to the three fatal cases here recorded, I have found in the pathological registers kept by Drs. Gairdner and Haldane seven other cases, in which, as the result of chronic cerebral, cardiac, renal, or other pulmonary disease (such as phthisis), pneumonia appeared before death, adding a fatal complication to previously existing maladies. Not one of these can properly be considered as a case of acute pneumonia, or indeed of pneumonia at all. They have all been entered by the clerks in the ward books as softening of the brain, morbus cordis, Bright's disease, or other lesion for which the patients entered the infirmary and were treat- ed. In most of them it was the pneumonic des agonizans of the French. These, then, are positively all the cases of acute pneumonia which have entered the infirmary under my care during the last ten years, so far as I can discover them. They have been all analysed and tabulated by myself and by my clinical resident physicians, to whom I am much indebted for the great care and pains they have taken in confirming these results. Every case has been treated publicly, and is open for inspection in the ward books, and the result is, as I have stated, that the mortality of acute pneumonia, in the practice of the clinical wards while under my care, is 1 in 26, and that of all the cases of uncomplicated pneu- monia, 65 in number, not one has died, although many of them have been very severe, involving the whole of one lung, and in 13 cases por- tions of both lungs. So far, I think, I approach very near correctness by saying that the result of a vigorous antiphlogistic treatment of pneumonia as formerly practised is a mortality of 1 in 3 cases; that the result of a treatment by tartar emetic in large doses, according to Rasori, and more recently to Dietl, is a mortality of 1 in 5 cases—but according to Laennec, 1 in 10 cases; that the result of moderate bleedings, as iu the treatment of Grisolle, is a mortality of 1 in G£ cases ; and that the result of a dietetic treatment with occasional bleedings and emetics in severe cases, as with Skoda, is a mortality of 1 in 7, and if pure, as under Dietl, a mortality of 1 in 13 cases, all carried on in large public hospitals. Further, that the mortality from pneumonia in the army and navy, occurring generally among healthy able-bodied men, has been also a mortality of 1 in 13 eases. Lastly, that the result of a treatment directed to further the natural progress of the disease as I have explained it, is, in the clinical wards of the Royal Infirmary of Edinburgh, when under my care, up to this time (January, 1^49) a mortality of 1 in 26 cases. From these facts it follows that uncomplicated pneumonia, especially in young and vigorous constitutions, always get well, if instead of being lowered, the vital powers are supported, and the excretion of effete pro- ducts assisted. It is exactly in these cases, however, that we were for- merly enjoined to bleed most copiously, and that our systematic works even now direct us to draw blood largely and repeatedly in consequence 276 PRINCIPLES OF MEDICINE. of the supposed imminent danger of suppuration destroying the texture of the lung. Such danger is altogether illusory, and the destruction to lung tissue, so far from being prevented, is far more likely to be produced by the practice. In fact, the only cases in which it occurs are in aged or enfeebled constitutions, in which nutrients and not antiphlogistics are the remedies indicated. We can, however, readily understand how blood-letting, practised early and in young and vigorous constitutions, does less harm, or, to use a common expression, " is borne better," than when the disease is advanced or the patient weak, and this, because then the vital powers are less affected by it. Hence the diminished mortality in the second series of Louis's cases, and probably in the army and navy cases. But that it cures the greater number of persons attacked, or shortens the duration of the disease, is disproved by every fact with which we are acquainted. At the same time there are cases, which were formerly often mistaken for inflammation, in which blood-letting may still be useful. I allude to those where an obstruction to the circulation exists in the heart and lung dependent on over-distension of the right side of the former organ, or on venous congestion, engorgement, and perhaps oedema of the latter ; also certain cases of bronchitis preventing aeration, of aneurism and of asphyxia. Although even here the true value of the remedy has yet to be positively ascertained, the special cases demanding it more carefully discriminated, and the mechanical principles which justify the practice determined. The temporary benefit occasioned in many of these cases by the loss of a trifling amount of blood is often very remarkable, and has been previously referred to (p. 264). I have seen instances where great dyspnoea and pain, caused by large thoracic aneurisms in vigorous men, have been greatly alleviated, and inexpressible relief produced for from twelve to twenty-four hours, by a bleeding to the extent of only five ounces. It seems probable that this may arise from diminishing for a time the tension of the whole vascular system. But whatever be the explanation of this fact, I hold that, as a palliative, and practised to a limited extent in cases where no great debility exists, blood-letting may still be had recourse to. So with regard to antimonials, although in the large doses, which weaken the heart and force of the pulse, they are not serviceable—in smaller doses, together with other neutral salts, they may assist in diminishing the viscosity of the blood, and in favouring the excretion of the effete matters by the skin and kidneys. As to mercurials, the confident belief in their power of causing absorp- tion of lymph, by operating on the blood, is not only opposed to sound theory, as formerly explained, but, like blood-letting, is not supported by that experience which has been so confidently appealed to in their favour. They have been most praised in the treatment of serous inflammations and in iritis. But recent careful observation has demonstrated that the moment these diseases are treated with mercury, they are uninfluenced (except iu certain cases for the worse) by this drug. Thus, from an analysis of 40 cases of pericarditis, treated with mercury, and recorded with unusual care by the late Dr. John Taylor, only 4 appear even coin- cidentally to have benefited in any way.* And of 64 cases of iritis, of * British and Foreign Medical Review, vol. xxiv. p. 565 ; and Lancet, May 1845 to October 184G. THE BLOOD-LETTING CONTROVERSY OF 1857-3. 277 every deg ree of severity, including its idiopathic, traumatic, rheumatic, and syphilitic varieties, treated without mercury, by Dr. H. W. Williams of Boston, U. S., the results—with four exceptions, which were neglected at the commencement—were perfectly good.* I cannot, therefore, resist the conclusion that the principles which led to an antiphlogistic practice in acute inflammations were erroneous, and are no longer in harmony with the existing state of pathology. I think it has been further shown that in recent times our success in treatment has been great, just in proportion as we have abandoned heroic remedies, and directed our attention to furthering the natural progress of the disease. Thus, in our large public hospitals, under circumstances pretty much the same, it has been shown that the mortality of pneumonia has been diminished from 1 in 3 to 1 in 7 cases, then to 1 in 13, and lastly, to 1 in 26 cases. In other words, death from this disease takes place nearly nine times less frequently now than it did twenty years ago. I am satisfied also that deaths from acute pericarditis are far less common now than formerly, and that post-mortem examinations as a consequence demonstrate adhesions of the pericardium much more frequently. This great improvement in practice, it appears to me, is attributable—1st, To the greater accuracy with which we can now detect inflammations of the lung and heart ; and 2d, To our better acquaintance with their pathology —and the result is not the less certain with men of experience, because these causes operate insensibly to themselves. How often, during the last seventeen years, have we been asked, of what use are your stetho- scopes, your microscopes, and your chemical analyses at the bed-side ? In reply, we point to the revolution now going on in the practice of medicine, to the establishment of scientific laws instead of empirical rules, and to the abandonment of a palliative in favour of a curative plan of treatment. Note.—Reply to the Objections which have been urged to the Author's Remarks on the Treatment of Internal Inflammations. So much has been published in reference to the foregoing observations on blood- letting, the treatment of pneumonia, and the supposed change of type in inflamma- tions, that it -will be impossible for me to allude in detail to all that has been said. It is evident that the definition of the word inflammation, the ideas to be attached to the pathological condition it expresses, as well as all that refers to its causes and treatment, require to be re-systematised, in order that our present knowledge of the pathology of the process may be brought into harmony with modern practice. To this task I shall address myself, as soon as my avocations will permit. In the mean- time, in deference to the distinguished men who have criticised my opinions and facts, I propose saying a few words in reply to the more important objections which have been made to them. In a paper published in the Edinburgh Medical Journal for May 1857, Dr. Alison has cited some cases, and one especially recorded by Dr. Gregory, where, after large bleedings, recovery took place. The graphic account of such cases is well cal- culated to make a strong impression on the public, and even on the minds of some professional men, although it is difficult to see how isolated cases bear on the ques- * Boston Medical and Surgical Journal. 1856. 278 PRINCIPLES OF MEDICINE. tion at all. According to Dr. Gregory, a young man enters the clinical wards after several days' illness—neither he nor his pupils had any doubt as to the nature of the disease (pleurisy), the urgent nature of it, or the proper remedy for it (bleeding); he was bled largely and repeatedly in consequence, and recovered, in Dr. Gergory's opinion, much faster than such patients ordinarily do. Now, this case differs in no particular from those of other young men constantly to be seen in the wards of M Bouillaud, at la Charite, Paris ; and there is no proof whatever that the practice adopted by Gregory in past, or by Bouillaud in modern times, cuts short the progress of the disease one hour, however it may have modified the symptoms. Yet, so important does this case appear to Dr. Alison, that he observes of it, " if we were to think it necessary to suppose that such bleedings as those described by Dr. Gregory in the case read, were only injurious to the lungs of the man who left the hospital apparently well within a fortnight" (this does not appear from the case) " after the violent pleurisy, and all these bleedings besides, I should think these facts alone quite sufficient to stagger my belief in any such theory." But I have never maintained such a theory. On the contrary, I have proved that two persons out of every three treated in this way for pneumonia, in public hospitals, recovered; and there can be no doubt that the medical men who practised these bleedings conscientiously believed, and many of them still believe, that they were beneficial, and saved the lives of their patients. But I have also proved that recovery is more frequent and more speedy when there are no such bleedings, and, if so, the conclusion seems irresistible, that, as a rule of practice, they are inert or injurious. What is required to show the excellence of Dr. Gregory's practice, is not a descrip- tion of the cases which recovered, but a demonstration that a greater number of persons affected were saved by it than there would have been under an opposite treatment. But as there are now no data whereby we are enabled to judge of this, it still appears to me that no reliance can be placed on the experience of Cullen and Gregory as to the general effects of bleeding. Dr. Alison, however, contends that blood letting, to be useful in pnenumonia, should be practised during the first three days, and that, if certain characteristic symptoms are present, it is not safe to dispense with it. On this point I have only to remark, that the records of the Royal Infirmary, during the period when blood- letting was largely practised, prove that bleeding was seldom had recourse to there at that early period, even by Dr. Alison himself. If it be now urged that that explains the great mortality, I reply, it may have assisted, inasmuch as the earlier a bleeding is practised, the less dangerous it is. With regard to its not being safe to dispense with it, I have also proved that in all places where pneumonia ha3 been largely treated without blood-letting, the mortality, so far from being increased, has invariably diminished. In confirmation of* this important result of modern expe- rience, I may cite a passage from a letter I received from Dr. Arthur Mitchell, dated Vienna, April 2, 1857, in answer to one of mine, requesting him to furnish me with the conclusions of the Viennese physicians. He says—"I have met no man here who will entertain for a moment the idea that the change in the treatment of pneu- monia has resulted from any change in its type. They say that when physicians became more expert in the physical examination of pulmonary disease, they found that bleeding did not affect, in a favourable manner, the real progress of the disease, and therefore they were led to discontinue it. They all seem to be of opinion, how- ever, that although there is, as the result of this change, a diminution of the mortality, it is not very great, but that the recoveries are quicker, and much more satisfactory.' —(See also Dr. Mitchell's paper on the Statistics of Pneumonia in Vienna, Edinburgh Medical Journal, November, 1857.) No better proof could be given of the influence of modern diagnosis on the treatment of disease. THE BLOOD-LETTING CONTROVERSY OF 1857-8. 279 I beg, therefore, again to repeat, that " the real tests of successful practice are not to be sought for in the relief of symptoms, but in the removal of the disease; and that that treatment will be best which, ceteris paribus, is followed by fewest deaths, and leads to recovery in the shortest time." See p. 2 70. Dr. Alison seems to suppose that my observations were made principally on the dead body. But, in fact, they have been made on the transparent parts of living ani- mals, as well as on patients labouring under inflammation; and all the phenomena observed in them I have found perfectly consistent with what was discoverable after death. Neither have I ever asserted that exudation of liquor sanguinis, in order to constitute inflammation, must be visible to the naked eye. On the contrary, I have always maintained that those who have not studied this morbid process with the aid of high magnifying powers, can know very little of it, inasmuch as all the primary changes are invisible to unassisted sight. But the question is not how a doctrine is arrived at, but whether that doctrine be true and consistent with all known facts? On this point Dr. Alison argues that inflammation is not, as I have defined it, viz., " a change in a part characterised by the exudation of lymph through the walls of the minute vessels, resulting from changes more or less well marked in the nervous, vascular, sanguineous, and parenchymatous elements of that part," p. 253. He adheres to his former statement, viz., that it is '' the tendency always observed, even when these changes have been of short dura- tion, to effusion from the blood-vessels of some new products, speedily assuming, in most instances, the form either of coagulable lymph or pus," etc. The difference between us, then, is this, that whilst I call active congestion plus exudation—inflam- mation, he says it is active congestion plus a tendency or nisus to exudation. But how, in any given case or group of cases, this "tendency" to a certain act can be separated from the act itself, or how, if it can, it is to be recognised in the living body, so as to constitute a foundation for practice, Dr. Alison has not informed us. It is evidently an assumption which, even were it true, could never lead to any ad- vancement in our knowledge, or improve our treatment. For, if it be affirmed that congestion, in any given case, presents a tendency to exudation; and if on bleeding no exudation follows, how is it possible to know whether the tendency was present 1 But when, as most frequently happens, exudation occurs, and continues to spread, not- withstanding bleeding, it is then only we have any proof that such tendency existed, together with the certainty that in all such cases the remedy has failed to fulfil its supposed function. This assumption of what is the tendency of morbid lesions prevails largely in the writings of medical men, who assert that a certain disease, of the nature of which they often know nothing, has a tendency to destroy texture, and kill; and that in some cases (as phthisis) remedies are useless in arresting it, whilst in others (as pneumonia) their application cuts it short. I have long maintained, and this seems now to be generally admitted, that the notion of the necessarily fatal character of phthisis was erroneous, and that it can be arrested by art,* while, in the present work, I contend that pneumonia is by no means a fatal disease in sound constitu- tions, and cannot be cut short. This last proposition I endeavour to prove by esta- blishing three series of facts, viz.—1st, That when the tendency to inflammation was generally attempted to be checked by antiphlogistics, there was a great mor- tality (1 case in 3); 2d, That a pneumonia, when established in sound constitutions, runs through its whole course, including exudation of lymph and suppuration, with- out any destruction of tissue at all; and 3d, That when a treatment is adopted to favour these processes instead of trying to check thsm or cut them short, the former On " Pulmonary Tubercles," Svo., 1S53, 280 PRINCIPLES OF MEDICINE. great mortality of 1 case in 3 is diminished to 1 case in 26. These facts appear to me irreconcilable with the opinions and statements put forth by Dr. Alison. With regard to what Dr. Alison calls the " ingenious speculation'' contained in my third proposition; it is satisfactory to me to observe that he agrees with it. But this so-called speculation is, in fact, an attempt to show that the mechanical principles which have hitherto guided practitioners in their attempts to cut short internal inflam- mations by bleeding, are erroneous, and not in harmony with the present advanced state of pathology. In other words, my third proposition (p. 259, et seq.) points out that the preliminary, essential, and resulting changes of this morbid process, are essen- tially vital in their nature, and require for their perfect and healthful performance that the vital force of the economy, so far from being depressed, ought to be main- tained, and, if necessary, supported. If, then, so acute a thinker as Dr. Alison has detected no fallacy in my reasoning, I may be pardoned for considering this propo- sition as having been clearly demonstrated. In a discussion of this kind it would be easy to meet opinion with opinion, assertion with assertion, and case with case; but I decline to do so, because such a mode of procedure cannot, under existing circumstances, lead to a solution of the questions at issue. My object has been to furnish a contribution towards the settlement of an im- portant point for practice. This I have done, 1st, By showing how the modern views of physiology and pathology have superseded the doctrines which formerly prevailed; and 2d, How an improved practice has of late years taken place, and brought about diminished mortality, and more rapid convalescence in pneumonia. If what has previously been stated fails to convince, a mere repetition of the facts and arguments advanced will not do so, and we must wait for further results, Hence, it is not my purpose to follow Dr. Alison into what may be the proper practice in many diseases he has alluded to. Neither is it necessary to enter into a lengthened refutation of the idea, that the natural progress of an inflammation is like the burning of a house, nor of the application of Archbishop Whately's remarks on the action of fire-engines, to the modus operandi of blood-letting. I would only remark how curious it is that now, as in ancient times, analogies should be drawn between blazing buildings, and that morbid process unfortunately named from the Latin word infiammo. To suppose that inflammation has any relation to burning with fire, is about as reasonable as to imagine that a growing tree or animal is being consumed. In a subsequent communication, inserted in the same Journal for October, 1857, Dr. Alison says:—" I believe it to be a matter of real practical importance, that practitioners in all parts of the world should make up their minds without delay as to the question whether or not there is sufficient evidence of such changes of type in inflammatory diseases, as are described in several of the inclosed extracts of letters with which I have lately been honoured—being part of the general dispensations of Providence as to those diseases, and, as far as we yet know, an ultimate fact in their history." But on careful perusal of the letters from various practitioners, published with that paper, I find, it is true, strong opinions stating that the type of inflamma- tions has changed, together with some cases which have recovered after large bleed- ings, but not one fact or argument to support the doctrine now advanced by Dr. Ali- son, that such change of type is an ultimate fact or law in the history of inflamma- tions. Surely a conclusion of such importance ought to be based on something more positive than the fluctuating opinions of medical practitioners, however eminent they may be. Experience alone is exceedingly fallacious, for there is such a thing as experience in wrong as well as in right; and notwithstanding my great respect for the originator of this doctrine, I think it would not be becoming in us, with due re- THE BLOOD-LETTING CONTROVERSY OF 1857-8. 281 gard to the interests of science, to yield to the authority of distinguished practition- ers of the art, unless they can show that their theory, like every other that is reallv correct is consistent with all known facts. To this test every theory must be put, from whatever high authority it may originate. Now, at p. 255, et seq., in Proposition 2, I have pointed out that we have no facts to show that the pulse and general vigour of the constitution have undergone any change for the worse among mankind. It so happens that there is no subject in all physiology with regard to which we possess more elaborate and more exact infor- mation than we do concerning the pulse. Hales published a remarkable series of experiments, in reference to the static force of the pulse, in 1731, and similar obser- vations made by Poiseulle in 1828, by Valentin in 1844, by Ludwig in 1847, and by Vierrordt so late as 1855, show that no great variation has taken place during 127 years. What proof has been advanced by the supporters of change of type to show that it has ? Certainly none whatever. As to the vigour of the human constitution, the theory, if it means anything, proceeds upon the supposition, that when a man of average strength, now-a-days is seized with inflammation, he presents all the symptoms that used to be observed in a weak one. This is asserting that the human race has so degenerated within the last twenty years, that the lowering treatment which formerly was beneficial is now injurious. But so far is this notion from being supported by facts, that it might easily be shown that men in these countries are now more vigorous, better fed, clothed, and housed, and that human life is more valuable than it was formerly. Mere opinion, however, could never establish one doctrine or the other.- Some have even gone so far as to attempt an explanation of the supposititious fact, thinking that the use of potatoes, of tea, or the introduction of railways, has something to do with it. Dr. Watson is of opinion that it is attributable to the epidemics of cholera, which " leave traces of their operation on the health and vitality of a community, long after they have ceased to prevail as epidemics." (Practice of Physic, 4th edition, p. 97.) Mr. Robertson of Manchester is satisfied, from experience, that it is since the boil epidemic appeared that the change has taken place (Edin. Med. Jour- nal, Oct. 1857, p. 299). Surely it would be well, before speculating as to causes, to determine in the first place, whether the alleged change in pulse and type has taken place at all. How often do our senses deceive us, when objects are at hand ? how little can they be depended on when it is simply asserted by this or that prac- titioner, that a pulse was stronger twenty years ago than it is now! Yet we have no further evidence than this advanced by the supporters of a theory, which claims for its fundamental fact a diminished vital force in the heart and pulse of man and animals, to explain a change of medical practice. Indeed, it should not be forgotten that veterinary surgeons have also ceased to bleed in inflammation. Have animals then also degenerated, and is the type of organic diseases changed in them ? This question was answered by a farmer, in the Scotsman newspaper for October 22d, 1857, as follows ;—" Dr.------, in his communication of the 15th ultimo, makes the startling announcement that physical and moral decay are undermining the vigour and energy which formerly charac- terised the inhabitants of this country; and, as a proof of the assertion that physical decay was at work, states that the free blood-lettings in the case of inflammatory diseases, which formerly was the practice, cannot now be resorted to with benefit. I am neither a medical man nor a veterinary surgeon, but I own a few horses, and other animals of the cattle and sheep tribes. How comes it, then, that some thirty yeas ago, when any of these animals were seized with any inflammatory affection however slight, that profuse bleeding was resorted to, and with advantage ? Now, however, the veterinary surgeon never bleeds save on very rare occasions; at the 282 PRINCIPLES OF MEDICINE, same time telling me that the animal cannot afford to lose any blood, and this treat- ment is equally successful as the former was. On Dr. ------'s principle, then, our horses should be physically inferior to what they were thirty years ago. Is this the fact ? My experience says they are at least equal in physical power, energy, and vigour to what they were then. Do the horses of Glasgow or Edinburgh draw lighter loads; do our carts convey less grain to market; do we plough with a shallower furrow; do our race -horses run at a slower pace ? The general answer will be they do not. For instance, the last Derby was one of the quickest-run races on record. How does the doctor account for this on his theory ?" I need scarcely say that the doctor has made no rejoinder. If it had been contended that the greater vigour of the population had so influ- enced the symptoms as to have rendered dyspnoea, quick pulse, and other pheno- mena of weakness less apparent, it would have been more accordant with pathology. But as the former therapeutical rule was, that bleeding was demanded only in cases of robust and strong constitutions, such a doctrine would have been inconsistent. In the meantime it seems to me apparent that there are no facts upon which the theory of change of type in inflammation can be based, as in any way explanatory of the change in our treatment. Dr. Watson of London, in a recent edition of his work on The Principles and Practice of Physic, has added to the chapter on inflammation a note, in which he alludes to my remarks. He argues that Cullen and Gregory not being certain as to the exact seat of the inflammation, is nothing to the purpose, if they were compe- tent to ascertain that inflammation was going on somewhere in the chest. But that they could even do this with certainty, is very doubtful. Besides, I argue against the general opinions of Cullen and Gregory as to large bleedings in internal inflam- mations, not only because they were incapable of separating pneumonia from other inflammations of the chest, but because, so far as we are now capable of determining, their practice was a fatal one ; because those who have imitated it, and carefully examined the results, have found it to be so (Louis, Dietl); and because all those who have abandoned it declare, that not only do their cases get well as soon, but sooner, when blood-letting is not practised. Now, I can find no facts or arguments to controvert this position among the statements of my opponents. Again : " Who," says Dr. Watson, " treats knowingly the extravasated products of inflammation by general bleeding ?" The word " knowingly" here is all important, because the fact is, Cullen, Gregory, and all those who followed them, did bleed largely after exudation had occurred. Hence, very probably, the large mortality, and hence the difference between the first and second series of Louis' cases. But our improved knowledge of diagnosis having taught us how to detect such exudation, we now do not bleed under circumstances where our predecessors did. This is why I contend that the change of treatment is owing to an improved diagnosis rather than to a change of type. Then, as to pathology, Dr. Watson is of opinion that our knowledge, arrived at by chemical and microscopical investiga- tion is not yet complete or ripe enongh to warrant any exclusive reliance upon it as a guide to treatment. But no one has ever contended for the exclusiveness of this or any other mode of investigation. That pathology, as a science, has of late years made rapid strides in advance, cannot be denied; and if so, why should it not do in modern times what it has done in all times past, viz., suggest to our minds the reasonableness or unreasonableness of particular modes of practice? It is in vain telling us to adhere to the routine of our forefathers when the principles which guided them are proved to be erroneous. But when, in addition to change in theory, actual experience demonstrates that we are right, when modern pathology THE BLOOD-LETTING CONTROVERSY OF 1857-8. 283 and modern practice harmonize with and support one another, then it appears to me that the time has arrived for demonstrating the errors of former teaching, as well as of past empirical observations. Dr. Watson also objects to statistics, as being inconclusive and liable to mislead when applied to the treatment of separate esses of disease. Now, no one is more thoroughly persuaded of the fallacies inherent in medical statistics than I am, and no one has more constantly pointed these out to others. (See Monthly Journal of Medical Science, October. 1847.) But the error of some statistics resides more in the jumbling together of different experiences, and of the cases of various practi- tioners, than in an endeavour by a better method to arrive at the results of a par- ticular practice in the hands of any one well-qualified observer. Surely the statistics of Louis on phthisis, and on the effects of bleeding in pneumonia, are trustworthy, as are also those of Cri-olle and Dietl. And I venture to affirm that my own sta- tistics of 78 cases of pneumonia may challenge the strictest inquiry into their accuracy. Then, no one, so far as I am aware, uses or withholds any given remedy merely because of numerical calculations, but, having seen occasion to try this or that practice, he determines its good or bad effects by counting as well as watching. Above all, he should watch and report on those who die, as well as on those who recover under a particular treatment, if he wish to ascertain its real value; and what is this but counting cases ? Is such observation not better than arraying opinion against opinion, placing the vague statements of senior in opposition to those of junior practitioner, or contrasting the scholastic views of London and Edinburgh with those of Paris and Vienna ? Thus, when it is shown that of 78 cases of pneu- monia which entered my clinical wards, only 1 in 26 died, but that of 75 similar cases which entered the wards of La Charite under M. Louis, 1 in 3^ died; then I think it reasonable to conclude, that, as in my cases the vital processes were fur- thered and supported, whereas in those of M. Louis they were diminished or sub- dued, the great mortality of 1 in 3 was owing to the treatment, and that such is a legitimate application of statistics. When, moreover, I ascertain that this conclusion is borne out by the experience of other hospital physicians, then the conviction is forced on my mind, that the number of deaths from pneumonia is lessened in modern times in consequence of our change in practice, rather than of a change of type in the disease. I cannot agree with Dr. Watson that the whole matter in dispute is virtually con- ceded, because I admit that symptoms are relieved by blood-letting. A rigorous anti- phlogistic treatment was formerly put in force with a view of cutting short the disease. Now, this object I contend is not attained; but, on the contrary, the real disorder is prolonged, and rendered proportionally more fatal by that practice. On the other hand, small bleedings, which do not lower the vital strength, are sufficient to relieve urgent symptoms; it being recognised that the lesion otherwise is to be assisted in its natural progress. Surely this is a complete revolution in the principles, as well as in the practice, referable to internal inflammations. But that we should " so bleed as to secure the advantages of the remedy, and avoid its disadvantages," is a happy practical conclusion of Dr. Watson's, in which all parties must concur. Dr. Bell of Glasgow, in the Glasgow Medical Journal, July 1857, has done me the honour of criticising my opinions and facts at great length, and has endeavoured to show that not only is my theory erroneous, and practice bad, but that even my phraseology is illogical and unmeaning. And yet a careful perusal of Dr. Bell's paper will only serve, I think, to establish that he confessedly does not comprehend modern pathology; that his cases support all I have stated as to treatment; and that he seems to understand my meaning tolerably well. Of 27 cases of acute pneumonia 284 PRINCIPLES OF MEDICINE. under his care in the Glasgow Royal Infirmary, admitted in the early stage, he say*, 23 were sthenic and only 4 asthenic. These were bled, mercurialized, pureed and blistered, according to ancient usage, except that the amount of blood taken never exceeded 20 oz., the average quantity being 14. oz. All these cases got well. The duration of the treatment was eighteen days. Now, if these cases were really sthenic in character, and if they were cured by the means employed, then Dr. Bell is the strongest opponent of Dr. Alison's views that has yet appeared. But the fact is, all these cases entered the infirmary very early in the disease, before hepatization was far advanced, and would, I am satisfied, have got well much sooner than in eighteen days, had a lowering treatment not been employed. Besides, the very moderate bleedings practised at the commencement of the disease, cannot be considered as an antiphlogistic, but rather as a palliative remedy. They did not diminish to any serious extent the vital power of the economy, hence the patients ultimately recovered. The mischief of Dr. Bell's practice, however, will be best understood by quotincr his general results, which are, out of 71 cases, 4 deaths, although the complicated cases with phthisis and albuminuria, are not included. Of the cases in which hepatization existed on admission, he tells us that the average time they were in the hospital was 47 days, and the average time they were under treatment was 22 days. " This lengthened duration," he observes, " affords a startling commentary on the bad effects which may be expected to follow the natural plan of treatment recom- mended by Dr. Bennett." Startling indeed. An average treatment of 22 days, and a lingering convalescence of 47 days, with a mortality of four, after the exclusion of complicated cases, will not well contrast with my average duration of 14^ days, and with the fact that the only three fatal cases I have had were just of that kind that Dr. Bell carefully excludes from his list. Had I followed Dr. Bell's plan, there would have been no mortality among my cases at all. I have also calculated the average number of days my uncomplicated cases were in the hospital, and find it to be 241 days, including the cases of double pneumonia. Dr. Bell has also endeavoured to throw doubts upon the accuracy of my state- ments, and has demanded an explanation of his own erroneous conclusions with regard to them. This I shall give. On looking over some former cases on pneumonia published by me, Dr. Bell thinks he has discovered three fatal cases which are in- cluded in my series, but not counted. But he overlooks the obvious fact, that the first case was not treated by me at the commencement; that it was probably one of phthisis, a point, however, I could not determine, because, as stated in the commen- tary, "I had only just then taken charge of the wards." The second case was one of organic lesion of the heart, with Bright's disease, and the pneumonia after death was recent and vesicular—that is, confined to isolated air vesicles. Surely such a case is not one to be included among ordinary cases of acute pneumonia. The third was a case of either phthisis or chronic pneumonia of the apex, and of course, there- fore, was not placed in the list of acute pneumonias. Hence, then, these three cases are not included among my 78 cases. Again, Dr. Bell fancies that the same cases prove that I have not invariably treated every case of pneumonia by furthering the natural progress of the disease. He is again mistaken. It is true that in 1849 I was not so certain of the uselessness of bleeding as I am now, and did say of a case bled before admission, early in the disease, that the practice was judicious. I confess, also, to having thought then, and to having said, that a large bleeding before exudation comes on, may cut short its progress, etc. But I can see nothing so contradictory in all this as Dr. Bell does. Neither has my ordering antimonials, and applying a blister in a few cases, ever amounted to an antiphlogistic practice, or vitiated the general plan I have described. THE BLOOD-LETTING CONTROVERSY OF 1857-8. 285 All the facts contained in Dr. Bell's paper, therefore, it appears to me, fully hear out the correctness of the principles and practice which I have so long recommended in the treatment of internal inflammations. Dr. Christison, in the Edinburgh Medical Journal for January 1858, thinks that Dr. Alison's view is supported by the changes which have taken place in the treatment of fevers. But I cannot see any analogy between inflammation of a part which gives rise to constitutional disturbance, and an essential fever criginatino- in the blood from some morbid poison. I agree with Dr. Christison in thinking thkt we know little more of the pathology of fever now than we did forty years ago. But it is very different with regard to inflammation. The unknown and varying causes producing epidemics are well illustrated in the case of cholera, which visits us at \incertain periods, for reasons of which we are profoundly ignorant. The causes producing inflammation in a part have always been the same, and are unchangeable. Unless, therefore, the non-bleeding in fevers should have shaken the confidence of practi- tioners in the use of blood- letting as an empirical remedy in all cases, I do not see how the treatment of constitutional fever under such different circumstances can cor- rectly be compared with that of inflammation. Dr. Christison, like Dr. Watson, points out that I have advanced no argument, to show that the febrile phenomena must always be the same. But I humbly think it is not for me to show that the human constitution is incapable of undergoing alterations. The onus probandi must be laid on those who assert that any such change is sufficient to account for the remarkable modifications which have taken place in medical practice during the last twenty years. Iu a continuation of his paper in the July No. of the same Journal, 1858, Dr. Christison strongly affirms that the change in the amount of fever, and the strength of the pulse accompanying inflammations, sufficiently explains the abandonment of bleeding in recent times, and that what he misses in the present character of the pulse is its incompressibility. He contends that as soon as the pulse acquired the comparatively soft and easily compressible character, medical men practised blood- letting with great caution. "But," says Dr. Christison, referring to bis general opinion of change of type, " unfortunately I am not able to refer to any recorded facts in support of this proposition." Such an admission appears to me alone fatal to all Dr. Christison's theories on the subject, because numerous facts prove that twenty or thirty years ago antiphlogistic remedies and blood-letting were practised as a mat- ter of course in pneumonia, altogether independent of the state of the pulse. The question at that time regulated by the pulse was not the practice itself, but only the extent to which it should be carried. Besides, if Dr. Christison could have de- monstrated that the practice of which he speaks had been a good one, his memory might have been depended on as furnishing evidence to a certain extent of what he asserts. But as I have shown that all authentic records of the past prove blood-letting and antiphlogistics to have been a most fatal practice, the probability is that the pulse was of just the same character then as it is now. Dr. Easton of Glasgow, in a clinical lecture published in the Edinburgh Medical Journal for February 1858, agrees with me as to the impossibility of inflammations undergoing any change of type, and believes that there is no analogy between the morbid actions of fever and inflammation. At the same time he thinks with Dr. Watson, " that there are waves of time," which influence organic diseases. This seems to me rather contradictory, because if such waves of time exist, and if they modify inflammations, this is what Dr. Alison understands by change of type. He impresses upon his pupils " the fact (?) that in large towns, and more particularly in 286 PRINCIPLES OF MEDICINE. hospitals, blood-letting exercises an injurious effect on the vast majority of the cases of pneumonia which are now met with in these situations ; while, on the other hand, it would be exceedingly improper not to admit, that in country districts, and more particularly if the disease be seen at the very outset, or shortly thereafter, not other- wise, cases may be found in which a single blood-letting will arrest the further pro- gress of the disease." But where are these cases ? Dr. Bell tells us that even in the Glasgow Infirmary, when patients enter at an early stage, they present a sthenic type, but he has not shown that one of his cases was arrested by blood-letting, and admits that, although treated early, their duration on an average was eighteen days. I fear I must be guilty of'the impropriety (as Dr. Easton seems to consider it) of not admitting the probability of finding such cases, as well as of believing that the so-called fact is no fact at all. Dr. Easton also reminds me that exudation of liquor sanguinis is not necessary to constitute inflammation of the lungs, and con. tinues: "Many cases of that disease are met with, while yet in the primary stage of engorgement; and it ought to be our duty, by appropriate treatment—including even blood-lettino- if necessary—to prevent that very exudation which, without reason, without proof, and in defiance of all experience, he (Dr. B.) assumes to be the sine qua non of the malady." This is only a repetition of the argument of Dr. Alison, and is only adding assertion to assertion, and opinion to opinion. Admitting that cases in the sta°-e of primary engorgement are met with, I ask both physicians, how are these to be recognised as cases of pneumonia ? how are the constitutional symp- toms to be separated from those of fever ? and how, without exudation, are we to be satisfied that a blood-letting has cut short an inflammation ? When these ques- tions are answered, it will be time enough to say that my attempt to render the mean- ing of inflammation definite instead of vague, and to distinguish it from mere conges- tion or engorgement of the blood-vessels, is without reason, without proof, and in defiance of all experience. Dr. Henry Kennedy of Dublin has inserted a paper in the Edinburgh Medical Journal for January 1859, in which I have failed to detect any facts bearing on the subject, or any arguments which have not been previously answered. He says that changes in the " epidemic constitution " of animal and vegetable life have existed from the earliest periods of recorded time (p. 625). If so, they must have influenced the phenomena of inflammation formerly as they do now, and cannot, therefore, ex- plain the present unanimity of opinion with regard to the inutility of antiphlogistic3. Dr. Kennedy accuses me of being desirous to reduce inflammation to a uniform stand- ard, and of adhering to a routine of treatment; whereas he says inflammation may vary in six persons affected with it and each case may require a different treatment, Here also I can discover no argument bearing on the question at issue, for the same circumstances which induce the variations in six persons now, were in operation when Cullen and Gregory flourished ; and if their treatment was successful then, why is it not so now ? Dr. Kennedy deals largely in assertion ; but his paper is destitute of all proof, and what he says only amounts to his agreeing in opinion with Drs. Alison, Watson, and others. He indeed enters into an argument (p. 632) to show that nature does not always cure pneumonia. But I have never said that it did. On the con- trary, while my Proposition 4 maintains that medical art cannot cut short an inflammation, it maintains that our efforts are most valuable in conducting it to a favourable termination. In this and many other points of his essay Dr. Kennedy has apparently so completely misunderstood my remarks, that it will be sufficient for me, I hope, to call his attention to the further observations contained in this lengthy note to the original paper. In reply to what Dr. Kennedy says concerning statistics, routine, mercury, etc. (p. 637, et seq.), I would refer him to the cases publicly THE BLOOD-LETTING CONTROVERSY OF 1857-8. 287 treated by me in the Royal Infirmary, of which he has taken no notice, and several of which are recorded in this work. (See Pneumonia.) His confident conviction that my treatment " will be found inert, and fail in everything but loss of time," is suffi- ciently answered by the amount of success and rapidity of cure which that treatment has been proved to occasion, as described p. 274. But whilst several eminent men have thus opposed the principles of practice con- tained in this work, I am happy to know that many able and distinguished physicians agree with me essentially in the views I have taken on this important practical subject. Among these, Dr. Todd of London has long successfully practised on principles which, if not identical, are closely allied to them. In a recent paper of his, inserted in the 1st and 2nd Nos. of Beak's Archives of Medicine, 1857-8, there occur the following passages:—"Internal inflammations are cured not by the ingesta administered, nor by the egesta promoted by the drugs of the physician, but by a natural process as distinct and definite as that process itself of abnormal nutrition to which we give the name of inflammation. What we may do by our interference may either aid, promote, and even accelerate, this natural tendency to get well; or it may very seriously impair and retard, and even altogether stop, that salutary process. " If, then, this view of the nature of the means by which inflammation is resolved in internal organs be correct, it is not unreasonable to assume that a very depressed state of vital power is unfavourable to the healing process. Indeed, if you watch those cases in which nothing at all has been done, or in which nothing has been done to lower the vital powers, you will find that the mere inflammatory process itself, es- pecially in an organ so important as the lung, depresses the strength of the patient each day more and more. " You will perceive, then, that according to these views, there are strong d priori reasons in favour of the policy of upholding our patients, even in the earliest stages of acute disease, by such food as may be best suited to their digestive organs, such as is most readily assimilated, and calls for the least effort, the smallest expenditure of .vital force, for its primary digestion. Nutritive matter in a state of solution—broths, soups, farinaceous matters—answers this purpose best, and also alcohol, which is directly absorbed without any previous change, and tends to feed the calorifacient process, and to diminish the waste of tissues which would necessarily follow in order to maintain it. "Inflammation is a deranged nutrition. Like the normal nutrition, it involves supply and waste, and as the latter is considerable, the former will be proportionably so. The tendency in inflammation is to the more or less rapid formation of abnormal products, such as lymph and pus; and the supplies for these formations must be drawn from the blood, or from the tissues, in both cases with the effect of more or less exhaustion of the vital force, with more or less extensive organic disintegration. The active chemical process which accompanies all these changes, engenders the great heat of the inflamed part. " The more this process of inflammation draws upon the blood the greater will be the exhaustion of vital force, and the more the whole frame will suffer; the more it feeds on the tissues, the greater will be the difficulty of the reparative process. Is it not, then, important that adequate supplies should be conveyed to this process, abnormal though it be ? And is it not likely that the most appropriate supplies may be conveyed to it through the blood, so that the waste of tissue may be stopped, and the tendency to abnormal formations be checked, at least from that direction ? " And this, in truth, seems to me to be but the plain and simple fact; you must feed inflammations as you would other active vital processes. You must, that is, 288 PRINCIPLES OF MEDICINE. feed them to prevent them from extending to, and preying on, healthy organic struc. tures, and committing great destruction. Bear in mind, too, that you cannot stop an inflammation so long as the exciting cause of irritation is inherent in the inflamed part; you cannot cure an inflamed eye so long as the irritating particle of dust remains adherent to it. It is wise policy, then, to try and gain time, until by anti- dotal means, or by elimination, you can get rid of the local irritation, whatever that may be." Dr. Markham, in an able series of communications in the Lancet for November and December 1857, and in the Edinburgh Medical Journal for 1857-8, pp. 886, 1058, not only upholds them, but advances new and, it seems to me, unanswerable argu- ments in their support. The following is a summary of the more important points insisted on by him :— The hypothesis that venesection was a right remedy in inflammations in former days is entirely founded on the supposition that the practice of physicians iu those days was a proper practice ; but it is impossible for us now to arrive at any just conclusions on this point; they have left us nothing but their assertions and convictions whereby to try the value of their practice. This we know, that their experience quite differs from ours in this particular of practice ; herein all are agreed, and those who have faith in the infallible clear-sightedness of our forefathers, in order to reconcile the apparent discrepancy which thus arises between the practice of past and present days, call in the agency of a change-of-type theory. Thus, theory is called in to support hypothesis; and as may be readily anticipated, the whole fabric melts away under the touch of modern medical argumentation. Clinical medicine (as now understood) is entirely a modern invention. Our fore- fathers bled in pneumonia, that is, for everything that occurred wrong and produced inflammatory symptoms within the thorax: they bled in tubercular disease, in pneu- monia, in heart diseases of all sorts, in rheumatism of the thoracic muscles, etc., etc., and from thence they concluded that venesection was good in pneumonia, and we are called upon to endorse and accept their sentiments. Now, it is a fact beyond all cavil, and worthy of note, that the whole profession (for individuals have differed in all ages about bleeding) began to change their opinions about venesection, at the very time that they began to study medicine by the lights of modern investigation, viz., modern pathology and diagnosis. The reason is plain. Every well-kept record of diseases showed the injury done by large bleedings in inflammations; and, doubtless, the accu- mulated facts, duly reasoned on, at length brought physicians to hesitate in the prac- tice, and at last to denounce it. The change of type theory rests wholly on a belief in the testimony of the expe- rience of skilled physicians in past days. These men were strong-minded men, full of sense, and their well-educated senses, we are told, were little likely to have their judgment misled; they bled, saw the excellent results of bleeding, and justly con- cluded that no remedy was so admirable in inflammation; therefore the diseases for which they bled undoubtedly demanded bleeding. We bleed not as they, therefore disease has changed its type. True, they lauded venesection to the skies, but they have left us no records, whereby we may judge of the correctness of their opinions. Others, however, who loved and admired bleeding equally as they did, and whose authority, none will deny, equals the best of theirs, have put on record the data whereon their love of the practice was based, and we can judge them. Had Andral, like Cullen and Gregory, left nothing recorded but his unbounded eulogy of venesec- tion in pneumonia, he also, like them, would have been quoted as an authoritative proof of the efficacy of it; but he has given us the data, whereby we may test the value of his assertions, and we find them utterly condemnatory of his practice. Can THE BLOOD-LETTING CONTROVERSY OF 1857-8. 289 any one doubt, that the practice of those other worthies would stand equally con- demned, could it be brought in a like manner to the bar of modern criticism ? If Andral was deceived, why not they ? Andral tells us, that the experience of ao-es has taught us to be more prodigal in the taking of blood in pneumonia than in any other disease ; that there is no period of the disease, no condition of the pulse, no apparent debility of system, no age, which forbids its practice. Let us see how his conclusions are justified. He records 65 cases of pneumonia ; of these 36, more than one-half, are fatal. Of the uncomplicated cases, there are 9, which reach only the stage of engorgement, and two of them—about 1 in 4—die. Thirteen reach the sec- ond stage, and of these 5 die—1 in 2\. Seven cases reach the third stage, and they all die. Of complicated cases he gives 36 ; of these 22 die ! Another fatal argument against the change-of-type theory is this telling fact, that wise men have, in all ages, and still do in this age with equal fervour, differ as to the value of remedies. From the days of Celsus down to our own, men have fought for and against bleeding, just as some do now. In France and England, mercury is a specific in syphilis ; in Scotland, mercury is a poison in syphilis. In the wards of the same hospital, physicians with European reputations, on the same day, treat fever, one by copious bleedings, the other by copious draughts of wine, both honestly con- vinced, from the results of their treatment, of the propriety of their practice. That which alone gives undoubted value to a remedy is the consentaneous opinion of experi- enced men, which is universally accepted as true, and is not contradicted by the opinion of equally experienced men. Then, again, if we look at the treatment by venesection of other acute diseases in past days, we must admit, from the very nature of them as taught us by modern pathology, that bleeding never could have been the remedy for them. Could it ever have been the right remedy for tubercular disease ? yet it doubtless was the remedy, for in those times phthisis was "pneumonia." Could it ever have been needed in rheumatic fever ? and yet has there been any disease to overcome which more blood has been shed ? From Sydenham down to Bouillaud, the practice has been sustained as steadily as an infallible dogma : to this moment authoritative text-books impress its use upon the rising generation of phlebotomists. The idea was, that the materies morbi could be " evacuated at the mouth of the vein," and of course the practice was logically followed. But modern pathology has taught us this: that there is a poisonous matter in the body producing those peculiar symptoms, and empirical treatment has demonstrated to us through manifest results, constantly ensuing, and not contradicted by opposing opinions, that we possess an agent, which will neutralise that poisoning element. But rheumatism must surely have ever been the same disease; consequently, the wisdom of the ancients notwithstanding, bleeding never could have been the remedy for acute rheumatism. The injury done by it in such disease, physicians of all late ages have not failed to mention. If our forefathers were wrong here, why not in other inflammations ? Dr. Markham, in a paper lately read before the Medico-Chirurgical Society of London, has endeavoured to show what is the manner in which venesection does act when it acts beneficially in inflammation. He therein argues that bleeding is useless, as regards the inflammation ; but that it is frequently of service by relieving certain of the secondary consequences which result from the inflammation, viz., congestion of the heart. (See pp. 295-6.) He believes that it is never of service in any case, except when this congestion of the heart exists. He quotes cases of diseased condi- tions of the brain, of the abdomen, of the heart, and of the lungs, in all of whicii congestion of the heart secondarily arose, and in which venesection gave relief. He argues for the inefficacy of bleeding over internal inflammations, from what we see of its inefficacy in external inflammations. Venesection has no visible influence 19 290 PRINCIPLES OF MEDICINE. over ophthalmia or rheumatism, or any other external inflammation, except when very large, and then only temporarily. Why should it have any influence over in- ternal inflammation ? Surgeons have long since given it up, because they saw its inutility ; but physicians could not see their way so clearly to a like conclusion, until modern pathology enlarged their powers of vision. He considers that practice clearly demonstrates the fact, that bleeding is not required except when congestion of the heart exists, and that the beneficial influence of bleeding is more marked in proportion as this condition of the heart exists in a more marked manner. Of course, however, there are congestions of the heart, and periods in the course of all congestions, in which the remedy can give no relief. When, indeed, is bleeding now-a-days resorted to except in those cases in which this congestion exists ? If the position maintained by him be correct, then he thinks it follows that the objects of, and indications for, bleeding become clear and definite. Dr. Markham also draws attention strongly to the distinction which is to be drawn between venesection and the direct abstraction of blood from an inflamed part. We have, he says, the positive ocular demonstration of the benefits of local bleeding in external inflammations. A few leeches applied to an inflamed rheumatic joint or around an eye rarely ever fail to reduce the chief characteristics of the inflammation— the pain, heat, redness, and swelling. Twenty ounces of blood taken from the arm produces no such effect. Arguing from what we see in external inflammations, he concludes that local abstraction of blood must be also beneficial in all those internal inflammations in which there is a direct vascular communication between the inflamed part and the skin from whence the blood is drawn. Practice, he affirms, entirely corroborates this view. Leeches on the thorax are of use in pneumonia, because they relieve the pain of the inflamed parietal pleura; they manifestly draw no drop of blood from the lungs. They are of service in pericarditis applied over the cardiac region, because they also relieve the local pleuritic inflammation, which he believes to be the cause of the pain. Acute pain does not always accompany pericarditis, he says; neither does local pleurisy, and we may legitimately account for the absence of the one by the absence of the other. Leeches are useless as regards hepatic affections, but they sometimes relieve the pain of the peritoneal inflammation, which is sometimes excited by those affections, and of whose existence we find frequent proof in the dead-house, in the shape of old organised adhesions of liver to abdominal walls. In peritonitis he thinks them of service; but in kidney affections useless; the relief so often apparently given by them being caused by those still more powerful remedies—the warmth and repose in bed, which their application necessarily occa- sions or indicates. In fine, he says the absence or presence of this vascular con- nexion gives us an explanation of the fact, that leeches often do no good in internal inflammations, and that they often are of no service. Of the mode of action of the leeches on local inflammations he has nothing to offer; he accepts the fact as cer- tain. He does not deny the benefits of local irritation; he believes that it may act in a reflex manner through the vaso-motor nerves on the vessels of the inflamed part; but the pathological history of this wonderful nervous agency has yet all to be written. It is possible that leeches may thus sometimes, by irritation, influence the vascular states of inflamed or healthy organs within the body, in cases where no vascular communication exists between the parts whence they draw blood and the organs within. Dr. George Balfour, in a paper published in the Edinburgh Medical Journal for September, 1858, shews that from the earliest times certain medical men have suc- cessfully treated inflammations without blood-letting. But his notion that this has resulted from blind empiricism, rather than from theory, I think disproved by his THE BLOOD-LETTING CONTROVERSY OF 1857-8. 291 own observations. The following quotation contains his views on the subject:__ " Brought up in the professional tenets of one so respected and loved as Dr. Alison I can never forget the horror with which I at first regarded the practice of Skoda the incredulity with which I listened to his explanations, or my astonishment when extended observation had convinced me of the correctness of his conclusions, the truth of which eleven years of private practice in this country have but tended to confirm. True pneumonia has been, in my experience, a comparatively rare disease, and I have had under my care only seventeen cases, all of which recovered. All bore a strong resemblance to Cullen's type, and would, I believe, have borne blood- letting well; that they would have therefore recovered better is impossible; that they would have recovered quicker is unlikely, as, ' after full or repeated blood- letting, convalescence is generally slow' (Alison), forming a striking contrast to the rapid recovery of those who have never been bled. I may say, then; that my own personal experience has not led me to suppose that the practice of not bleeding in pneumonia has been brought about by any change of type ; neither has my reading given me any reason to think that there has been any wave or waves of changing type, but rather to agree with Dr. Duncan that, as far as regards inflam- mation at least, such ' changes exist only in the imagination of physicians,' and that from the time of Pythagoras downwards to the present, the non-bleeding treatment of pneumonia has been in all ages at least as successful as its opposite ; has seldom, if ever, wanted an exponent, and has been practised by quite as many of the ' cla- rions medicii1 Modern pathology has no doubt rectified many mistakes into which a refined physical diagnosis had led physicians, and by clearly explaining the modus operandi of the treatment, has rendered it more easily adopted by a certain class of minds; just as the spread of civilisation, its vices, its malaria, and overwork of both body and mind, has rendered a proportion, at least, of our population less tolerant of blood-letting in disease than our less refined forefathers, and so enabled another class of minds more easily to adopt the non-bleeding system. Yet ths whole course of medical history tends to teach us, that though blood-letting has been practised in all ages, it has been necessary in none. Its opponents have clearly shown that it can correct no humours, evacuate no materies morbi, and has no influence over exudation; while those of its advocates who have most ably investigated its use, have distinctly proved that it cannot cut short the disease (Chomel, Andral, Louis), prevent exudation, or jugulate any symptom (Grisolle). So little influence has it over those phenomena which may be supposed to precede inflammation, that it is precisely in the case of those who have lost much blood previous to the occurrence of inflammation that we have most to dread a fatal termination ; and in commenting on a fatal case of this character, one of the greatest clinical teachers of this or any other age commences by the strong assertion, that the first consideration suggested by it is, ' the tendency which excessive depletion produces to the formation of inflammation.'" (Graves.) Such is an account of the blood-letting controversy excited by my remarks, and which has been carried on during the years 1857-8. That the extraordinary acti- vity which, during the last fifteen years, has been communicated to the natural sciences, should fail to produce any change in medical practice, was scarcely to be expected, any more than that such change could be effected without great opposi- tion and much discussion. Yet, singular to say, the discussion in this case, instead of preceding, has followed the change, inasmuch as many of those who are now con- tending for the advantages of blood-letting and antiphlogistics in inflammation, are the very parties who acknowledge that they no longer employ them. But, though tardy, the discussion may still be useful, should it serve to direct men's minds to 2[)2 PRINCIPLES OF MEDICINE. what I conceive to be the true principles which should guide our endeavours to advance medicine. These are—1st, That an empirical treatment, derived from blind authority, and an expectant treatment, originating in an equally blind faith in nature, are both wrong; 2d!y, That a knowledge of physiology, pathology, and therapeutics, and not experience alone, is the real foundation for the practice of the medical art; and, 3dly, That a true experience can only have for its proper aim the determination of how far the laws evolved during the advance of these sciences can be efficiently made available for the cure of disease. THE INFLUENCE OF PREDOMINANT IDEAS ON THE HEALTHY AND DISORDERED FUNCTIONS OF THE BODY. Dr. Henry Monro,* speaking of monomonia, says that " in these cases neither the controlling agency of the will nor the reason is suspended on most subjects, though it is so on certain points; these people can guide their thoughts well enough on most questions, can see the full relations that cause bears to effect, and that mental impressions bear to external things, but they cannot properly control those impressions which are most strongly fixed on the mind. This state has very fre- quently a stage of contest and conscious difficulty at first, when the struggle between the morbid impressions and the faculties by which to control them is great; indeed, we may say that all morbid and excessive impressions which exclude all other considerations bear the rudimentary form of this affection, though insanity cannot be said strictly to be fully developed until the contest is decided by such a victory on the part of the morbid impressions that the moral liberty to exercise their reason- ing faculties on these subjects is gone. Now, the first stage of the process here so accurately described, viz., that in which persons cannot control those impressions which are most strongly fixed on the mind,—may be produced artificially in about one out of twenty individuals of the entire population. Thus, if that num- ber be chosen indiscriminately, and directed to gaze steadily at any ob- ject for about ten minutes, a peculiar condition of the cerebral functions will be produced in one or more of them (especially if they be young); and under this condition those affected may be made to act in accordance with any train of ideas which may be suggested to them, their motion and sensation being influenced in a variety of ways.f It seems as if their mental faculties become fatigued, in consequence of which they lose the power of controlling any idea that becomes predominant. The peculiar mental condition thus produced manifests itself while * Remarks on Insanity, etc. f The mode of producing this condition may be varied, but it is in all cases essen- tially the same. Thus Mesmer caused individuals to sit in a kind of trough, and they were directed to look at a wire placed in their hand. The Fakirs of India throw them- selves into a trance by looking at the extremity of their own noses. Mr. Braid of Manchester holds an object a little above the eyes, so as to fatigue them sooner. Dr. Darling causes them to look at a small coin placed in the palms of their hands, whilst others fix the attention of persons on themselves, on the tips of their fingers extended towards their eyec, and make motions or so-called passes which arrest the attention. INFLUENCE OF PREDOMINANT IDEAS ON THE BODY. 21)3 the individual is gazing upon the object, in the first instance, by a misti- ness of vision, succeeded in some by a feeling of lassitude and desire to sleep, in others only by a stiffness of the eyelids, and in a third class by deep-drawn sighs, hurried respiration, heaving of the chest, or other signs of general excitement. If now such persons are repeatedly told,- in a confident manner, that they cannot open their eyes, it will be found that thoy cannot do so, especially if the operator directs particular atten- tion to the eyelids by touching or pointing to them. But on receiving permission, or on being commanded to open them, they will do so at once. In the same manner, an individual so affected may be made to make every conceivable kind of motion against his will, or, on the other hand, such movements as he may wish to make can be impeded, arrested, or perverted. Thus I have seen a person unable to speak, from inability to open the jaws; not able to bend an arm or a leg; fixed to a chair, or prevented from sitting down; unable to approach a particular object, or irresistibly impelled towards it; unable to cross a real or imaginary line on the floor ; the arm suspended and fixed in the act of drinking, or the body arrested in the act of dancing; the individual made to walk, dance, or run, as directed; to imitate riding on horseback, when seated on a chair; or to stagger about the room in a supposed state of intoxication, etc. Many of the lower animals also appear to be susceptible of being impressed by Avhat strongly arrests their attention, in such a way that they are rendered incapable of voluntary motion, or irresistibly impel- led towards the object. Hence the long-glittering bodies of serpents, or the glaring eyes of other animals, fascinate birds and small quadru- peds, and render them an easy prey to their enemies. Hares and all sorts of animals, also, are often run over by railway trains. Similar ef- fects are produced in individuals who look from heights and precipices, and experience an uncontrollable desire to leap down, although they know it will be to certain destruction. In like manner, during this condition, all the sensations may be in- creased, perverted, or destroyed, through the medium of suggestive ideas communicated to the mind. By fixing attention on any part of the skin it may be made to feel hot or cold, tingling and painful, or benumbed and destitute of sensibility, according to the ideas communicated. Sight may be Inst or rendered painful, spectral images may be presented to the vision, or various objects made to resemble others to which they bear no analogy. Smell also may be perverted, and any kind of odour given to inodorous substances. A rose, in the mind of such an individ- ual, may have the smell of an onion, and plain water the fragrance of eau de Cologne. A'arious noises, in like manner, may be heard; hearing is frequently very acute, at other times it is apparently abolished. Last- ly, the taste may be affected, and plain water made to present to such a person the sweetness of honey, the bitterness of wormwood, or the acidity of vinegar. Then, as regards the mental faculties, memory may be lost, whilst judgment and comparison for the time being cannot be exercised. The imaginative faculties, on the other hand, may be very vivid, so that the individual readily assumes the manners of other persons in various walks of life—goes through the operations of different mechanical trades, con- ceiving himself to be an artisan—endeavours to escape from imaginary 294 PRINCIPLES OF MEDICINE. dangers or tries to repel them—and acts as he himself or others might be naturally supposed to do under any given circumstances or conditions. Thus he may be made to fight, to swim, to run, to stagger as if intoxi- cated, and so on. Even the sex may in this manner be mentally changed, and a lady may assume the manners, tone of voice, and language of her husband. Such persons also may readily be conducted in imagina- tion to various distant countries or cities, when they will act and talk as if they were really there ; or they may be led through a very complicated series of actions, such as a quarrel terminating in a duel; a fishing or shooting excursion in which they catch numerous fish, or bag a quantity of game, etc. etc. In the same way sleep may be most readily induced, and become so sound that all ordinary stimuli will not awake the sleepers; sensation even being occasionally annihilated for the time. Yet it often happens, that at the command of him who has communicated the suggestive ideas, they immediately awake from a condition of sopor out of which local painful applications failed to arouse them. Susceptible persons may be even commanded to sleep at a particular hour on a certain day, and awake at a particular time, and this they will do under the idea that at the hour named some peculiar influence is exerted on them. This con- dition is analogous to that of somnambulism, trance, or ecstasy, and presents all the intermediate gradations between these states and ordi- nary dreaming and reverie. What is very curious in connection with many of these nervous aberratior.s is, that a person may be perfectly conscious during the whole time of what he is doing, and even of the absurdity of his actions. He may know that the water he drinks is not milk or syrup, and yet he declares it to have the taste of those liquids. Frequently, when his movements are influenced, he evidently resists, but seems to be controlled by a will stronger than his own. He even laughs at his own ridiculous actions, but acknowledges his helplessness. The efforts at resistance only induce fatigue, and tend to render him more certainly the victim of the influence by which he is governed. This condition is certainly closely allied to the inc:pient stage of monomania. It should also he noticed that, although young and nervous persons are undoubtedly those who are most commonly affected, such is by no means always the case, as many individuals, apparently in good health and robust, have been made to exhibit all the phenomena described. Such are only some of the phenomena which may be produced in those affected with the peculiar nervous condition which I am describing. They admit of infinite modifications, but the symptoms are all referable to increase, diminution, or perversion of intelligence, sensation, or vol- untary motion, variously combined, according to the endless train of suggestive ideas that may be communicated to the individual. Similar phenomena have occurred in all ages, produced in certain persons by predominant ideas, and variously modified according to the education, politics, or religion of the period. Thus the effects produced on many votaries during their initiation into the ancient mysteries; the ecstasies of the Pythian and other priestesses ; the influence of religious enthusiasm ; the dancing epidemics.of St, Vitus, or of Tarantism, in the middle ages; the hallucinations of the Convulsionaires at the tomb of INFLUENCE OF PREDOMINANT IDEAS ON THE BODY. 295 St. Medard, in Paris, etc. etc., are of a like character* Numerous per- versions of the nervous functions, identical in their nature with those described, consisting of sensory illusions, muscular convulsions or rigid- ity, and peculiar trains of thought influencing acts and conversation, may be found in the histories of witchcraft or demonology, in the legends of the saints, the Journal of Mr. Wesley, and in the accounts given by travellers of the religious camp meetings in the woods of America. They are perhaps more common now than previously, and excite even more astonishment among the ignorant, the only difference being that the same phenomena which in a dark age were attributed to divination or incantation now assume the garb of science, and are ascribed to Magnetism or Electricity. I consider it unnecessary to enter into any lengthened argument to refute the numerous hypotheses which ascribe these effects to external influences. I know of no series of well-ascertained facts capable of supporting such a doctrine. Lately, I have tried numerous experiments with the aid of those who believe in Animal Magnetism, all of which have only convinced me that no such principle exists, and that all the phenomena really occasioned depend on suggestive ideas communicated to the person affected. But while these theories scarcely merit atten- tion, the facts themselves are highly important and demand the careful consideration of the physiologist and medical practitioner. Let us, then, examine into what can reasonably be advanced in explanation of these nervous phenomena. We have seen that sensation may be defined to be the consciousness of an impression, and we know that the mind strongly intent upon an object is unconscious of those impressions which are going on around— so that no sensation results from these. Every physiologist is aware that the body of a decapitated animal may be thrown into violent con- vulsions, and cases have occurred even in man of the limbs having been thrown about, as if in the greatest agony, although in reality no pain whatever has been experienced. All-absorbing mental ideas prevent sensation of local impressions unconnected with them; hence wounds are not felt in battle, blows and falls are unheeded during the excitement of intoxication or of nitrous oxide gas, and Indian warriors and religious enthusiasts, intent on particular trains of thought, have not suffered from any of the supposed torments which are inflicted on their bodies. These facts, then, offer a sufficient explanation to the physiologist of the occasional insensibility of somnambulists or others labouring under some predominant idea. Whilst, however, an individual may be unconscious of impressions unconnected with his particular train of ideas, everything in relation to these is often perceived with extraordinary readiness. The abolition of sensation with regard to general impressions seems to be counterbal- anced by an exquisite sensitiveness relative to the one impression either actually made or suggested. Dr. Holland has very ably pointed out the effects of mental attention on the bodily organs, showing that there are few persons who do not experience irritation or some imaginary tirling iu parts to which his attention is much directed.! If at night, * Hecker's Epidemics of the Middle Ages. t Medical Notes and Reflections, chap. 5. 296 PRINCIPLES OF MEDICINE. owing to some unusual position, we feel a beating at the heart or at the temples, we easily imagine there is something alarming; the respirations are altered, if we think about them ; if we suppose the mouth is dry, we immediately swallow the saliva and render it so; if we fancy we have a cough, we cough immediately and clear the air passages; and if we suppose any source of irritation exists on the skin, we involuntarily apply our hand to and rub the part. Nothing is more common for medical students, when first studying individual diseases, than to imagine them- selves to be the victims of each in succession. Then, in certain condi- tions of the system, it is well known that actual pain may be produced in a part by fixing our attention upon it. Hypochondriacs are martyrs to these erroneous impressions. Supposed pains in the limbs or stomach prevent their walking or eating, and their health suffers from want of exercise or want of food. Sir Benjamin Brodie has given some singular cases where so-called nervous pains of this description have actually led to tenderness and swelling of the integuments covering the part. It may easily be understood how facts of this kind may be made to assume the appearance of prophecy, and how informing a valetudinarian that he will certainly have a rheumatic or neuralgic pain on any given day, is likely to produce it. As illustrative of the strong influence of predominant ideas even in healthy persons, I may mention the following circumstances :—Mr. Mac- farlan, druggist. North Bridge, Edinburgh, informed me, that on one occasion a butcher was brought into his shop, from the market-place opposite, labouring under a terrible accident. The man, on trying to hook up a heavy piece of meat above his head, slipped, and the sharp hook penetrated his arm, so that he himself was suspended. On being examined, he was pale, almost pulseless, and expressed himself as suffer- ing acute agony. The arm could not be moved without causing excessive pain, and in cutting off the sleeve he frequently cried out, yet when the arm was exposed it was found to be quite uninjured, the hook having only traversed the sleeve of his coat. A clergyman told me, that some time ago suspicions were entertained in his parish of a woman, who was supposed to have poisoned her newly-born infant. The coffin was exhumed, and the procurator-fiscal, who attended with the medical men to examine the body, declared that he already perceived the odour of decomposition, which made him feel faint, and in consequence he with- drew. But, on opening the coffin, it was found to be empty, and it was afterwards ascertained that no child had been born, and consequently no murder committed. Numerous instances might be given of individuals engaged in duels, or on other occasions, who have supposed themselves to be wounded, and have fallen down as if dead, without having received the slightest injury. Then, as regards irregular movements in connection with predominant ideas, the phenomena of hysteria and chorea will at once suggest them- selves to you. In the latter disease, peculiar movements are always occasioned by the exercise of volition, or by certain impulses which can- not be controlled. Iu hydrophobia there is a remarkable susceptibility to the most minute circumstances, which give rise in any way to the idea of drink, and invariably excite the most fearful spasms. Numerous singular instances of occasional and partial perversion of the voluntary INFLUENCE OF PREDOMINANT IDEAS ON THE BODY. 297 movements might be quoted, either arising spontaneously, or acquired by habit, or produced in animals by injuring certain parts of the nervous system, or by giving particular drugs; but I shall content myself with relating two cases, formerly under the care of Dr. Christison, which he was so good as to communicate to me. The first was that of a gentleman who frequently could not carry out what he willed to perform. Often on endeavouring to undress, he was two hours before he could get off his coat, all his other mental faculties being perfect. On one occasion, having ordered a glass of water, it was presented to him on a tray, but he could not take it, though anxious to do so, and he kept the servant standing before him half an hour, when the obstruction was overcome. In the other case the peculiarity was limited. If, when walking in the street, he came to a gap in the line of houses, his will suddenly became inoperative, and he could not proceed. An unbuilt-on space in the street was sure to stop him. Crossing a street also was very difficult, and on going in or out of a door he was always arrested for some min- utes. Both these gentlemen graphically described their feelings to be "as if another person had taken possession of their will." These and similar perversions of motion, whether of excess or diminution, however produced, cannot always be governed by predominant ideas, but that they frequently are so is proved by a multitude of facts. The old story of Boerhaave is as apposite as any other, who is said to have immediately cured several girls at school of cholera, by threatening, in a loud voice, that the next who was attacked should have the actual cautery applied. The power of imitation, which must operate through the mind of the individual, is known by medical men to be very strong, however inex- plicable. Immoderate laughter is very catching; few can resist even a well-imitated yawn, and on board ship nothing more certainly brings on sea-sickness than seeing others ill. Habits, modes of expression, dialect, carriage of the body, and peculiar movements, are also readily acquired from those around us. On visiting the Bosjesmen, who were exhibited here some years ago, the effect of their dance on the audience was strik- ing. Beginning slow, to the rhythmical beatings of their clubs, the noise became gradually louder, more and more exciting, every step and ges- ture keeping exact time. I myself, and some friends with me, at length felt a peculiar jar through all our systems, our own feet involuntarily kept time with the dancers, and from the feelings then experienced, we could at all events comprehend the nature of those impulses which have caused multitudes to join in the dance of St. Vitus or of Tarantism. In all these, and various other cases which might be cited, it must be evident that the effect is produced by operating on the mind of the indi- vidual, and through that on his bodily powers. In short, predominant ideas, whether originating spontaneously or suggested by the words and actions of others, seem to be the exciting cause in individuals affected with a peculiar condition of the cerebral functions. As regards the nature of this condition, it seems analogous to that of sleep or dreaming, in which certain faculties of the mind are active, and may be even stimu- lated into excessive action, whilst others are suspended. Hence it has been called Hypnotism by Mr. Braid.* All the phenomena produced * Neurypnology, or the Rationale of Nervous Sleep. 1843. 298 PRINCIPLES OF MEDICINE. are strictly analogous to what medical men are acquainted with in vari- ous morbid states ; and it must now be considered as well established, that in certain conditions of the nervous system they may be induced at will. This conclusion, however, is something new, for it has but recently been admitted in physiology or pathology, that a condition of the cerebral functions may be occasioned in apparently healthy persons, during which suggestive ideas are capable of producing those phenomena we have described, and which render them, for the time, as irresponsible as monomaniacs. Yet such is really the fact, which, once admitted into physiology, must have an important influence on the theory and practice of medicine. This condition may probably be accounted for physiologi- cally in the following manner :— We have previously seen that the cerebral lobes contain white fibres, whicii run in three directions. 1st, Those which pass from below up- wards, and connect the hemispherical ganglion with the spinal cord. 2d, Those which pass transversely, forming the commissures, and which unite the two hemispheres. And 3d, Those which run from before backwards, uniting the anterior with the posterior lobes on each side (p. Ill); tliese fibres being also probably subservient to that combina- tion of the mental faculties which characterises thought (p. 112). Now all metaphysicians and physiologists are agreed that the mind is com- posed of various faculties, and that different portions of the nervous mass are necessary for their manifestation. True, it is by no means deter- mined of how many faculties the mind is made up, and still less is it known which parts of the brain are necessary for the manifestation of each individual faculty. But let the first proposition be granted, then there is no difficulty in supposing that one or more of these may be par- alysed or suspended, whilst others are entire, any more than there is in knowing that sensation may be lost whilst motion remains intact, al- though the nerve fibres of both run side by side. I presume, then, that certain mental faculties are, as the result of exhausted attention, tempo- rarily paralysed or suspended, whilst others are rendered active in con- sequence of being stimulated by suggestive ideas; that the psychical stimuli of the former make no impressions on the cerebral conducting fibres, whilst those of the latter are increased in intensity; that the proper balance of the mind is thereby disturbed, and thus the individual for the time being acts and talks as if the predominant idea was a reality. The condition is analogous so far with ordinary somnambulism, certain forms of hypochondriasis and monomania, but admits of infinite changes according to the nature of the idea suggested. According to this theory, therefore, we suppose that a psychical sti- mulus is generated, which, uncontrolled by the other mental operations acting under ordinary circumstances, induces impressions on the peri- pheral extremities of the cerebral fibres, the influence of which only is conveyed outwards to the muscles moved. In the same manner the remembrance of sensations can always be called up by the mind; but under ordinary circumstances we know they are onlg remembrances. from the exercise of judgment, comparison, and other mental faculties; but these being exhausted, in the condition under consideration, while the suggested idea is predominant, leave the individual a believer in its reality. INFLUENCE OF PREDOMINANT IDEAS ON THE BODY. 299 In this manner we attribute to the faculties of the mind a certain power of correcting the fallacies which each is liable to fall into, in the same way that the illusions of one sense are capable of being detected by the healthy use of the other senses. We further believe that the appa- ratus necessary for the former operations consists of the nerve fibres whicii unite different parts of the hemispherical ganglion, whi'st that necessary for the latter are the nerve fibres connecting together the organs of sense and the ganglia at the base of the encephalon. A healthy and sound mind is characterised by the proper balance of all the mental faculties, in the same manner that a healthy body is dependent on the proper action of all the nerves. There are mental, illusions and sensorial illusions, one caused by predominant ideas, and corrected by proper reasoning; the other caused by perversion of one sense, and corrected by the right application of the others. Both these conditions are intimately united, and operate on each other, inasmuch as voluntary and emotional movements and sensations are mental operations. This theory, if further elaborated, appears to me consistent with the facts described at the commencement of this lecture, and capable of explaining them oh physiological principles.* We may ask ourselves whether the facts which have been ascer- tained, and the generalizations which flow from them, are capable of being rendered useful in the practice of medicine ? The beneficial influence of hope and confidence over disease is as well known to medical men as the injurious tendency of fear and despondency. This effect of mind on the body has from the earliest periods been seized upon by individuals as a ground for veneration or astonishment. In ancient times the heathen priests were the physicians, and the temples were converted into so many dispensaries, at which the sick applied for relief. In catholic countries, during the middle ages, the offices of priests and physicians were frequently united in one person, so that the powerful effects of certain shrines, and the benefits of pilgrimages in cases not admitting of simple cure, met with every encouragement. From what has preceded, it must be allowed, that, so far from its being improbable that real cures were so effected, all that we know of the effects of confident promises on the one hand, and belief on the other, renders it very likely that many such occurred. The legends of the saints, the history of witchcraft, the jour- nal of Mr. Wesley, the accounts of celebrated pilgrimages, and of the virtues of particular shrines, and the writings of religious enthusiasts generally, abound in wonderful cures. Charms, amulets, and relics, are stated to have at once banished all kinds of agony, and removed nume- rous nervous diseases. Many of these tales are certainly incredible, whilst others are perfectly conceivable. The benefits of the royal touch are confirmed by the observations of Richard Wiseman, and the cures per- formed by Greatrakes are warranted by Robert Boyle. In all these cases, there can be little doubt that any benefit which did occur may be * It has lately been proposed by Mr. Braid to call the condition of which we have been speaking, and whicii results from a dominant idea—monoideism. The term mono-ideology would indicate the doctrine of the influence of dominant ideas in control- ling mental and physical action. To monoideise might express the act of performing processes for inducing monoideism, and monoideiser designate the person who mono- ideises. Then monoideised will indicate the condition of the person, and monoideody- namics the mental and physical changes which result from the process. 300 PRINCIPLES OF MEDICINE. attributed to a strong belief, on the part of the patient, in the efficacy of the means employed.* In recent times more systematic attempts have been made in this way to relieve pain, control nervous excitement, lessen muscular debility, and stimulate certain secretions. If it be considered, that the power of producing profound sleep, and acting on the nervous functions, may be manifested in so many individuals as one iu twenty of the whole popula- tion, it must be evident that in a class of persons particularly predisposed, the number capable of being affected would be much greater. This sub- ject, however, is yet in its infancy, and has to be separated from the charlatanism whicii has hitherto been mingled with it. The labours of Dr. Eisdale among the natives of India, and of Mr. Braid in Manchester, exhibit a worthy commencement to the rational treatment of disorders by the means now alluded to ; and there can be little doubt that in no long time its influence, when further studied, will be acknowledged. But how far this influence is dependent on the confidence of the patient; on .the belief in some mysterious circumstance, which is presumed to pro- duce the effect, or on some unknown law-regulating function through the mind, further observation alone can determine. In the meantime, it seems to me that we are indebted to Mr. Braid not only for having first clearly demonstrated that the phenomena de- scribed are wholly occasioned by predominant ideas in the individual, but for the first contribution of any value to the mode of applying this theory to the cure of disease. By suggesting thoughts to the patients in various ways, sometimes by speaking so that they may hear what is said, at others by directing their thoughts to certain subjects, and occa- sionally rendering these more vivid by repetition or by definite physical impressions, we can fix certain ideas strongly in their minds. These ideas act as stimulants or sedatives according to their purport, and the current of thought directed to or withdrawn from particular organs or functions. Remarkable cases have been met with, where a judicious application of this doctrine has removed insomnolence or various kinds of pain, spasms, and other evidences of excitement; where hysterical paralyses of the limbs or special organs of sense have been relieved or cured, and where the torpid functions of lactation, perspiration, defalca- tion, menstruation, etc., have been rendered more active, f That such * The wonderful cures performed by Mesmer, and all those who have convinced themselves and others of the advantages of the ephemeral systems which are continu- ally springing up around us, are much indebted to belief in their efficacy on the part of the patient. Dr. Haygarth,' of Bath, performed all the cures of Mesmer and Perkins with two bits of wood made to resemble the metallic tractors of the latter,—that is, so long as he kept the secret,—for the moment he published his book, and the impo- sition was known, no more cures were accomplished. In the same manner, there is every reason to believe that the efficacy of many public nostrums resides in the repu- tation which surrounds them. Miss Harriet Martineau, in publishing her own case, naively remarks :—"If at any time during my illness I had been asked, with serious purpose, whether 1 believed there was no resource for me ? I should have replied that Mesmerism might perhaps give me partial relief."—Letters on Mesmerism, 1*1'>. p. 4.) No wonder, therefore, that when at length it was tried, it produced the desired effect; and the medical attendant, seeing the delusion that existed, perhaps acted judiciously in bringing the lady en rapport with the first magnetiser he could procure. t See Braid on Hypnotic Therapeutics—Monthly Journal of Medical Science, -July, 18.33. INFLUENCE OF PREDOMINANT IDEAS ON THE BODY. 301 results may be induced must be admitted by all who reflect—1st, On the undoubted fact that certain persons are and can be made slaves of domi- nant ideas; and 2d, On the equally undoubted fact that such mental ideas are known by universal experience to exercise a stimulating or depressing effect on all the bodily functions. Hence the beneficial effects of many drugs and systems of treatment, which are really inert or uncertain in their action, and which are supposed to act through the blood or on the tissues directly, operate by exciting expectant ideas, and through these ideas, indirectly on the parts disordered. On the other hand, the indiscriminate performance of experiments on nervous individuals may be injurious. During the session of 1850-51, society in Edinburgh was greatly agitated by this subject. Fashionable parties were converted into scenes of experiments on the cerebral func- tions. Noblemen, members of the learned professions, and respectable citizens, amused themselves in private, whilst public discourses and exhibitions to an unusual extent were got up for the entertainment of the public. On one occasion the Royal Medical Society was operated. on; and if a proof of the correctness of the facts described be required, it would be found in the circumstance, that the nervous aberrations noticed were readily exhibited in some of its most sceptical members. The result of this excitement was an increased degree of nervousness in many individuals. In some educational establishments, girls and boys threw themselves into states of trance and ecstasy, or showed their fixed eyeballs and rigid limbs, for the amusement of their companions. Sensi- tive ladies did not object to indulge in the emotions so occasioned, and exhibited themselves in a like way for the entertainment of evening parties. Several instances were known to me where intelligent young men—students in this University—were, for a longer or shorter time, incapacitated from following their ordinary occupations, and obliged, from want of attention and mental power, to stay away from their classes. Some of these, from a feeling of the injury they have sustained, very properly refused to allow any experiments to be tried on them ; and the parents of very sensitive young persons, from the obvious detri- ment their health has sustained, also forbade a repetition of these scenes. One young man, of great promise, who was at that time frequently operated on, is at this moment in a lunatic asylum. I thought myself warranted in calling such a state of things " The Edinburgh Mesmeric Mania of 1851." Such experiments cannot be considered as free from danger. The great object of all who seek proper self-education is to control the emo- tions and passions, and regulate the imagination by the severer faculties of judgment, comparison, and attention. Hitherto medical men, so far from exciting, have done all in their power to prevent such phenomena as have been described; but now, that it has been clearly shown that they may be produced in numbers of people by the ignorant and mer- cenary, every effort should be made to discourage them. It is well known that cases are on record of individuals who, commencing by the imitation of hysterical or epileptic convulsions, have at length found themselves really labouring under those diseases; nor is it unreasonable to suppose, that the mental faculties will be greatly injured in persons who frequently surrender up their own wills, and act iu accordance with 302 PRINCIPLES OF MEDICINE. the extravagant ideas suggested to them. After all, the pleasure of excitement principally consists in feeling that it can be regulated, and is under command. The moment it ceases to be so, a sense of the imper- fection becomes most agonizing to the mind, and gives rise to that despondency so common among the insane. Hence those only who have studied this subject, and are prepared as medical men to exercise judiciously the influence they may possess on the minds of their pa- tients, ought to attempt the cure of nervous diseases in the manner now referred to. If, then, it has been satisfactorily shown, in consequence of our ad- vanced knowledge of diagnosis and pathology, that an antiphlogistic prac- tice is opposed to the cure of diseases of nutrition, whilst predominant mental ideas may be made to influence diseases of innervation, it follows that many of the principles which have hitherto guided us in their treat- ment must be considerably modified. That medical practice has under- gone a great revolution during the last fifteen years, is a fact already so well established, that it can be no longer denied. Firmly believing that many of the changes which have been effected are permanent improve- ments in our art, and may be traced to the advance in the sciences on which that.art is based, it will be our special object in the succeeding pages to point out in what way more perfect principles have led to a better practice. Amid the multiplicity of conflicting statements, and the clashing of opposing systems, it will be our honest desire to separate what is known from what is unknown, and lay down such rules for treat- ment as both science and experience may alike confirm. SECTION TV. DISEASES OF THE NERVOUS SYSTEM. The diagnosis of nervous disorders is dependent on a kind of knowledge altogether different from that appertaining to the consideration of cuta- neous, pulmonary, or cardiac affections. In these last, as we shall see, a direct appeal to the senses enables us to arrive at conclusions with tolerable accuracy. An arbitrary classification of skin diseases once established, with clear definitions, we have only to apply these to the appearances observed to ascertain the disorder. Once master the prac- tical difficulty of distinguishing with exactitude moist from dry rales— whether a murmur replace the first or second sound of the heart, and what is its position, and we possess a key which, with the aid of percus- sion, will frequently enable us to arrive at the certain diagnosis of pul- monary and cardiac affections. But, with regard to nervous diseases, no such exactitude is attainable in the present state of the science or art of medicine. The encephalon is an aggregation of various parts, more or less connected together, the functions of which are by no means determined. In health these act in harmony, but in disease they are so irregularly disordered that, while the action of one is excited, that of another may be perverted or annihilated. Then, again, we frequently observe that some of the most fatal nervous diseases, such as hydropho- bia, leave after death no lesion detectable by the most careful histological examination, whilst on other occasions tumours and extensive destruc- tion of the cerebral mass may exist, without producing any symptoms whatever. And yet, notwithstanding the obvious difficulties which oppose themselves to exactitude of diagnosis of nervous diseases, careful observation, conjoined with a knowledge of physiology and pathology, will enable us to approximate closely towards, if not actually to reach, a correct opinion in the great majority of cases. The same circumstances render a pathological classification of nervous diseases impossible. Thus any one special lesion may produce the most remarkably different effects, accordingly as it occurs rapidly or slowly; as it is single or multiple ; as it is small or great in amount; as its na- ture is simple or compound ; or as it affects different parts of the nervous 304 PRINCIPLES OF MEDICINE. mass. Thus the compound functional character of the brain alone if disordered, may give rise to increase, perversion, or loss of three func- tions, viz., intelligence, sensation, and motion, each as different in its modes of manifestation and effects, as are the important functions of digestion, respiration and secretion. Neither can we satisfactorily arrange nervous diseases in accordance with the symptoms which may be present, as these are so various and so complicated in different cases. This, however, is the method which has stamped its features on medical literature since the days of Hippocrates, and from which, in consequence, without anything more certain to offer, it is in the present state of medical science impossible to escape. What we, how- ever, strenuously contend for, is the inconsistency in our nomenclature of applying to morbid lesions the same names as have long been recoguised in a different sense as indicating groups of symptoms. Apo- plexy, for instance, is not necessarily hemorrhage into the brain, nor does every hemorrhage produce apoplexy. If, then, we use a mixed classification which seems to be the best now open to us, that is, one partly anatomical, founded on altered structures, aud partly physiologi- cal, founded on altered functions (that is, symptoms)—let us define accurately in all instances, what we mean by the names employed. Thus we can use the terms congestion, softening, and suppuration of, or exudation, effusion, and hemorrhage into the brain and spinal cord, as we do when these lesions affect any other organs. But we should understand by apoplexy, loss of consciousness and voluntary motion, beginning at the brain; by epilepsy, paroxysmal loss of consciousness with convulsion; by spasm, increased tonic; and by convulsion, increased clonic contractions of the muscles; and by paralysis, loss of motor, or sensitive power of a part, etc. If wc employ morbid lesions to designate the disease, we regard groups of symptoms as their effects, But if we use groups of symptoms to denominate the disease, then, however well we may observe these, we are often incapable of deter- mining what are the structural changes on which they immediately depend. The key to the diagnosis of nervous diseases will be found in the general sketch we have given of the function of innervation (p. Ill), and especially in the pathological laws which regulate diseased action of the nervous system; and to these we refer the reader (p. 115). The morbid anatomy of the nervous system will be found treated of in various parts of the work.* Bat there is one predominant lesion, which has lately had much light thrown upon it histologically, and which is so important in a diagnostic point of view, that we propose alluding to it, before entering on the consideration of individual nervous diseases. * Congestion of the cerebral vessels, pp. 115 to 118. Exudative softenings, pp. 131, 132. Albuminous degeneration, pp. 2l3, 214. Pigmentary degeneration, p. -->■ Mineral degeneration, p. 235. CEREBRAL AND SPINAL SOFTENINGS. 305 ON THE PATHOLOGY OF CEREBRAL AND SPINAL SOFTENINGS, AND ON THE NECESSITY OF EMPLOYING THE MICROSCOPE TO ASCERTAIN THEIR NATURE. The nature of cerebral and spinal softening has been much disputed. Some attribute it entirely to chronic or acute inflammation; others, while they acknowledge that softening is undoubtedly thus produced, are also of opinion, that it may occasionally depend upon other causes. Thus softening has been considered a lesion sui generis, similar to what occurs in ataxic fever (Recamier), gangrcna senilis (Rostan, Aber- cromby), to obliteration of the arteries (Bright, Carswell), or to a diminution of nutrition (Delaberge, Monneret). It has also been refer- red to post mortem maceration (Carswell, Paterson of Leith), and is un- doubtedly often produced by mechanical violence after death. The difficulty hitherto has been how to distinguish with precision one kind of softening from another. From a careful analysis of numerous cases of cerebral softenings, I have arrived at the conclusion that they may originate in six ways. 1st, From exudation which is infiltrated among the elementary nervous structures; 2d, from a mechanical breaking-up of these structures by hemorrhagic extravasations, whether in large masses or infiltrated in small isolated points; 3d, from fatty degeneration of the nerve cells, independent of exudation ; 4th, from the mere imbibition of serum which loosens the connection between the nerve tubes and cells; bth, from mechanical violence in exposing the nervous centres; and tith, from putrefaction. 1st, Exudative or inflammatory softening always contains granules aud granule cells, which are nume- rous according to the degree of softening. The granules are for the most part seen coating the vessels (Figs. Ill, 311, and 294), aud the cells also may occasionally be seen there in various stages of development (Fig. 113). Iu the demonstrations that are made under the microscope, they are frequently seen diffused among the.tubes (Fig. 381), which, according to the se- Fi„ 88i verity and extent of the lesion, are easily separated from one another, or broken up in a variety of ways. When recent, the serum which accompanies the exudation is infiltrated into the nervous substance, and may assist occasionally in producing soft- rig. 381. Structure of inflammatory exudative softening of the lumbar portion of the spinal cord, showing granule cells infiltrated among the nerve-tubes in a para- plegic individual.—(Wedl.) 20 306 DISEASES OF THE NERVOUS SYSTEM. ening, although for the most part it is rapidly absorbed. In chronic cases this form of softening may be regarded in one sense as a fatty de- generation, although when speaking of this last lesion, I have stated my reasons for considering it as a transformation of the exudation, and not of the nervous substance. (See p. 222.) Simple, tubercular, and can- cerous exudations, alike cause cerebral or spinal softenings, as shown by the presence of the characters peculiar to each. Tubercular masses in %fe^->°^ Fig. 3S2. the brain are generally surrounde'd by a layer of cerebral substance ex- hibiting all the characters of this form of softening (Fig. 383). Cance- rous exudation into the brain is very rare (Fig. 277). 2d, Hemorrhagic softening.—When blood is extravasated with force into the cerebral structure, it breaks up the nerve-tubes of the part and coagulates. The coagulum then forms a solid mass, whilst the serum, more or le>s tinged with colouring matter, is infiltrated to a greater or less distance and absorbed. Under such circumstances, the softened ner- vous tissue surrounding the clot pre- sents fragments of the nerve-tubes alone, which under the microscope frequently exhibit a peculiar ten- dency to form circular, oval, or irre- gularly-formed globules, with double outlines, as in Fig. 384. There are none of the granule cells so charac- teristic of an inflammatory softening, although they may appear later, as the result of exudation from the cere- Iu such cases the greatest variation in the appearance of the nerve-tubes is observable, from a slight diminution in their natural firmness and consistence, which renders them easily separable, or causes varicosities or swellings in them to be readily pro- Fig. 3S4. bral vessels surrounding the clot. Fig. 382. Structure of a tubercular exudation in the cerebellum, composed of gra- nules and tubercle corpuscles, with a few fragments of nerve-tubes. Fig. 383. Structure of the softened cerebellum, immediately external to the same tubercular mass, containing a larger number of fragments of the nerve tubes, with numerous granular corpuscles. Fig. 384. Structure of the softened cerebral substance, surrounding a recent clot of blood, showing the appearance assumed by the nerve-tubes when broken up, and softened by imbibition with serum.—See Apoplexy, case of Pitbladdo. 250 diam. CEREBRAL AND SPINAL SOFTENINGS. 307 duced on pressure, up to a condition when they exhibit nothing but fragments and separate globules, as in fig. 3*4. The coloured cerebral softenings which, are subsequently produced as a result of hemorrhage are owing to the transformations which go on in the coaguluni itself. They assume a bright orange, brick red, yellow, fawn, or dirty brown colour, and under the microscope are found to con- sist of hematine in various forms and tints. Thus the whole may be granular, or mingled with crystals of hematoidine or melanine; and the granules, granular masses, and. celloid degenerations, may present nu- merous shades of orange, red, brown, black, etc. etc. (See Pigmentary Degeneration, p. 227, et seq.) 3d, Trite fatty softening.—This lesion, that is, a primary fatty de- generation indepeudeut of exudation or hemorrhage, is one of the exist- ence of which I was for a long time very doubtful. Careful investigation, however, has satisfied me, that it does occasionally, though rarely, present itself, apparently as a consequence of obstruction of arteries. In this case the vessels are not coated necessa- rily with granular exudation, but the nerve- cells undergo the fatty degeneration prima- rily and are enlarged. The walls of many of them also are dissolved, leaving triangu- lar or crescentic-shaped granular masses be- tween the nerve-tubes This alteration is accompanied with diminution of the cere- bral density, and the nerve-tubes are also easily separated and broken up, though not so readily as in the last form of softening noticed. 4th, Serous or dropsical softening.—This kind of softening is due to imbibition of the serum, which is effused into the ventricles in cases of hydrocephalus aud other diseases. Hence it is only found in the neigh- bourhood of such effusions, aud most commonly in the central portions of the brain, as in the white matter of the septum lucidum, fornix, etc. It is the white softening of morbid anatomists, and consists structurally of nothing but the cedematous normal elements of the parts, without any- of the changes peculiar to the exudative, hemorrhagic, or true fatty soft- enings. The observations of Dr. Robert Paterson of Leith tend to show that the brain substance is very porous, and that if a slice of it is placed in water, it readily imbibes a considerable quantity, becoming at the same time more soft. Whether such softening ever occurs in the living body is very doubtful; it is most probably a post-mortem change. Sometimes serum is found to a considerable extent in the ventricles, without soften- ing of the surrounding parts. The fluid apparently in such cases has not passed through the lining membrane of the ventricles. At other times this has occurred, and the softening so occasioned is found to be greatest Fig. 385. r'ig. '<><>. Structure of the softened pons varolii, in a case where the basilar artery was obstructed, showing true fatty degeneration of the nerve-cells, among somewhat softened and broken up nerve-tubes.—See Cerebral Hemorrhage, case of Alexander Walker. 250 diam. 308 DISEASES OF THE NERVOUS SYSTEM. near the central parts, and to diminish according to the distance from them. The causes which produce, and at others impede post-mortem imbi- bition are unknown. bth, Mechanical softening.—I have frequently seen softenings occa- sioned in the brain, and more frequently still in the spinal cord, through crushing the nervous texture, after death, in various ways. Thus the saw or chisel may occasion mechanical softenings in the superficial parts of the brain, when the calvarium is being removed by inexperienced or unskilful operators. In France, where the hammer is used for this pur- pose, it is a frequent cause of superficial softenings. The spinal cord is especially liable to be injured, by slipping of the chisel or lever used in elevating the posterior spinous processes of the vertebrae. Portions of soft nervous tissue, such as the corpus striatum, have frequently had their texture reduced to a pulpy consistence by mere handling, or by constant application of the finger simply to ascertain whether it be softened or no. I have seen softenings exactly resembling such as may be occasioned by disease, produced in all these ways, and thus give rise to most erro- neous conclusions. They are only to be distinguished by a microscopi- cal examination, and by a careful consideration of the symptoms observed during life, and of the causes which probably may have produced them after death. 6th, Putrefactive softening.—This may occur in warm weather, from the body having been examined long after death, or from accidental causes. Hence the necessity of always stating the number of hours after death that the examination is made. Such softenings are always diffused through considerable masses of cerebral texture, aud may be recognised by this circumstance combined with an absence of all the signs which distinguish the otlier forms. Of these six kinds of softening found in the body after death, only the first three occur in the living subject, aud give rise to symptoms, and of these three, the pure fatty degeneration, though frequently associated with the others, has been so seldom noticed, that we are to a great extent unacquainted with its symptoms as a special lesion. As regards the last three, they have been frequently confounded by morbid anatomists with the others, and all attributed to one cause. I think we are now enabled to distinguish accurately such as are the resalt of exudation from such as are not. From a careful analysis of 32 cases of softening of the nervous cen- tres, which I published in 1842-3,* it was shown that different symp- toms were connected with exudative or inflammatory, from those which occurred in non-inflammatory softening. In 24 of these cases in which cerebral softening was observed, granular corpuscles were present in 18, whilst in six no traces of these bodies could be found. On analysing the symptoms of the 24 cases, a marked difference was found between those resulting from the two lesions. Thus, in the cases where only inflamma- tory softening was present, well-marked symptoms invariably existed, such as loss of consciousness, preceded or followed by duluass of intel- lect, contraction aud rigidity of the extremities, or paralysis. On the other hand, in the six cases of non-inflammatory softening, there was no paralysis or contraction, and no dulness or disturbanca in the intellect. *Eliaburgh Madical aud Surgical Journal, N03. 153, 155, and 157. CEREBRAL AND SPINAL SOFTENINGS. 309 Again, in the four cases where both lesions were present, symptoms were always observed in the side of the body opposite to the seat of the inflam- matory softening, but none existed in the opposite side in the non-inflam- matory. An analysis of these 24 cases, therefore, leads me to the con- clusion, that the two kinds of softening I have endeavoured to establish, are alike distinguishable, by their intimate structure, and by the symp- toms accompanying them during life. Now all practical men agree in considering it a matter of extreme diffi- culty to reconcile, with any certainty, the morbid appearances found in the brain, with the symptoms observed during life. The future micro- scopic examination of the softening may serve to prevent much of the error that has hitherto been committed. For instance, softening of the fornix, septum lucidum, and central parts of the brain, may exist in two cases. To the naked eye they may be in every respect identical, and yet the microscope enables us to determine that the one contains granular corpuscles, whilst, in the other, not one of these bodies is to be found. It becomes evident, then, that previous to this distinction having been made, two different lesions were confounded together; and that a differ- ent train of symptoms should, under such circumstances, be occasioned, is only to be expected. Again, it has frequently excited surprise, that, notwithstanding the existence of well-marked symptoms of softening, nothing was to be discovered after death. Now I have demonstrated in several instances that, although to the naked sight no morbid lesion was apparent, still portions of brain might contain the same granular cor- puscles as are to be seen in more apparent lesions; and that by consid- ering such parts diseased, all the symptoms might be explained according to the pathological laws I have previously referred to (p. 115, et seq.). By excluding these sources of error, therefore, and by distinguishing the lesion dependent on inflammation from others which simulate it, we shall be enabled to obtain more exact data for future investigations. From the observations recorded, however, the two following propositions may, I think, be established. 1st, That pathologists have often con- founded softening dependent on disease during life, with softening occasioned by post-mortem changes or mechanical violence. 2d, That notwithstanding the most anxious search, and the existence during life of the most decided symptoms of softening, the organic disease, though really present, has frequently escaped observation. Proposition 1.—That pathologists have often confounded softening dependent on disease during life, with softening occasioned by post-mortem changes or mechanical violence. With respect to this proposition, it may be observed that, in many cases where no symptoms were present during life, extensive softening of the brain has been found after death. This is a well-known fact, and is one which tends in no small degree to throw confusion on the patho- logy of nervous diseases. Thus, in one case of a series I published in lM.'!.* there was extensive softening of the central portion of the brain * Pathological and Histological Researches on Inflammation of the Nervous Centres. By the Author. Edinburgh, 1843. 310 DISEASES OF THE NERVOUS SYSTEM. corpora striata, and optic thalami, which, however, contained no granu- lar corpuscles. The symptoms attending these lesions were sudden insensibility and convulsions, which evidently depended on a capillary apoplexy that was also present. No paralysis or contraction existed. Four other cases were recorded, with more or less softening of the brain, without head symptoms, and without granular corpuscles in the softened portions. Now in all these five cases there was an extensive softening, the nature of which it was impossible for any one to distinguish positively, by unaided sight. In none of them did granular corpuscles exist, and in none did those symptoms occur which are peculiar to softenings pro- duced during life. In addition to these five cases there were four others, where, conjoined with an exudative softening producing particular symptoms, there was also a softening, occasioning no symptoms whatever, and containing no granule cells. The circumstances attendant on these nine cases, there- fore, must convince us that softenings produced mechanically, or by post- mortem changes, have frequently been mistaken for those occurring dur- ing life, and must necessarily be so, so long as unaided sight is made the sole means of forming a judgment with respect to their nature. A perusal of these cases must satisfy any one that pathologists have hitherto been confounding two distinct lesions, viz., a softening depen- dent on vital changes, and a softening dependent on inechauical or other causes. Proposition 2.—That notwithstanding the most anxious search, and th existence during life of the most decided symptoms of softening, the orga- nic disease, though really present, his frequently escaped observation. In the series of cases alluded to there are several which serve to esta- blish this proposition, of which I may more especially refer to two. Case 1, a man had paralysis, with complete resolution of the limbs on the right side, and intense rigidity of those on the left. Death occurred in six hours. On dissection, a large coaguluni of blood was discovered in the left hemisphere, thus explaining the paralysis on the right side. In the right hemisphere an old apoplectic cyst was found, aud a number of small cavities, described by Dr. Sims as chronic softening undergoing a cure. Here, then, there was nothing acute, nothing to explain the intense rigidity. A microscopic examination demonstrated that these cavities contained numerous granular corpuscles and granules, thus prov- ing the existence of structural changes iu the right lobe of the brain, and explaining the rigidity on the left side of tbVbody. Case 2 was that of a man who entered the Iuhrmary, under Dr. Paterson, in 1842. All the symptoms of acute softening were present; paralysis of the left side, including rigidity and contraction of the left arm, dulness of intellect, and tonic spasms of the muscles of the mouth and neck. The right side was also affected in a slighter degree. As the case excited considerable interest, great care was taken in examin- ing the braiu after death. When the lateral ventricles were opened, it became a question whether the right corpus striatum was softened, CEREBRAL AND SPINAL SOFTENINGS. 311 Several persons applied their fingers, and endeavoured to ascertain the point. As the manual examination proceeded, the normal consistence of the part diminished, until at length it presented all the appearance of pultaceous softening. In this state it was shown to Dr. Paterson, who naturally enough considered it to be the result of disease. I differed from him in opinion, first, because I had carefully observed the gradual increase of the softening in the manner alluded to; and secondly, because disease of the corpus striatum, in one side of the brain, could not have explained the well-marked symptoms which existed on both sides of the body. When the pons varolii was bisected, Dr. Peacock, who conducted the examination, conceived it to be softened; others who examined it could perceive no difference in the texture ; its colour and consistency were unchanged. Reasoning from the symptoms, the lesion was very likely to exist. But how, it was argued, could a judg- ment be formed ; we ought to reason from facts, not theories ? Here, then, was an evident lesion of the corpus striatum, which explained nothing, and a problematical lesion of the pons varolii, which, however, did it exist, would satisfactorily account for the symptoms. In this state of uncertainty the microscope was sent for, and I demonstrated, and made evident to Drs. Paterson, Peacock, aud all the students pre- sent, that the corpus striatum contained no granular corpuscles, whilst in the pons varolii they were very abundant. I have endeavoured to describe what took place on this occasion, from which it must be evideut that had not the microscope been appealed to, the right corpus striatum would have been pronounced softened, whilst the real lesion in the pons varolii might have escaped observation. Under such circumstances this case would have added another to the inexplicable observations with which the records of nervous diseases abound. What renders these cases, and several others I could relate, so remark- able and satisfactory is, that they are not instances where the dissection was performed in a hurried manner, and by incompetent persons. On the contrary, from the particular symptoms connected with them during life, the post-mortem examination was in all conducted with extreme care. The physician who had charge of the case was present. The examinations were witnessed or conducted by myself, in the presence of clerks and numerous students, and I may say that we were all in doubt until the microscope cleared up the difficulty. These cases, therefore, sufficiently demonstrate that the naked sight is positively unable to detect lesions, even although they are directly indicated by the symptoms, and care- fully looked for by experienced morbid anatomists. If, then, the two propositions formerly stated have been satisfactorily proved, and it is agreed that pathologists have been confounding vital with post-mortem softening, and overlooking the former, although un- doubtedly present, it must be evident that many of the contradictions which have apparently existed in connection with the pathology of ner- vous diseases may be accounted for. It must also be clear that no confidence can be placed in the analysis of cases, however numerous, when the sources of error now indicated have not been carefully ex- cluded. 312 DISEASES OF THE NERVOUS SYSTEM. ACUTE HYDROCEPHALUS. Case I.*—Acute Hydrocephalus—Recovery. History.—Janet Reid, set. 12—admitted June 12th, 1850. About three weeks ago she fell down and struck the back of her head violently, but soon recovered, and remained well until two days ago, when febrile symptoms, with headache, occurred- The following morning these continued, and vomiting came on, with great restlessnessi and crying at night. Symptoms on Admission.—On admission, she is very drowsy, and starts occa- sionally in her sleep. When roused she is fretful and irritable, and complains of head- ache. The pupils are dilated, but contractile on exposure to a strong light; pulse 104, of good strength; skin hot; tongue covered with a white fur, and dry; no appetite; great thirst; bowels not open for two days. Urine, sp. gr. 10-30, with phosphatic deposits. R. Calomel, gr. iij; Pulv. Scammon. gr. v., Fiant pulv. talet duo. Sumat unum statim, et alter urn post koras tres.—Applicent. hirudincs iv. capiti. Progress of thk Case.—June 13lh.—Leeches bled well. Took both powders, and had an injection, which brought away one stool of a dark greenish colour. Still com- plains of pain in the head, and general uneasiness when moved. But there has been no more vomiting, and there is no intolerance of light. Pupils natural; pulse 120, rather sharp; skin still hot and dry; continues drowsy, and fretful when moved; tongue white and moist.—Sumat Ext. Sennce, 3 ij, ex aqua, et repetatur post horas qua- tuor si opus sit. June 15th.—No headache, and not so drowsy. June 22d.—Since last report has been gradually improving; the febrile symptoms have ceased, and she was dismissed quite well. Case II.t—Acute Hydrocephalus in a Scrofulous Child—Recovery. History.—John M'Aulay, aet. 9, son of a servant—admitted July 5, 1855. This boy is of a scrofulous constitution, and was admitted into the Surgical Hospital, June 22d, for a scrofulous sore on the left ankle. Three days afterwards he was attacked with scarlatina, which ran a mild course, and from which he was convalescent on the 29th. June 30th, however, he complained of not having slept, vomited several times, and was very restless, July 1st, he refused to eat anything, and in the course of the day screamed violently several times. There was also cephalalgia, drowsiness, pho- tophobia, and great irritation when roused. In this condition he remained until ad- mitted into the Medical Clinical ward, the tendency to constipation having been counteracted by the administration of purgatives twice. Symptoms on Admission.—On admission, the face is pinched, and expressive of great irritability. He cries fretfully when touched or disturbed. The eyes are spas- modically closed, and he resists all attempts to open them; but when this is done, both pupils are seen to be dilated, and not moveable on exposure to the light. On being left quiet, he turns away from the light, and relapses into a doze, interrupted by occasional moanings. Pulse slow and feeble, difficult to count from resistance of the child; skin and head of natural temperature. There is still a scrofulous ulcer on the * Reported by Mr. E. S. Wason, Clinical Clerk. f Reported by Mr. Robert Byers, Clinical Clerk. ACUTE HYDROCEPHALUS. 313 left ankle, discharging pus of an offensive odour. Tongue furred; refuses food; bowels constipated ; has no cough or pulmonary symptoms, and has never had stra- bismus, grinding of teeth, convulsion, or paralysis.—To have beef tea, milk, and nutri- ents, with 3 iij of sherry wine daily. . PJ. Pulv. Jalap, gr. v. ; Hydrarg. Chlorid. gr. ij.; ft. pulv. hord somni sumendus. Progress of the Case.—July 6th.—At seven a.m. passed a copious, dark, offen- sive stool. Has been persuaded to take a little milk, but refuses other nourishment. Still fretful and irritable, but the nurse says he did not scream or toss about so much dnring the night. Pulse 64, weak. Otherwise the same. July 11 th.—Since last report the general irritability has somewhat diminished, and last night he slept well. Has gradually been induced to take more nourishment. Does not scream now, but moans occasionally, and tosses about until exhaustion produces sleep. Now and then he puts his hand to the forehead, and says he feels pain there. His sight is occa- sionally dim, but at other times he sees well. Cannot sustain any train of thought or conversation long. Still constipation, which is relieved every third day with the powder of calomel and jalap. July 20th.—There has been gradual improvement on tlie whole, although much variation from day to day. Some nights are more restless than others, with occasional screaming. He still puts his hand to the head, which is sometimes, he says, " sore." The pulse has varied from CO to 80. The appetite has improved, and he takes more nourishment. Sight and memory more perfect. August 3d.—Has been occasionally screaming a good deal at night, but is now much better, and walks about on crutches, the scrofulous sore on the ankle being no better. August 8th.—It having been stated that he was affected with worms, be has taken some doses of the etherial extract of the Male Shield Fern, followed by purgatives. These have produced several stools, but no worms. His appetite and general health have now been greatly restored. There is no pain in the head, or restlessness at night, and he was sent back to the surgical wards to have his ulcer treated. Commentary.—In the two preceding cases we have good examples of that congestive and irritative state of the brain, which occurring in children has been regarded as indicative of acute hydrocephalus. Whether in either of them the disease had proceeded to actual effusion it is of course difficult to determine, although the pain in the head aud restlessness passing into somnolence render this probable. In the first case, where the child was tolerably healthy, febrile phenomena with ex- citement were more pronounced than in the second scrofulous case, in which exhaustion was evident from the first. Hence why a few leeches and laxatives constituted the treatment in the girl Reid, although, it will be observed, that their employment produced no marked improvement in the symptoms, the pulse on the following day being 120, sharp, the skin hot and dry, with a continuance of the drowsiness. Notwithstand- ing, no further antiphlogistic remedies were persisted in, and two days subsequently the patient became convalescent. In the second case an opposite plan of treatment was practised from the first. Here the pulse was slow and feeble, the symptoms were indicative of exhaustion, and this child not only had a scrofulous sore, but had recently recovered from an attack of scarlatina. Nutrients with wine, therefore, were persever- ingly pressed upon the patient, notwithstanding the deficient appetite and nausea, with the effect of ultimately establishing a recovery. 314 DISEASES OF THE NERVOUS SYSTEM. Case III.v—Acute Hydrocephalus—Phthisis Pulmonalis—Death—Effusion into the Lateral Ventricles—Non-Inflammatory softening of the central parts of the Brain —Meningitis at the base of Cranium—General Tuberculosis. History.—Mary Ann Flynn, set. G—admitted June 2G, 1S45. She is an intelli- gent child, of scrofulous and cachectic appearance, and greatly emaciated. From her own statement, she had influenza a year ago, and has had a cough ever since. Her diet has always been very poor, chiefly consisting of potatoes without any milk or ani- mal food. Latterly she has experienced pain in the head, has been feverish and rest- less at night, and yesterday she vomited several times. Symptoms on Admission.—On admission she complains of headache, pain in the back, great thir.-t, nausea and cough. The pain in the head is felt over the forehead, sometimes .extending to the entire head ; is constant hut not severe at present. She has also slight pains in the back, not increased on pressure. Her intellectual powers are for her age unusually good; pupils and eyeballs natural; never had fits or other derangement of the nervous system. She has no appetite, refuses all food, but con- stantly desires drink ; tongue covered with a whitish fur; mouth dry. She has not vomited since admission, but complains of distressing nausea ; abdomen feels natural; had diarrhoea of light yellow fluid stools two days ago, which has now ceased; has frequent prolonged cough, not accompanied by much expectoration. On percussing the chest, there is a comparative dulness under the right clavicle, and on auscultation over this part, a loud moist rattle accompanies the inspiration, extending down to the third rib. Here also there is bronchophony. Similar signs exist on the right side posteriorly, at the apex of lung, and over the rest of the chest there is great harshness with inspiration, and prolonged expiration with occasional sibilation. Respi- rations are 26 in the minute; pulse 150, small and somewhat hard; heart sounds rapid, but normal in character ; skin hot, covered with perspiration; head unusually warm.—Applicent. hiru lines iv. temporib'is— Habeat Viui Ipecac. 3 ss. Progress of the Case.—June 27th.—The emetic operated powerfully; nausea removed; headache relieved by the leeches; otherwise the same. July 2d.—Since the 28th there has been frequent vomiting, for which naphtha, hydrocyanic acid, and other remedies, have been given without benefit. Little food has been taken. Loud gurgling audible under right clavicle ; constant cough, with purulent expectoration. The surface is pale, and she cannot be spoken to or touched without causing cries and moaning. Bowels open; stools natural. There has been occasional diarrhoea, which has been checked by chalk mixture. Constant pains in the head, with great restlessness at night. Pupils slightly dilated ; pulse 100, of good strength. Abradatur Capillitium et applicet Emp. Lyttce. Milk diet with beef tea and wine in small quanti- ties. July 1th.—Has continued much the same since last report, the vomiting being considerably less frequent, however. Last night it is reported she was comatose, and could not be roused, and that convergent strabismus of the left eye was undoubt- edly present. To-day she is lying on the right side, the knees drawn up to the abdomen; the face pale; surface cool; respiration easy. She does not answer ques- tions, or protrude her tongue when desired, although her eyes and look are intelli- gent. No paralysis. Metallic resonance when she speaks or cries under right clavicle. Pulse 104, of good strength. Habeat Calomel, gr. ij, tertll qudque hord. duly 12th.—There has been alternate looseness and constipation of the bowels, the stools being of a spinach colour. Sometimes better, at others complaining of great pain in the head. The expression of countenance is now worn and haggard, with evident anxiety; eye and mind still peculiarly, and even painfully intelligent. No * Reported by Mr. D. P. Morris, Clinical Clerk. ACUTE HYDROCEPHALUS. 315 convulsion or paralysis, but great restlessness occasionally at night. At other times she sleeps well. Pulse is more frequent and weak, generally about 150 a minute. Omit. Pulv. Calomel. Habeat Vini, 3 ij., secundd qudque hord. July IZlh.—Has been gradually sinking since last report. To-day at the visit, pulse 180, feeble. Still intelligent, and answers questions. Tongue of unchanging colour. Died at five r.M., apparently from exhaustion, without previous coma, strabismus, convulsions, rigidity, or paralysis. Scetio Cadaveris.—Eorty-three hours after death. Body greatly emaciated. Head.—On removing the dura mater from the superior surface of the hemispheres, the arachnoid covering them was found unusually dry, and the pia mater somewhat pale. On stripping the membranes from the convolutions, and holding them up before the light, they could be seen to be sprinkled at irregular distances with minute white hard points, having the appearance of tubercle, deposited in the sub-arachnoid tissue. The glandula? Pacchioni could easily be distinguished from them by their situation, softer consistence, and larger size. On removing slices from the hemispheres, fluctua- tion of fluid in the ventricles could readily be felt below. A puncture was cautiously made in the roof of the left lateral ventricle, and 5 iiiss of colourless serum were remove-' with a pipette. On declining the head towards the left side, ? j more fluid was removed, which had evidently passed from the right ventricle into the left through the foramen of Monro. This last portion was turbid, and contained small floating fragments of lymph. On opening the right ventricle it was collapsed. The foramen of Monro was the size of a large pea. The fornix, internal walls of the ventricle and cerebral portions in the neighbourhood of the ventricles, were of pulpy consistence, but of their normal colour. On removing the brain from the cranium, the pons varolii, medulla oblongata, and corpora albicantia, were seen to be covered with a layer of pale gelatinous lymph, one-eighth of an inch in thickness. This layer only extended to the medulla oblongata inferiorly, where it passed through the foramen magnum, as was proved by careful examination of the spinal cord, which was healthy throughout. The third and fourth ventricles of the brain were enlarged, and distended with serum. The left lateral ventricle was also enlarged, especially its posterior and inferior cornua. The enlargement of the right lateral ventricle was confined principally to the anterior cornu. Chest.—Pleura? on right side sprinkled with miliary tubercle, situated below serous surface. Both lungs studded throughout with hard miliary tubercle, of a grey colour; in some places, however, it was yellow and soft. The intervening pulmo- nary tissue was of a bright red colour, engorged, but pervious to air. In the supe- rior lobe of right lung the tubercles were closely aggregated together, and contained numerous anfractuous cavities varying in size. Some were lined by a distinct mem- brane, and all were filled with scrofulous pus. Heart and vessels healthy. The bronchial glands enlarged from infiltration of yellow cheesy tubercle, mixed with pigmentary deposit. Abdomen.—Liver of natural size. Gall ducts and gall bladder distended with fluid green bile. Kidneys healthy in size and general structure, but the cortical substance sprinkled over with minute grains of tubercle. Stomach healthy. The ilium was the seat of tubercular ulceration throughout, situated principally in the aggregate glands. Large intestines healthy. Mesenteric and lumbar glands for the most part enlarged in consequence of tubercular infiltration. Spleen throughout studded with yellow cheesy tubercle, in granules varying in size from a pin's head to that of a pea. Peritoneum here and there dotted over with hard miliary tubercle, deposited however below the serous membrane. 316 DISEASES OF THE NERVOUS SYSTEM. Microscopic Examination.—The pale gelatinous lymph at the base of the brain was principally composed of molecular matter, in which a few granular cells might here and there be detected. The turbid fluid at the floor of the ventricles contained epithelium cells, some of which were undergoing the fatty degeneration. The white cerebral softening contained no granules nor granule cells. The hard grey and soft yellow tubercles in various parts of the body were carefully examined, and were found to present their usual characters (Figs. 133, 135). Commentary.—This is a well characterised case of acute hydroce- phalus in a child also affected with general tuberculosis. From the first it was certain that it would be fatal, for in addition to the cerebral lesion we had to do with an advanced phthisical condition. With the excep- tion of a few leeches applied immediately on admission, and afterwards calomel in small doses, the treatment generally was nutrient. The appearances after death are strictly in accordance with all the symptoms whicii were carefully observed during life. Her mind throughout was unaffected, except when occasional drowsiness or coma prevailed, and the circumference of the hemisphere was normal, while the lesions observed were confined to the ventricles and base of the cerebrum. Then there was no paralysis or convulsion, and the softening of the cen- tral parts was proved to be serous. The pain, irritation, stupor, and other symptoms, are readily explicable by the tubercular meningitis and gradual distension of the ventricles with fluid. The nature of acute hydrocephalus has been keenly disputed, and whether it be inflammatory or non-inflammatory, and should he treated with antiphlogistics or nutrients, will be found to be discussed at great length in systematic works and numerous monographs.* The fact is, that the group of symptoms indicating the occurrence of water in the brain is altogether insufficient to prove the existence of this morbid pro- duct in acute cases. What we observe are symptoms of excitement, gradually passing into those of depression, occasionally accompanied with paroxysms of pain, restlessness, aud screaming, alternating with drowsiness, exhaustion, and coma. These symptoms are common to various lesions of the brain, and may be the result of mere congestion, or of this state terminating in effusion and frequently in exudation. Hence why sometimes after death we find no lesion whatever; at others more or less distension of the ventricles with serum, and very commonly in addition exudation at the base of the cranium. In every case the symptoms are referable not so much to one or the other of these lesions, as to something which they all have in common, and this undoubtedly is more or less pressure on various portions of the brain, causing first irritation and then perversion of function, or so operating as to excite some parts and to depress others. In the great majority of cases the fluid distending the ventricles is more allied to the dropsies than to the exudations. Nay, even when lymph is thrown out at the base of the brain, the amount of serum in the ventricles is altogether disproportioned to the quantity of coagulated fibrin deposited. Hence I am disposed to think that, even when evidence of so-called inflammation does exist, a.- in ■ See the author's article on Hydrocephalus, in the Library of Medicine. Vol. u. London, 1840. ACUTE HYDROCEPHALUS. 317 Case III., still the fluid which distends the ventricles is owing to a mechanical obstruction of the vessels, causing dropsical effusion. As to the central white softening so commonly found in hydrocephalic cases, it is, in the vast majority of instances, a post-mortem appearance, caused by mechanical imbibition of the serum into the porous substance of the white tubular structure of the brain. I have seen this softening most extensive in cases where, immediately before death, the transmitting functions of the white central parts were perfect; and the fact that no relation exists between the symptoms during life and such softening after death has been noticed by numerous observers. In a special work on this subject (London: 1843), Dr. Risdon Ben- nett, looking to the scrofulous character of the children usually affected with this disease, refers its nature to "vital changes in the brain, chiefly in the central white parts, of the character probably of tubercular dege- neration,—and that softening, effusion into the ventricles, aud meningitis, are all consequences of antecedent alterations of nutrition."'—(Pp. 1-18- 9). This view, which contains the general truth, may, I thiuk, now be more specifically stated as follows :—All circumstances, including scro- fula, which weaken the general nutrition of the econo.uy, tend to occasion languor and obstruction of the cerebral circulation. This defective nu- trition is, iu young children, especially liable to occasion congestions within the cranium, causing effusions and exudations, either simple or tubercu- lar, and as a mechanical result of such effusion, those softenings so frequently found after death. Such appears to me the true pathology of acute hydrocephalus, including the " hydrocephaloid disease " of Dr. Marshall Hall. In the treatment of this disease much stress has been laid by practi- tioners on the question, as to whether in any given case the symptoms are or are not dependent on inflammation, and if so, what may be the character, seat, and stage of the inflammation. If the disease be inflam- matory, blood-letting, with antiphlogistics and calomel, has been enjoined. When, on the other hand, it arises from diarrhoea, or after exhaustive diseases, an opposite line of treatment has been the rule. The profession canuot be too grateful to Dr. Marshall Hall for clearly pointing out how all the symptoms of hydrocephalus frequently arise in children after long-continued diarrhoea, febrile eruptions, or other exhaustive causes, aud how they may frequently be restored under such circumstanc3s by nutrients and stimulants. But it may now be asked whether, iu fact, we possess the means of clearly distinguishing the inflammatory from the non-inflammatory forms, and whether, if we did, we are justified in treating the former by antiphlogistic remedies ? In reply to these questions, I would observe in the first place that all authors are agreed as to the difficulty of separating acute hydrocepha- lus from remittent fever, and no one, so far as I am aware, has ever pre- tended that he could point out with exactitude the symptoms which distinguish cases in which there are, and those in which there are not, exudations of lymph within the cranium. After the most careful exa- mination of many cases, both during life and after death, I feel satisfied that, conjoined with exactly the same train of symptoms, we may some- times fiud only effusion of serum in the ventricles, with white softening, and at others more or less meningitis of the base. Again, I also feel 318 DISEASES OF THE NERVOUS SYSTEM. satisfied that this meningitis, as proved after death by the existence of layers of lymph, so far from indicating a so-called sthenic constitution in children, much more frequently occurs in scrofulous and weak children. Of this, Case III. is an example, where with phthisis and general tuber- culosis, there was found conjoined with effusion into the ventricles, inflammatory exudation at- the base of the cranium. The distinctions therefore, hitherto so much dwelt upon, of two distinct forms—an inflammatory and a non-inflammatory, as guides to treatment—have no real existence, and are opposed to ail positive research, as well as to a large experience in the observation and treatment of individual cases. When, in addition, it is considered that all the symptoms of acute hydro- cephalus are referable to more or less pressure on different parts of the brain ; that this pressure may be occasioned by congestion, effusion, or exudation; and that we have no means of determining which or how much of each is present in any individual case, it must, I think, be certain that it is impossible in the vast majority of cases, and highly doubtful in all, to determine the existence of meuingitis or cerebritis as a concomitant of acute hydrocephalus. Lastly, the symptoms of the " hydrocephaloid disease," so well described by Dr. Marshall Hall, in whicii all the phenomena of hydrocephalus occur, and which are only distinguishable by the circumstance that they originate from exhaustive causes, should alone make us pause before we have recourse to a lower- ing system of practice. But supposing we had the power to detect in any given case the occurrence of active exudation going on within the cranium, should we even then be justified in having recourse to blood-lettiug, general or local? The considerations we have previously entered into (p. -Ml, et seq.), first, as to the incompetency of this remedy (and of antiphlo- gistics generally) to meet the end in view, and secondly, as to the fact that we can only reach the circulation within the cranium, by influenc- ing the force of the heart (p. 115, et seq.), are sufficient answers to this question. It follows then, that the uucertainty of diagnosis, as well as the evil effects likely to result from a lowering practice in these cases, which almost always occur in weak children, are not only opposed to it, but perhaps sufficiently explain the acknowledged great mortality of the disease. For the like reasons the use of calomel to cause absorption of matters, whose existence we have no means of detecting, appears equally unreasonable, even supposing it had been proved to possess an absorbing power, which it certainly has not. On the other hand, the two first cases we have recorded are examples of what may be done by an opposite plan of treatmeut in acute hydro- cephalus, and in the third case, we believe the practice followed to have been the only warrantable one iu the desperate and necessarily fatal circumstances. It bore reference to improving the general constitution and nutritive powers of the patient, which in all ca—Fifty-six hours after death. Body somewhat emaciated. ' Head.—The convolutions on the surface of the cerebral hemispheres were some- what flattened, but not preternaturally dry. The substance of the brain was normal. The lateral ventricles distended with turbid serum, slightly tinged with blood, to the extent of § ij. Central substance of brain healthy. The sub-arachnoid tissue at the base everywhere infiltrated with recent coagulated lymph. In the substance of the pons varolii was a tubercular mass, the size of a pea, firm externally, soft towards the centre, and surrounded by a zone of congested vessels. The membranes covering the hemispheres, and other portions of the brain, healthy. Thorax.—Heart healthy. Pleuras on both sides, adherent by chronic bands of lymph, especially at the apices of the lungs. Here both lungs were indurated and puckered, and contained several cretaceous and calcareous concretions. Their ante- rior margins were emphysematous, and the posterior and inferior portions engorged, and the bronchi more or less filled with purulent mucus. Here and there, scattered * Reported by Mr. David Christison, Clinical Clerk. CEREBRAL MENINGITIS. 323 throughout the inferior portions of both lungs, were masses of old tubercle, con- verted into calcareous matter, and varying in size from a barley-corn to that of a cherry stone. Abdomen.—Abdominal organs healthy. Microscopic Examination.—The turbid serum in the lateral ventricles contained numerous granule cells, and a few blood corpuscles. The lymph at the base of the brain was molecular, with here and there masses of pus corpuscles in a state of dis- integration. The cerebral substance around the tubercular mass in the pons varolii was healthy. Commentary.—In this case prostration was so marked that stimu- lants and nutrients were given on his admission, but without the effect of overcoming his exhaustion. It is to be observed, that although for- merly of a tuberculous constitution, which had left traces of its existence both in the brain and lungs, he had overcome this to such a degree that on exposure once again to exhausting causes, a simple or inflammatory rather than a tubercular exudation was the result. The structure of the exudation at the base of the cranium, and the granule cells in the serous fluid of the ventricles, indicated that the lesion was already somewhat chronic. In this, as well as the preceding case, it appears to me that the original headache and fever indicated the period of congestion aud exudation, that vomiting pointed to commencing, and stupor to more intense pressure from the subsequent effusion. The seat of meningitis is the so-called subarachnoid cavity, in which there is a quantity of loose areolar tissue, richly furnished with blood- vessels. It generally results that the exudation poured into this cavity, instead of undergoing the transformation into fibres which usually occurs on serous surfaces, follows the law which regulates its passage into pus. Hence I have ascertained that what is generally called a recent layer of coagulable lymph, covering the convolutions in meningitis, is, in point of fact, a layer of pus. That the exudation should not readily be poured out into the cavity of the arachnoid is explicable by the circumstance, that the solid and unyielding walls of the cranium would oppose any ten- dency to the enlargement of that space. Indeed, the greater the amount of exudation or effusion, especially in the deeper parts of the brain, the more would the two layers of the arachnoid be compressed together, and hence arises the dryness of this membrane in meningitis with effusion into the ventricles. If, as I have stated, the exudation in acute meningitis be examined microscopically, it will be found to consist principally of pus corpuscles, presenting an unusually molecular character, and associated with nume- rous loose molecules and granules. In the chronic forms the pus cor- puscles are seen to be broken down, and the whole is reduced to an amorphous granular mass, more or less mingled with fat granules. The blood-vessels, also, which enter into this mass may frequently be seen under- going the fatty degeneration. When the ventricles are the seats of exu- dation there are generally in the fluid epithelial cells of a globular form, which present various appearances according as they are swollen through endosmose, or have undergone the fatty degeneration and become granular cells. I have also noticed a great variety of changes in the villi of the choroid plexus under such circumstances. Occasionally their 324 DISEASES OF THE NERVOUS SYSTEM. epithelial coating is much increased in thickness, and at other times is raised up in the form of small bullae, being probably the incipient stage of simple cystic formation. They frequently also contain a greater or less number of the amyloid bodies represented, Fig. 349, the connection of which with active disease in the ventricles, however, has not yet been demonstrated. As to the diagnosis, notwithstanding the efforts which have been made to distinguish meningitis of the convolutions from that of the base, or either of these from a simple effusion into the ventricles, I have in vain sought for any precise symptoms which could be relied on as indica- tive of the situatiou of the disease. Pain in the head, vomiting, drowsiness, and coma, causing slow and subsequent rapid pulse, .suc- ceeded by more or less jactitation and convulsion before death, are the leading symptoms. The gradual mode of invasion, and the succession of these symptoms to one another, are also characteristic, and differ from those which attend sudden attacks caused by haemorrhage, and the slow progress of chronic cerebritis. They are all the results evidently of geueral pressure on the brain, and hence why mere effusion cannot be distinguished from meningitis. The febrile state attending meningitis cannot be depended on as a source of distinction, and the other symptoms are pretty much the same. Hitherto the treatment of meningitis, whether real or supposed, has been antiphlogistic, but it is impossible to say that any benefit has ever been effected by the practice. The early stage of the disease is gene- rally overlooked, the vomiting and pain in the head, so long as the patient retains his consciousness, seldom leading to a suspicion of menin- gitis. It is only when exudation or effusion has been poured out iu such quantity as to cause drowsiness and stupor that our suspicions are awakened, and thus it is very difficult to understand how bleeding or purging could facilitate its absorption. Besides, we have seen that the tendency of such exudation is to pass into pus; hence the treatment which favours the transformation of cell growth, as previously explained (Section III. p. 257, et seq.), must be the most effectual. For this pur- pose time is required, and the vital strength, instead of being lowered, should be supported. It becomes, however, in actual practice very diffi- cult to carry out these indications. The drowsiness and coma greatly interfere with the means we possess of nourishing the patient, because ali- ment cannot be introduced in sufficient quantity, whilst the depression of the nervous force so disorders the whole glandular system as to occasion a profound alteration of the nutritive functions. Under such circumstances the mucous membranes become deranged, the tongue aud throat parched, the stomach contracted, the bowels constipated, and it often has appeared to me that under such circumstances patients literally die of exhaustion from want of food. The tissues become deteriorated, while the absence of volition aud sensation, as iu cases of fever, favours the sloughing process over the dependent parts of the body, which are continuously pressed upon. All these changes are remarkably well seen in those cases of the disease which occur without any complication, and when the tissue of the brain itself is free from organic lesion. In such instances a man is deprived of his intellectual faculties merely; he is reduced to the con- dition of an animal which has lost its cerebral lobes ; but the man cannot CEREBRAL MENINGITIS. 325 be kept alive in consequence of the pressure on the encephalon deranging the nutritive functions, whereas a bird, after the experiment, may be fed and retain its vitality for months. Still the duty of the medical prac- titioner is to support the economy as much as possible—to give nutri- ents with moderate stimulants—to foresee the possibility of sloughs forming on the back and nates, and do all in his power to prevent them —to unload the bowels and bladder from time to time artificially, and thus, as far as possible, counteract their torpid action—and in this way endeavour to gain time, which will enable the exudation to pass through its natural transformations, and ultimately to be absorbed. It has always appeared to me that the collection of mere serous fluid, whether in the ventricles or over the surface of the brain, either with or without exudation, is consecutive on obstruction of the vessels, and is therefore more allied to the dropsies than to the inflammations. Thus, when lymph is poured into the subarachnoid tissue at the base, it com- presses the vessels leading to the choroid plexuses and lining mem- brane of the ventricles, and so induces effusion ; and consequently effu- sion follows, and does not precede the exudation. It is the collection of serum which does the mischief, presses on the brain, and causes the somnolence and coma. If so, the occurrence of these symptoms should be regarded as secondary instead of as primary, and as analogous to the ascites or anasarca following hepatic or renal disease.* I have occasion- ally seen in the ventricles of the brain what may be called a desquama- tive meningitis, occasioned by the same minute changes which cause the corresponding disorder in the kidneys. These pathological considera- tions are, it appears to me, wholly opposed to the idea of blood-letting and antiphlogistics being beneficial after exudation and effusion has occurred. Case VII.f—Chronic Meningitis—Serous Effusion into the Ventricles—Tubercular Mass in left lobe of the Cerebelhim—Cretaceous Tubercle in the Lungs, with Fibrous Cicatrix. History.—James Scott, set. 30, a writer's clerk—admitted October 29, 1849. * This view was singularly confirmed by a case which entered my clinical ward during the summer of 1857. It was that of George M'Leod, set. 25, a policeman, of sound constitution. A month before admission he experienced headache, whicii gradually increased in intensity. Nine days before admission vomiting came on, which was frequently repeated after taking food. On admission he was drowsy, and rapidly became comatose, the pulse 60, respirat'on slow. During the subsequent, nine days he was two or three times less soporous, and on one occasion even answered questions confusedly. Latterly the pulse became rapid, and he died without convul- sion or paralysis. A post-mortem examination showed the presence of a firm, chronic exudation, upwards of one-eighth of an inch thick at the base, surrounding the basilur and carotid arteries, and infiltrated through the subarachnoid cavity, so as to »um.nnd the pons varolii. The ventricles contained ? ij of clear serum. The indu- rated exudation, on microscopic examination, was shown to be chronic, and with its contained vessels commencing to undergo the fatty degeneration. The serum con- tained nothing but a few epithelial cells. In this case cupping, leeches, ice applied to the shaven scalp, and counter-irritants, were of no benefit whatever, and the only thing that appeared to do gocd was unloading the bowels by means of enemata ; latterly, brandy iu:d beef-tea were administered. I : m of opinion that the exudation at the base was poured out long before he entered the house, but that the subsequent effusion into the ventricles, producing pressure on the brain, and causing the coma, came on after his admission. t Reported by Mr. Alexander Christison, Clinical Clerk. 326 DISEASES OF THE NERVOUS SYSTEM. The only account that can be obtained of him is that he was seized with vomiting about a week ago, and has been ill ever since. Symptoms on Admission.— On admission he seems to be labouring under mental oppression. There is considerable deafness and confusion of ideas, so that he cannot answer questions. He does not complain of, nor does he appear to suffer pain. The eyes are somewhat suffused. Tongue furred, and covered with a moist fur. Skin hot and dry. Pulse 70, full. Drinks freely when water is given him. No paralysis can be detected. Other functions normal. Head to be shaved, and cold applied. A saline mixture. Progress of the Case.—October 30.—In the same state, the bowels have been freely moved. Some headache, with wandering of ideas. 3 viij of blood to be re- moved by cupping from the neck. October 31.—No relief from loss of blood. Stupor more pronounced, with slight twitchings in the face arid hands. At the visit, coma is complete. To have a turpentine injection, but he expired about 1 p.m. Sectio Cadaveris.—Twenty-four hours after death. Body robust and well formed. Head.—On removing the calvarium the cerebral meninges were unusually dry, and the convolutions somewhat flattened. The lateral ventricles were much dis- tended, and contained 3 ij of clear fluid. Cerebral substance firm and normal. The left lobe of the cerebellum was firmly adherent to the dura mater covering it. On being cut through there was found a hardened mass embedded in it, the size of a pigeon's egg, resting inferiorly on a thin stratum of the softened cerebellar structure, about one-eighth of an inch in thickness, and of a reddish hue. It was of yellowish colour and cheesy consistence, most dense in the centre. Other portions of the brain healthy. Chest.—The plurse at the apices of both lungs were coherent by chronic bands of lymph. Immediately below the adhesions on both sides were several cretaceous encysted masses, about the size of peas, surrounded by dark, indurated pulmonary tissue. On the external surface of the apex of the left lung, was a dense fibrous cicatrix, three-fourths of an inch long. The bronchial glands were enlarged, and infiltrated with chronic tubercle, mostly cretaceous. Other thoracic organs healthy. Abdomen.—Abdominal organs, with the exception of the scrotum, which contained some chronic fistulse, healthy. Microscopic Examination.—The centre and circumference of the tubercular mass closely resembled the figures represented (Figs. 382, 383); but the external softened cerebral substance contained a larger number of granular cells. The serous fluid in the ventricles only contained a few epithelial cells. Commentary.—In this case, the meninges covering the left cerebellum were thickened and adherent to the dura mater: and below them was found a tubercular mass the size of a pigeon's egg. How long this lesion had existed it is impossible to say, but its presence, by compressing the vessels at the base of the cranium, was well calculated to render any temporary congestion more liable to terminate in effusion. This, what- ever the exciting cause, was what I presume must have occurred, pro- ducing dropsy of the ventricles, with the usual symptoms of pressure on the brain, and proving fatal. The case corroborates also the view that such effusions are rather the result of pre-existing lesions, than a direct consequence of inflammation. CEREBRAL MENINGITIS. 327 Case VIII.*—Chronic Cerebral Meningitis ; Induration surrounded by softening of a Portion of the I^eft Cerebral Hemisphere. History.—Mrs. Swan, set. 35, wife of a coach-builder, admitted December 8, 1850. She had always enjoyed good health up to four years ago, when, having contracted syphilis, and having taken a large quantity of mercury, she began to complain of headache, indigestion, occasional vomiting, constipation, and drowsiness. About six months ago, she had a fit, from which she recovered in the course of half an hour. She suffered from similar attacks afterwards, at intervals of from two to three weeks. These attacks were ushered in by severe headache, tinnitus aurium, vertigo, and dimness of vision, and they were followed by great muscular debility. During the paroxysms, which lasted for various lengths of time, she was insensible ; there were frothing at the mouth, and twitchings of the muscles of the limbs, espe- cially of the right arm. The last fit occurred two months since. Four weeks ago, she experienced, without any accompanying fit or insensibility, a twitching of the muscles of the right arm, together with a feeling of numbness in the fingers of the right hand. She subsequently experienced less power in the right arm, and some numbness in the right leg. Symptoms on Admission.—On admission, she appears debilitated and considerably emaciated. There is great mental confusion, and she often wanders. She complains of intense pain in the head. There is, however, no flushing of the face, nor conges- tion of the eyes, and no delirium. There is difficulty and slowness of articulation. The right side of the face is slightly paralysed. The tongue, when protruded, is slightly turned to the right side. There is no diminution of sensibility. The power of motion in the right arm is diminished ; she cannot close the hand, or hold anything firmly. Sensibility is unimpaired. The right leg is not affected with any diminution of muscular power, though there is a feeling of dragging when the limb is moved. The pulse is regular and of good strength ; no cough ; complains of loss of appetite ; tongue moist, white ; no vomiting nor sickness. Bowels constipated; menstruation is irregular, and the discharge scanty ; menstruated last, six weeks ago. Urine muddy, of 1023 sp. gr.; becomes clear on heating. Progress of the Case.—From this period until the 4th of January, 1851, she remained pretty much in the same condition, on some days the confusion of intellect and difficulty of speech being somewhat less than on others. The treatment con- sisted of the occasional application of leeches, and latterly of a blister to the nape of the neck, and purgatives. On the day mentioned, however, she was found comatose —did not answer question^, though she seemed to know that she was addressed—pupils moderately dilated—respiration stertorous. There was slight twitching of the muscles of the right side of the face. The right arm was rigidly flexed, and offered great resistance when an effort was made to extend it. January 5.—To-day appears better. No stupor. Expression not so drowsy. No stertorous breathing. Has spoken a little. Has no sickness or vomiting. There are still occasional twitchings of the muscles of the right side of the face. Right arm not so rigidly flexed. Ordered a purgative enema immediately. January G.—Has again relapsed into a state of coma. Breathing easy. Twitchings of the muscles of the right side of the face, of the right arm, and occasionally of the right leg, have again presented them- selves. Pulse rather full, and slow. Bowels freely opened by the enema. Sensibility in affected parts still unimpaired. January 7.—Continues in much the same condition. Does not seem conscious when spoken to. Sensibility still unimpaired. Pulse fre- * Reported by Mr. Henry Thorn, Clinical Clerk. 328 DISEASES OF THE NERVOUS SYSTEM. quent, and smaller than yesterday. Increased rigidity of the right arm and leg, with occasional twitchings. January 8.—Pulse frequent and very small. Breathing not stertorous. Lies on the left side ; and the muscles of the neck are so rigid that the head is quite immovable. Apparently sensible, though she can neither hear, speak, nor protrude the tongue. Twitchings still occasionally occur on right side of face, right arm, and right leg. Right arm rigidly contracted. Died early on the morning of the 9th. Sectio Cadavcris.—Thirty hours after death. Rigor mortis well marked. Head.—There were strong adhesions between the calvarium and dura mater over the vertex, at which place the latter membrane was considerably thickened. The arachnoid membrane covering the posterior half of the left cerebral hemisphere was thickened, dense, and opaque, closely adherent to the pia mater below. The thick- ening and adhesion existed to its greatest extent over a space about the size of half-a- crown, situated about two inches external to the falx, and at the anterior por- tion of the middle third of the hemisphere. Here the arachnoid membrane, united with the pia mater, was one-eighth of an inch thick ; and the dense layer being care- fully dissected off, exposed a discoloured spot in the cerebral convolutions measuring an inch and a half from before backwards, and one inch transversely. The centre of this spot was indurated to the feel, whilst its circumference was soft and pulpy. In the centre there was observed a hard deposit, the size of a pea, of a bright yellow colour, surrounded by a purple areola, passing into a pink colour, and disappearing gradually towards the margin of the spot alluded to. On making sections through this diseased portion, the discolouration was found to extend inwards and occupy a space about the size of a walnut. It contained imbedded in its substance five other indurated masses, varying in size from a millet seed to that of a pea, and similar to the one formerly noticed. The boundaries of this diseased mass internally presented the same colour and consistence as were noticed on the surface, with the exception perhaps that the disappearance of colour was more gradual internally, and passed into a pulpy white softening of the cerebral hemisphere, which extended from it in a straight line until it terminated in the external portion of the left optic thalamus. The two lateral ventricles contained each about half a drachm of slightly s inguino- lent fluid, and, in the left one, a vesicle the size of a pea, containing amber-coloured matter, sprung from the choroid plexus. Other portions of the encephalon were healthy. Chest.—Heart healthy. Valves normal. No adhesion of the pleura?. The bronchi, when cut, poured out a sero-sanguinolent fluid. Left lung throughout spongy and crepitant, with much pigmentary matter scattered through it. Bight lung was non-crepitant and engorged posteriorly and inferiorly, presenting a mottled appearance when cut, from a number of minute granulations scattered throughout. All the other viscera were quite healthy. Microscopic Examination.—The yellow indurated masses described as scattered throughout the diseased portion of the left cerebral hemisphere consisted of a dense aggregation of molecules and granules, without tubercle, pus, or any kind of corpuscle. The cerebral structure surrounding these masses was loaded with innumerable granular cells and masses, which existed throughout the whole discoloured portion of the brain, but became less and less numerous in the internal white softening as it approached the left optic thalamus. Indeed the most internal portion of the white softening near the optic thalamus contained none of them. Commentary.—This woman, when she first came under my notice, CEREBRITIS. 329 presented, in a very characteristic form, the general aspect and symp- toms of softening of the brain. The dulness and confusion of intellect, without loss of volition and sensation—the weakness of the right side of the body, and contraction of the right arm—latterly the rigidity of this extremity and the coma, could leave little doubt as to the nature of the lesion, and its seat in the left hemisphere. From the account re- ceived of her history, which, however, was not entirely to be depended on, it appeared that for four years previously she had been subject to head symptoms and " fits " of an epileptic character, at all events in- volving temporary loss of the mental functions, and convulsive move- ments of the limbs, especially on the right side. This account was con- firmed by the post-mortem examination, which exhibited chronic thick- ening, and adhesion to the brain, of the meninges on the left side, in addition to an inflammatory circumscribed softening, commencing in the circumference of the same hemisphere, and extending inwards to the optic thalamus of the same side. The yellow masses described were evidently a chronic form of exudation, and it is very difficult to determine whether they originated or followed the meningitis. Certainly they occasioned the surrounding discolouration and exudation, which had extended inwards to the central portions of the encephalon. As regards the connection of the symptoms with the post-mortem appearances, we can have little difficulty in ascribing the commencing symptoms and " fits " to the meningitis, which increasing in intensity, caused pressure on the cranial portion of the cord, and occasioned the convulsions. The same lesion, conjoined with the external softening and corresponding change of circulation within the cranium, was the cause of the confusion of intellect and stupidity latterly observed, whilst the continued irritation originating in the local cerebral inflammation, op- erating through the anterior portion of the optic thalamus, and perhaps a portion of the corpus striatum, caused the contraction and rigidity ob- servable in the right arm. It is of course impossible to determine the amount of pressure and its direction, which any lesion may occasion, ex- cept from its effect. But it seems to me that this case is an illustration of the correctness of the pathological laws formerly given. The first symptoms are those of excitation, and are paroxysmal; these pass into more permanent symptoms; and as the organic disease proceeds from the circumference to the centre, we observe the intelligence affected most, motion secondarily, and sensation not at all. CEREBRITIS. Case IX.*—Acute Cerebritis—Abscesses in the Brain—Old Tubercle in various Organs— Chronic Peritonitis. History.—Mary Melville, set. 22—admitted July 20, 1851. A girl of abandoned character, concerning whom no further information could be obtained, than that she had been drinking to excess, and had sunk into a state of stupor, from which she could not be recovered. * Reported by Mr. D. O. Hoile, Clinical Clerk. 330 DISEASES OF THE NERVOUS SYSTEM. Symptoms on Admission.—On admission she was insensible, but three hours after being placed in bed, so far recovered consciousness as apparently to understand ques- tions put to her, although she could not articulate. She cannot move the rith. —Galvanic currents to be applied to the right leg and arm. February 1st.—Can now move the right arm voluntarily to a certain extent. Right leg still immovable, Paralysis of jaw has disappeared. February 12th.—Had been doing well up to four o'clock this morning, when after having been assisted out of bed, she suddenly began to moan, and was seen by the nurse to apply her left hand to the head. She was seen by the house physician (Dr. M'Laren) ten minutes afterwards, and was found to be quite unconscious, breathing heavily. The left pupil dilated, the right contracted, and both were insensible to light. All the limbs were powerless, and fell on being raised like inert masses. The respirations rapidly became more laborious and less frequent, and she died at eleven o'clock. Sectio Cadaver is.—Fifty hours after death. Head.—On removing the calvarium and dura mater, the surface of the arachnoi * Reported by Mr. Almeric Seymour, Clinical Clerk. CEREBRAL HEMORRHAGE. 371 was observed to be unusually dry. In the right temporal region was a thin extra- vasation of blood, in the subarachnoid cellular tissue. The lateral ventricles con- tained above 3 ij of sangninolent serum, and communicated freely with each other by means of the foramen of Monro, which was the size of a goose's quill. The right corpus striatum and optic thalamus were healthy, but the left optic thalamus was disorganized throughout, its centre being occupied by a clot of blood the size of a hazel nut, dark in the centre, of a brick red colour externally, surrounded by softened cerebral matter of a yellow fawn colour. On removing the brain, the extravasation formerly noticed on the right side was seen to extend downwards over the base of the brain on the right side, and over a portion of each lobe of the cerebellum, forminw a thin layer of blood between the pia mater and arachnoid membranes. The arteries at the base of the brain presented numerous opaque patches of atheroma. On cutting into the pons an extravasation of blood had taken place into its substance, disintegrating the whole of it; it was of a dark red colour, evidently recently poured out, and was fluid in some places, and loosely coagulate in others. Chest.—With the exception of a few atheromatous patches on the aorta and mitral valve, which latter in no way impeded efficiency, the thoracic organs were healthy. Abdomen.—Abdominal organs also healthy. Microscopic Examination.—The softening of left optic thalamus consisted of dis- integration of the tubes ; fatty granules accumulated in the ganglionic cells ; numerous granule cells, several tinted of an orange colour, and others of a dusky red, in the immediate neighbourhood of this clot, mingled with several crystals of hematoidine, and masses of blood varying in tint. The centre of the clots presented a series of lamina? of a brownish black colour. The broken up pons varolii wa3 infiltrated with blood corpuscles, and the tubes were more or less disintegrated, Commentary.—In this case, circumscribed hemorrhage into the right optic thalamus caused apoplexy and hemiplegia on the left side, from which she was gradually recovering, when an unusual exertion caused a secondary fatal hemorrhage into the pons varolii. Here the primary disease was chronic arteritis, causing brittleness of the vessels. In all such cases too much care cannot be taken to avoid sudden exertion, agitation of mind, and every other circumstance which is likely to pro- duce increased pressure on the blood-vessels. Case XXVIII.*—Five years before admission, Hemiplegia, followed by Recovery— Four months before admission, Apoplexy, with Convulsions and Partial Recovery —Pulmonary Disease—Death by Asphyxia—Chronic Softening of Right Corpus Striatum—More Recent Hemorrhage into the Pons Varolii—Cardiac Hyper- trophy, with mitral constriction—Hemorrhage into the Lungs. History.—Mrs. Macpherson, set. 34, admitted December 22, 1850—of intemperate habits. She has been troubled for the last four years more or less with cough. Five years ago she had an attack of paralysis affecting the left side of whole body. Her speech was thick. The left cheek appeared more prominent than natural; there were twitchings also of the left arm. Leg not affected. Intellect unimpaired. She recovered perfectly in two or three months. She continued, however, her intemperate habits, and was addicted to taking laudanum. Four months ago, after taking a drachm of laudanum, she was suddenly seized with violent convulsions, sprang a little * Reported by Mr. Pearse, Clinical Clerk. 372 DISEASES OF THE NERVOUS SYSTEM. distance, and fell on her face. She was quite unconscious at the time, a condition from which she gradually emerged, but her mind has ever since been affected, and the power over the left side is much impaired. Since the second attack, she ha< been subject to violent and sudden fits of coughing, lasting for hours without intermission, whicii have latterly increased. Symptoms on Admission.—On admission, she leans to the right side when sitting, Countenance anxious, motions of chest rapid, with much elevation of thorax during inspiration. Dyspnoea urgent. Cough constant and paroxysmal. Expectoration copious. On percussion the anterior portion of the chest sounds resonant. There is dulness over the infra-scapular region of left side. On auscultation, the inspiration is short, and the expiration much prolonged ; and accompanied with sibilant and sonorous rales over the whole anterior surface of both sides; loud crepitating and mucous rales over the inferior portion of left back, with distinct crepitation also inferiorly in right back. Vocal resonance is increased over left infra-clavicular region. Heart's sounds normal, distant. Tongue of a brown colour, moist. Appetite bad. Bowels regular. Catamenia regular. Has no pain in head or any part of her body. Skin hot and moist. Progress of the Case.—December 30th.—She has been treated with various anodyne expectorant mixtures, sulphuric and nitric ether, ipecacuan wine, chloroform, morphia, etc., to relieve the cough and difficulty of breathing, but with little benefit. Is weaker to-day. Countenance sunk and anxious. Tossing about of arms. Breath- ing short and rapid. Cough almost ceased. Expectoration greatly diminished. Pulse weak, scarcely perceptible. Ordered two ounces of whisky and one pint of porter daily. January 1st.—Exhaustion still greater. With difficulty roused to answer questions; incoherent in her conversation; sleeps little; breathing rapid, short and laboured ; paroxysmal cough. The rales formerly noticed still continue; dulness over the left back more extensive and complete. Pulse small. Spirit commun. ; iv. January 2d.—Since yesterday there have been coldness and lividity of face, with stupor gradually increasing. Dyspnoea very urgent. Expectoration scanty. These symptoms increasing, she died at 3 a.m., January 3d. Sectio Cadavcris.—Xinc hours after death. Head.—The dura mater and arachnoid membrane was healthy in structure, but the subarachnoid cavity contained superiorly a small quantity of serum between the sulci. Both lateral ventricles contained about a drachm of fluid, hut that on the right side was opaque, of a greyish colour like dirty milk, while that on the left side was colourless and clear. Three-fourths of the right corpus striatum posteriorly was reduced to a fawn-coloured diffluent pulp, from wbich a turbid grey fluid flowed out on puncture, similar to what had tinged the serum in the ventricle. The white substance external to the coipus striatum was not affected, the lesion being limited to a space about the size of an almond nut. On cutting through the softened texture, a few bright yellow patches were observable, about the size of a millet seed, closely resembling in appearance the reticulum often seen in soft cancer. On slicing the pons varolii, there was observed near its centre, a little to the right of the median line, a hemorrhagic extravasation the size of a small pea, the centre of a dark red, and the circumference passing into a rusty brown. Other portions of the encephalon were healthy. Chest.—The left ventricle of the heart was somewhat hypertrophied, the apei rounded, the mitral orifice was smaller than usual—just admitting the thumb—bu there was no thickening or disease of the lining membrane. Lining membrane the heart and large vessels stained of a claret colour—blood fluid. Both lung anteriorly emphysematous. The lining membrane of the bronchi of dark mahogany CEREBRAL HEMORRHAGE. 373 colour, and more or less filled with sanguinolent mucus. Inferior lobe of left lun present. It has also been known to accompany hemorrhages, appa- rently unconnected with softening. The analysis of many cases in reference to this subject has led me to the conclusion, that on the whole muscular rigidity or contraction is a valuable sign of softening, when present, but that as the softening may be permanent, whilst the rigidity is only temporary and indicative of the irritating effects of the lesion, the absence of the one is no proof of the non-existence of the other. It should be remembered that much of this discussion took place for- merly when no means were known of distinguishing histologically between inflammatory, hemorrhagic, and post-mortem softenings. Dr. Todd has especially drawn attention to the state of the muscles in palsied limbs from cerebral disease,* arranging the cases into three classes :— 1st, Those in which the muscles of the paralytic limbs are completely relaxed; 3d, Those in which the paralysed muscles exhibit rigidity from the moment of, or soon after, the attack; 3d, Those in which rigidity comes on long after the paralysis. The first class of cases he considers usually results from hemorrhage, combined with previous softening of the brain and rupture of the tubes, the clot of blood being separated from healthy brain. The second class of cases depends on the clot of blood acting directly on sound brain at the point of implantation of the nerves of the affected muscles ; while the third class of cases are owing to a similar irritation from an attempt at cicatrization of the brain * substance. These views of Dr. Todd, though ingenious, must as yet only be regarded as probable speculations. The true generalization appears to me to be, that complete paralysis indicates such pressure on or obstruccion of cerebral tissue as to prevent all transmission of nervous influence, whilst rigidity, convulsion, and pain show that some * Clinical Lectures on Paralysis, etc. 1854. CEREBRAL HEMORRHAGE. 377 tubes of that issue are preternaturally excited. Both conditions may be occasioned by hemorrhage, exudation, effusion, tumours, or any lesion that affects the brain. The treatment of cerebral hemorrhage must refer to the attack, and to the subsequent management of the case. At the moment of attack, the steps to be pursued must always be a subject of anxious consideration. Formerly there wras little difficulty—venesection to a large extent being the established routine remedy. The advance of pathological knowledge, however, must have made it apparent, that the same proceeding is not likely to be beneficial in all cases where the nervous centres are similarly affected. We may have sudden loss of consciousness and volition from syncope, ns well as from coma, the only supposed difference between the two being, that the same nervous phenomena commence in the heart, with a weak pulse, in the one case, whilst they originate in the brain, and have a strong pulse, iu the other. But careful observation has sufficiently proved that there are many eases of even true hemorrhagic apoplexy which are closely allied to syncope, and which have recovered under the use of stimulants rather than of depletions. It seems to me also very probable that many of those individuals who died under what Abercrombie called simple apoplexy, and in whom no trace of disease could be found in the brain after death, were really the victims of one form of fatty degeneration of the heart—an affection in his day altogether unknown. The best rule, therefore, I can give you, is to judge from all the circumstances of the case. AVhenever the individual is of vigorous frame of body, if the face be flushed, the attack recent, and the pulse strong and full, a moderate bleeding may be beneficial. The extent must be influenced by its effect on the heart's action; for, as we have seen, the object of this measure is not to draw blood from the brain, which is impossible, but to diminish the pressure on that organ, by lessening the force with which the heart propels the blood through the carotid and vertebral arteries. On the other hand, if the individual be of spare habit, the face pale, the pulse weak and irregular, and the usual symptoms of shock be present, wine, brandy, stimulants generally, and restoratives are demanded. But it most frequently happens that when you are called in, neither one nor the other indication presents itself. It will be most prudent, under such circumstances, simply to apply cold to the head, administer an active purgative, and above all enjoin quietude. At the same time the patient should be placed in the horizontal position, with the head slightly elevated, whilst the cravat, stays, and all impediments to the respiratory and circulatory functions should be removed. Should the individual recover from the attack, quietude, mental and bodily, and supporting the economy by good nourishment, constitute the chief treatment. Thus long conversations, literary labour, business transactions, the sudden reception of joyful or distressing intelligence, etc., should be carefully avoided. Sudden exertions, rising from bed (see Case XXYIL), constipation, straining at stool, etc., must be guard- ed against, Of all these I believe the prevention of constipation to be the most important, as the straining at stool thereby occasioned is one of the most common causes of secondary attacks. If paralysis remain, 378 DISEASES OF THE NERVOUS SYSTEM. considerable caution must be exercised before having recourse to local stimulants, such as frictions, galvanism, or exercise of the affected parts. These are remedies of undoubted utility, but never to be employud at the risk of causing general excitement, and always very gradually applied and their increase well regulated. Exactly the same management is required in cases of chronic cerebritis, or where there is reason to suspect that coagula from the heart constitute the cause of the cerebral lesion. CANCER OF THE BRAIX. Case XXIX.*—Cancer of the Brain, Spinal Cord, Liver, and Bones. History.—George Gall, mt. 29, a stoker on board a steam vessel, admitted July 1st, 1857. About the beginning of December, 1856, he contracted a cold with cough, and profuse expectoration, and has not since enjoyed good health. At the end of March 1857, he began to feel pain in the lumbar and sacral regions, extending also to the neck, and affecting the shoulder joints, and spreading down to the joints and muscles of the arms. The knee joints were also painful. They are reported to have been swollen, but only for a short time. At the commencement of last April, he seemed to labour under confusion of thought, with shortness of memory, and incapa- bility of carrying on a train of ideas. "Was admitted to Ward IV. on the 29th April, and during the next two months became gradually more weak and emaciated; at length was unable to walk or to rise unassisted; passing his urine in fair quantity, but involuntarily during sleep. Symptoms on Admission.—Has no headache ; is very silent, but listens to ques- tions, and answers them after a slight pause intelligently. The questions, however, require only monosyllabic answers. He says little, and his thoughts are apparently few. Special senses normal. The pupils are unusually dilated, but contract on stimu- lus of light; are equal and parallel. No paralysis of the muscles of the face or tongue. Marked tenderness over dorsal and still more over lumbar vertebrae. Never had tin- gling or numbness of the extremities. All attempts to walk cause great pain in the back, to such a degree that he cries out. Great atrophy of the muscles; he moves very little ; lies often in a cramped position; cannot rise up in bed without assistance. The tongue is clean ; the appetite is reported to be good; but he frequently vomits, sometimes immediately after a meal, sometimes an hour or two afterwards. No in- crease in hepatic or splenic dulness; abdomen appears natural, except in being re- tracted and emaciated; the bowels are habitually costive. He has at present no cough, sputum, nor dyspnoea. The respiratory murmurs appear healthy; the cardiac sounds are natural. Pulse 82, small and weak. The urine is passed involuntarily during sleep, but voluntarily during the day. It is of a light straw colour, sp. gr. 1005 ; contains no albumen, but abundant chlorides. Is ordered nutritive food, mth laxative pills, and, if necessary, enemata. Progress of the Case.—July 6th.—Is growing weaker; pulse 96, small and wiry; has a headache, chiefly over the occipital region. July 9th.—The puin in his head continuing; the hair is shaved; cold cloths are applied to the scalp, and a blister is put over the nape of the neck. July 10th.—Pulse 104, very weak; hot skin; great * Reported by Mr. John R. Murray, Clinical Clerk. CANCER OF THE BRAIN. 379 thirst; little appetite, and frequent vomiting usually some time after taking food. Is ordered a saline mixture, and four ounces of port wine daily. July 12th.— On re-examination, besides the atrophy common to both lower extremities, there appears to be almost total want of sensibility and motion in the right le«-; the left leg being, for one so emaciated, quite normal. Pupils continue widely dilated ; there is no headache at present. July 14th.—Is able to move the right leg slightly, and feels irritants applied to the sole of the foot, but not to the limb generally. Ao-ain complains of pain diffused over the whole occiput; pulse 112, weak. July 18th.— Complains of his vision becoming impaired; can recognise objects, and name their number. Had an evacuation yesterday morning, and for two days has not vomited so much as formerly. Has headache, but it does not seem severe ; the application of cold has been continued. July 19th.—Pulse 148, small, weak, and hard. Respi- ration 22 per minute. Ordered two additional ounces of wine; continue nutrients. July 21st.—Vomiting recurred yesterday, after being nearly absent for a week; is observed to recur when the bowels have been much confined, and to disappear after copious evacuation. Ordered two pills, and, if necessary, an injection. July 29th.— Vomited less after operation of the laxatives; is extremely weak, but little change can be noticed from day to day. July 30th.—This morning he was found more exhausted; a cold sweat over the whole surface ; the respirations short and hurried ; the pulse extremely feeble, cardiac impulse at apex increased. Wine was freely given, but he sank, and finally expired at 2.30 p.m. Sectio Cadaveris.—Forty-eight hours after death. Body moderately emaciated. Head.—On removing the dura mater, the surfaces of the hemispheres were unusually smooth, from flattening of the convolutions. The vascularity of the mem- branes was normal. On slicing the brain it was seen to be studded throughout with nodules varying in size from a hemp seed to that of a large hazel nut. They were of a grey pinkish colour, the smaller of pulpy consistency, the larger more firm, and all capable of being easily enucleated from the surrounding brain sub- stance. None of them projected from the surface, but they were irregularly distri- buted, some in the grey, but most in the white matter. Here and there was slight softening round some of the masses, but there was no extravasation of blood. In the right hemisphere, projecting a little through the roof of the ventricle, was a mass the size of an ordinary marble. In the roof of the left ventricle was another of similar dimensions. The left corpus striatum contained two of these bodies, one the size of a small cherry, situated anteriorly; another that of a pea, some- what more posteriorly. Around these was no softening. The optic thalami were normal. Similar bodies were scattered through the cerebellum, but there were none in the pons varolii and medulla oblongata. Each lateral ventricle contained almost a drachm and a half of clear fluid. On removing any of these bodies, there could readily be squeezed from them a creamy matter, leaving behind an apparently membranous substance evidently very vascular. Spinal Column.—The four upper dorsal, and two or three of the lower dorsal and the first lumbar vertebra?, were soft and spongy, the osseous substance yielding on pressure a copious, thick, greyish juice. The membranes of the cord were healthy. On bisecting the cord, a mass the size of a pea, exactly similar to those ob.H'ived in the brain, was found in its right half, opposite the junction of the second and third dorsal vertebrae. Chest.—About the centre of the sternum was a slight bulging of reddish colour and soft consistence, yielding a dirty yellow coloured cancerous juice on pressure. similar soft enlargements were found in the anterior portions of the third and 380 DISEASES OF THE NERVOUS SYSTEM. fourth left ribs. The lower lobe of right lung contained an infiltrated indurated mass, about the size of the fist, in some places of a yellow brown, and in others of a dirty - nance over the whole chest anteriorly. On account of the pain the attempt gave him, and his weakness, his lungs could not be examined posteriorly. Trine has again an acid reaction; chlorides much diminished. Nov. 16th.—Yesterday evening he vomited about three ounces of a thin yellowish green fluid. Sense of constriction STRUCTURAL DISEASES OF THE SPINAL CORD. 387 of chest still remains, and the same mucous rales, etc., as formerly mentioned. Pulse 120, irregular. Complains of a burning in his throat; tongue covered with a dirty- greyish fur, and livid at the tip; feels slight nausea: can take no solid food, but only wine and beef-tea. Sleep is very much disturbed by pain and a sensation of pricking in his heels and ankle-joints, and this is but little relieved by the warm opiate fomentations applied over those parts. Nov. 17th.—Pain in the heels not relieved by aconite or warm fomentations with opium. It distresses him exceedingly. X.—Membranes of brain rather drier than usual, but nothing abnormal could be detected in the brain or its nerves. Spinal Cord.—Membranes healthy, but on slitting up the cord, its substance was found to be slightly softened in a space of about an inch in length, at the level of the third and fourth dorsal vertebra. The diseased portion of the cord presented its healthy appearance to the naked eye, but the softening, though apparent to the touch, was rendered evident by the flocculent surface produced on subjecting the section to a slender stream of water. Thorax.—The right lung was found to be strongly adherent to the thoracic wall, and there were many puckerings at its apex. The anterior edges of both lungs were emphysematous, and on section, were found to be of a prune juice colour, congested and dense in patches, the parts between being still crepitant. The condition was most marked at the base of both lungs, especially that of the right. The bronchi contained a large quantity of pus, the mucous membrane being congested, and of a mahogany colour. On squeezing a portion of the lung-substance, bloody and purulent matter was pressed out. All the other organs were healthy. Microscopic Examination.—The softened portion of the cord contained some granular exudation with a few granule cells. Several demonstrations were made from other parts of the cord, but nothing abnormal was found in them. Commentary.—Cases of acute myelitis are rare, and are almost uni- formly fatal. In the present instance the symptoms commenced with the usual signs of fever and of general muscular rheumatism, followed by retention of urine and difficulty of deglutition. The insomnolence and haggard expression of countenance led us to fear that the brain might be implicated; but the total absence of mental confusion, the local pain, and the appearance of paralysis in the arms, at once indicated the cervical portion of the cord as the seat of the disease. The fugitive character of the paralysis was remarkable, at first appearing in the right arm and leg; on the following day disappearing in the arms, then once more returning, and again, towards the close of the case, altogether dis- appearing from the limbs. This must have been dependent on the con- gestion, which was more intense at one time than another, and which preceded the exudation. The sense of constriction rouud the chest was hara^-ing, and latterly the lungs became engorged, one of the most com- mon complications preceding death in cases of myelitis at the upper part 388 DISEASES OF THE NERVOUS SYSTEM. of the cord. The treatment was on his admission directed to combat the supposed rheumatism, at first with alkaline salts, and secondly with Dover's powders. As soon as the spinal character of the disease was manifested, anodynes were freely given, with cupping over the seat of pain in the neck, as a palliative. But it is to be observed that none of these remedies, whether internal or external, gave him the slightest relief. The disease took its relentless course, and life was only prolonged by assiduous efforts to support the system by nutrients and by wine. Case XXXII.*—Slight Paraplegia—Recovery. History.—William Macpherson, set. 33, a blacksmith, a very muscular and apparently strong man—admitted June 1, 1853. For two months past he has suffered from pain between the shoulders, in the legs, and over the body generally, and during the last three weeks he has been very weak, frequently feeling as if the arms and legs were benumbed. He has been an intemperate man. but never had delirium tremens, paralysis, or other diseases of the nervous system. Symptoms on Admission.—There is no tenderness on percussion along the spinal column, and he only complains of pain between the scapulae, shooting into both shoulders, increased by coughing and by motion. He says that both arms are very weak and benumbed, and that they often tingle, especially when he coughs. The arms are muscular, but the grasp he takes of an object is feeble, while the sensibility of the skin is decidedly diminished. Both arms are similarly affected. The legs also are very weak, more especially the left one, which "shakes" when he walks, especially if going down a hill. During progression the gait is unsteady, the left leg being jerked outwards in a semi-circle. He cannot turn round rapidly, and has slight difficulty in standing with the eyes shut. The sensibility of the skin over the inferior extremities, as well as over the abdomen and thorax, is diminished to the same degree as in his arms. Occasionally there are involuntary starlings of the legs and arms, especially at night, which sometimes prevent his sleeping. In all other respects the functions are normal. Appetite excellent. No constipation. B 01. Olirar. 3 ss; 01. Crotonis 3 ij. M. ft. linimentum et inter scapulas applicetnr. R Hydrarg. Proto-iod. gr. vj ; Ext. Hyoscyam. ; Ext. Aloes, aa3j, M. etfiant pil. xij. Sumat unam ter in die. Progress of the Case.—June 6th.—Thinks himself somewhat better. Complains that his diet is insufficient. To have lib. of beef tea in addition to ordinary diet. From this time he gradually recovered, and was dismissed on the 17th, still a little weak, with the perfect use of all his limbs, and the sensibility normal. Case XXXIII.f—Paraplegia—Partial Recovery. History.—Benjamin Robertson, ajt. 42, a tailor, admitted July 11, 1853. States that he enjoyed excellent health, until between three and four months ago, when he began to experience a constant feeling of coldness in both feet, accompanied with a certain amount of numbness. The diminution of sensibility gradually extended up both limbs, and in the course of six weeks they were wholly affected. Together with the numbness, the power of walking became impaired. This be attributes partly to want of muscular strength, and partly to the feeling of insecurity caused by * Reported by Mr. Wm. M. Calder, Clinical Clerk. f Reported by Mr. Alexander Struthers, Clinical Clerk. STRUCTURAL DISEASES OF THE SPINAL CORD. 389 the loss of sensibility. After the lower limbs had become involved, the fingers of both hands became similarly affected. Occasionally he has felt as if a belt were firmly bound round the loins and lower part of the chest. He has never had pain in the back, or tenderness on percussion along the spine. For the last ten years his habits have been temperate, but previously he was much addicted to intoxication and venereal excesses. The treatment hitherto has consisted of counter irritation over the back, and internally iodide of potassium. Symptoms on Admission.—Has no pain anywhere, but sensibility is diminished in both lower extremities, and more especially in the feet. His power of movement in the ankle joints and toes is unimpaired, but he has less command over the knee and hip joints. He is unable to draw up the limbs in bed beyond a certain point, but the left leg seems to be a little stronger than the other. He has no involuntary startings of the limbs, but be has observed that they move about irregularly when friction is applied to them. He has great difficulty in walking, feeling as if his knee joints would bend under him, and before advancing he requires to steady himself on one foot for a little. On shutting his eyes, he falls forward immediately. The fingers are constantly benumbed, but he can move them perfectly. Arms unaffected. With the exception of defalcation, all the functions are normal; but on feeling an inclination to evacuate the bowels, he is obliged to comply instantly, or the foeces would pass involuntarily. B Strychnia; gr. j.; Ext. Gent. 3 ss. Micas Panis q. s. ft. massa in pil. xij divi- denda. Sumat unam ter indies. Progress of the Case.—The pills in the course of eight days produced involun- tary startings of the inferior extremities, but the symptoms otherwise remained the same. R 01. Olivar.; 01. Crotonis, aa 3 ss. To be rubbed over the lower half 6, an engraver—admitted September 22, 18.11. He has generally enjoyed good health. For some time his habits have been very jntemperate, and he has had much domestic annoyance. A year ago he had an attack of delirium tremens. During the last few weeks he has been drinking con- siderably, although he says not to excess. Fourteen days ago he began to feel very restless and uneasy while at work, and his sleep during the night became disturbed, but he has had no tremors or spectral illusions of any kind. Symptoms on Admission'.—He now complains of severe pain in the head, referred principally to the frontal region. No pains in any other part of the body. His hands when put out have a trembling fidgetty motion, but when kept by his side are steady. Tongue is moderately dry, and covered with a whit'sh fur. Bowels are generally costive, hut were open yesterday. Action of the heart hurried, and occa- sionally irregular : impulse strong. Pulse 9G, full and strong. Other functions normal, fy Sol. Mur. Morph. 2)ij: Vin. Antimon. Zj>'Tinct.AurantiiZy,Aquo!-'}. Ft. haustus hora somni sumendus. Progress of the Case.—S?ptember 23.—Notwithstanding the draught, passed a restless night. Bowels not open since admission. Pulse 90, of moderate. strength. 1} Pulv. Rheei Co. 3j; Aq. Mentha? Pip. 3J; Ft. haustus statim sumejidus. September 2t.—Passed a more quiet night. Bowels open. From this time all tremor in the hands and cephalalgia left him. He was dismissed quite wel] September 27. Case XL.f—Delirium Tremens with Ocular Spectra—Recovery. History.—Elizabeth Banks, ait. 3-1, married—admitted April 7, 1851. She states that a fortnight ago she was suddenly seized with pain in the head, trembling and dizziness, so that she was obliged to he supported. She ascribes the attack to the receipt of unpleasant intelligence. There have been several of these attacks since, during some of which, her husband says, she has been very violent in her attempts to escape from imaginary enemies. She confesses to have been for some time addicted to spirit drinking, and states that up to the time of th;s illness she has enjoyed good health. Symptoms ox Admission.—She has a healthy hut somewhat restless appearance. She answers questions rationally and is quite calm, remembering everything that has occurred, except during the sudden attacks of trembling, etc. She has pain over the whole head ; there is, however, no heat of scalp or suffusion of the eyes. The pupil is natural, and the iris contracts readily. She sees various things before her, especially different kinds of animals running about, which are most numerous and vivid at night. She feels also at times as if persons were making attempts upon her life. For the last three nights she has had no sleep, in consequence of these ocular appearances. Her hands are very unsteady, and the fingers are constantly playing with the bed clothes. Pulse 90, of good strength. Tongue furred, and rather dry. Bowels habitually constipated and unrelieved for three days. Other functions normal. R Elaterii gr. ss. ; Pulv. Gamb. gr. ij ; Potass. Bitart. gr. x. i Ft. pulvis statim sumendus. ]J Sol. Mur. Morphias ~ j ; Aepuas Z vij ; Ft. haustui hora somni sumendus. * Reported by Mr. Scott Sanderson. Clinical Clerk. t Reported by Mr. W. H. Pearce, Clinical Clerk FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 411 Progress of the Case.—April 8.—Has slept tolerably during the night. Is not bo restless, and has seen few ocular spectra. The hands and her whole appearance calm. The purgative powder only occasioned one stool. From this time she gradually recovered, and was discharged quite well on the 24th. Case XLL*—Delirium Tremens with Convulsion and Coma—Recovery. History.—David Seaton, a't. 25, a chimney-sweep—admitted on the evening of September 10, 1849. His friends state that he has been greatly addicted to the use of spirits, and that during the last three months he has had several apoplectic attacks. He has, notwithstanding, continued to indulge in drink ; was this morning extremely violent, and during the afternoon became insensible. Symptoms on Admission.—On admission the countenance is bloated and flushed, and bis short stout figure gives evidence of great strength. He is now comatose, breathes stertorously; pulse 60, full and strong. The head to be shaved, 12 leeches to be applied, a drop of croton oil to be placed on the back of the tongue with sugar, so as to insure deglutition, and to be repeated in an hour if necessary. Progress of the Case.—September 11.—During the night he several times par- tially recovered his senses, and again relapsed. To-day is much better, and can answer questions in a confused way. Four drops of croton oil have been given, and operated once. To have one drachm of sol. of morphia at night. September I'l.—Violent delirium during the night, with insomnolence. It became necessary to employ the strait waistcoat. Pulse quick and feeble. Ice water to be applied to the head. One drachm of sol. of morphia to be repeated at night. To have a turpentine enema. Sep- tember 13 and 14.—No improvement. September 15. — Is somewhat sensible; pulse rapid and feeble. To discontinue the morphia. To have §j of whisky every two hours. StjUember 16.—Slept a little last night. To-day talks sensibly. Pulse 80, stronger. Bowels open by means of an injection. From this time he gradually recovered, and was dismissed well September 27. Case XLII.f—Coma and Death from Excessive Drinking—Opacity of Arachnoid— Sub-arachnoid Effusion—Fluid Blood. History.—James Dick, set. 48, a joiner—admitted on the evening of January 31, 18,j1, in a moribund condition. He has been habitually intemperate for many years. For the last week has been in a constant state of intoxication. This evening became suddenly ill, and lost his consciousness. Shortly afterwards he was conveyed to the Infirmary. Appearance on Admission.—On admission he presented all the appearance of a corpse. No breathing was perceptible ; no beating of the heart could be heard with the stethoscope. The countenance pale; head thrown back; mouth open and frothy ; eyes turned up, and pupils dilated. All efforts at re-animation were of no avail; he was dead. Seetio Cadaveris.—Thirtg-eight hours after death. Body well formed and strong, not emaciated. A little tumidity of depending parts. Head.—On removing the calvarium, the sub-arachnoid tissue was seen to be * Reported by Mr. Alexander Christison, Clinical Clerk. f Reported by Mr. Sanderson, Clinical Clerk. 412 DISEASES OF THE NERVOUS SYSTEM. infiltrated with fluid, raising the arachnoid to the level of the convolutions. The sinuses were distended with fluid blood. The cerebral arachnoid presented considerable opacity all over the hemisphere, in some places diffused, in others exhibiting minute points closely aggregated together. The ventricles contained a small amount of fluid and several simple cysts in the choroid plexuses. Cerebral arteries and other portions of the brain perfectly healthy. Chest.—Both pleura? contained several ounces of serum, and were slMitly adherent at the apices. Both lungs were healthy, with the exception of unusual engorgement, posteriorly and inferiorly. A cretaceous concretion, the size of a barley- corn, in apex of right lung. Bronchi contained a moderate quantity of frothy mucus, which was more abundant in trachea and larynx. Pericardium contained one drachm of serum. Heart healthy. The blood in the cavities and large vessels remark- ably fluid. Abdomen.—The liver pale in colour, and very soft, weighed 3 lbs. 14 oz. A few serous cysts in the kidney. Other abdominal organs healthy. Microscopic Examination.—The cells cf the liver were loaded with oil granules of large size. The tubercles of the kidney here and there also contained several fatty granules. Cerebral substance healthy. Commentary.—Various opinions as to the nature of delirium tremens nave been held by medical men, who have successively placed it among the neuroses, the phlegmasiae, and the pyrexiae. Until recently, it was held that whilst drinking was its predisposing cause, the sudden abstrac- tion of the accustomed stimulus brought on the attack. This theory lias been very successfully combated by Dr. Peddie,* who has shown that the disease is seldom observed in our prisons, notwithstanding the large number of confirmed drunkards admitted there and immediately placed upon low diet. The view of its pathology now prevalent is, that alcohol, a poison dangerous to life in large doses, is also cumulative taken habitu- ally in small quantities. Like many others, it is one which especially affects the nervous system, and more particularly the brain, as shown by Percy, Huss, and other writers. Hence those effects denominated intoxi- cation, delirium tremens, etc. Formerly the treatment used to consist of supplying the accustomed stimulus; but now, whilst theoretically it is clear that this is tantamount to adding coals to fire, it has been shown by experience that patients more rapidly recover under the use of anti- monials and nutrients. In the vast majority of cases of delirium tremens, the poison becomes eliminated from the system in a certain time; whether antimony, in half or quarter grain doses, assists this process is not known. Generally speaking, if a good sleep can be obtained, it is critical, and the patient at once recovers. Opium lias been largely given to obtaiu this result, but it is much to be doubted whether its supposed beneficial action is not dependent on coincidence with the muscular fatigue and exhaus- tion which, with the tendency to repose, accompanies the eliminatioa of the alcoholic poison. Practically it is of great importance that the win- dows and doors of the room in which patients with delirium tremens are, should be well closed, because, although there is no violence, a tendency to escape from imaginary enemies has led to some deplorable accidents. Personal restraint should be avoided. Nutrition also should * Monthly Journal of Med. Science. June, 1854. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 413 be carefully maintained, as death, when it occurs, is for the most part the result of exhaustion, with serous effusion into the subarachnoid cavity. Case XLIIL*—Poisoning by Opium—Recovery. History.—Helen M'Dermott or Cuthbertson, set. 33, but looking ten years older, resiling in the Cowgate as the wife of a cooper, was admitted at 3 p.m. May 25th, 1857. She has not unfrequently been drunk, and had a quarrel lately with her hus- band. On the preceding day she had gone out and purchase! two ounces of lau- danum, namely, one ounce at two different druggists' shops, and had swallowsd them (it is said) half an hour before admission. Symptoms on Admission.—On admission, contracted pupils, great drowsiness, relaxation of muscles, and tendency to cold; with lividity of face and extremities. The stomach-pump was employed to wash out the stomich; this was first done with warm wit \r, and twice subsequently with mustard and water. The first vomited matters smelled of laudanum. TI13 patient was stimulated to walk about until toward 4.30 p.m. By that time her limbs became so relaxed that she sank to the ground ; and she was so drowsy as to fall asleep unless pushed or pricked. The galvanic battery was then applied to the popliteal spaces, and to the hands, breast, and neck—(Kemp's battery being the instrument employed). Meanwhile, as patient was in bed, warmth was maintained by clothes and hot bottles. Under stimulus of the battery, patient was also induced to swallow some coffee. At 6.30 p.m. she was so easily rou.ed by galvanism—the skin warm, the pulse (small and weak before) becoming more perceptible and strong—that the stimulus was more rarely applied, merely to prevent the sleep into which from time to time she fell from becoming pro- found. At 8 p.m. a drachm of brandy, and half a drachm of Sp. Ammoa Aromat, were administered, to be repeated every hour. During the first three administrations of this stimulant vomiting occurred, the vomited matter consisting of the coffee that had previously been swallowed. At ten, eleven, and twelve, she was seen dozing slightly, but was easily roused. Next morning complained of sickness, and of not having been able to sleep during the night; was quite conscious and thankful for her recovery. Slept during the day, taking tea and beef-tea. On the 27th, having fully recovered, she was discharged. Commentary.—The symptoms of poisoning by opium in man are altogether cerebral, the danger to be apprehended being a fatal stupor. To prevent this, the practice sucses.iftilly carried out in the above case is the oue now generally considered b^st. The dose of the poison taken was large, but fortunately the time after its administration was not great. Case XLIV.f—Poisoning by Hemlock—Death. History.—On Monday, April 21st, 184."), about seven o'clock in the evening, a man, called Duncan Gow, was brought intj the Infirmary by two policemen. It was stated that he had been found lying in the street, apparently in a state of intoxication, or in a fit. On being taken into the waiting-room, he was found to be dead. I subsequently learnt from his wife that the man, forty-three years of age, a tailor * Reported by Dr. John Glen, Resident Physician. t Published by me in the Edin. Med. and Surg. Journ., No. 164. 1S4j. 414 DISEASES OF THE NERVOUS SYSTEM. by trade, was in such reduced circumstances that he had not eaten anything on Mondav, until he took the substance which caused his death. Two of his children, a boy and girl, aged respectivly ten and six years of age, found what they took for parsley growing on the bank under Sir Walter Scott's Monument (which was then building), and knowing that their father was very fond of this, as well as other green vegetables, they gathered some to take to him. On visiting the place with the boy four days afterwards, I found that the spot from whence the plants were gathered had been covered over with fresh rubbish. But on the uncovered part of the bank, eighty yards westward, the Conium maculatam could be seen growing in considerable quantity. The children returned home between three and four o'clock p.m. The father, who had fasted the whole day, greedily ate the vegetables, together with a piece of bread, and said more than once how good they wer\ The quantity consumed could not be ascertained, for he ate nearly all that was brought. On finishing his meal, he rose, saying he would endeavour to get some monev, in order to procure food for his children. At this time he was in perfect health. From his own house, at the head of the Canongate, Gow walked about half a mile to the house of one "Wright, in the West Port, with the view of selling him some small matter. Wright, on his entering the room, thought at first that he was intoxicated, be3ause he staggered in walking. On passing through the door also, which was narrow, he faltered in his gait, and afterwards sat down hastily. He stayed ten minutes, during which time he conversed readily, drove a hard bargain, and obtained fourpence for what he sold. He did not complain of pain or un- easiness, was not excited in manner or speech, and his face was pale and wan. On rising from his chair, he was observed by Wright's boy to fall back again, as if he had some difficulty in rising. On making a second effort he got up, and was seen by Wright's wife to stagger out of the house and down the steps. This was a little after four o'clock. On leaving Wright's house, he was next seen standing with his back against the corner of the street, by Andrew Mc'All, a meal-dealer in the Grassmarket, about 200 yards from Wright's house. Mc'All saw him leave the corner he was leaning against, and stagger to a lamp-post a few yards further on. Here he again paused for a few minutes, and then again went forward in the same vacillating manner, passed Mc'All's shop, and sat down at the opening of the common stair next to it. Mc'All's words are, " He could not walk rightly, and was staggering as a man in liquor." His mode of progression attracted a number of boys and girls, who laughed at him, believing him to be intoxicated. He was heard to speak to them, but what he said is not known. He was also seen by two women, who told a policeman to take him away. The policeman (James Mitchell, No. 161) told me that, on finding Gow sitting at the foot of the common stair, he thought he was drunk. He spoke to him, ana in reply Gow desired to be taken to his own house, at the top of the Canongate. He also said that he had completely lost his sight, and had not the perfect use of his limbs, but expressed his willingness to walk forwards, until the policeman could obtain the assistance of his comrade in the Cowgate. He was then raised up and supported by one arm, hut, after moving with great difficulty past four or five shops, his legs bent under him; and he fell upon his knees. Mitchell then gave him some water to drink, which he was incapable of swallowing, and left him to get a barrow. On his return he found him surrounded by women, who were pouring cold water on his head, and sprinkling his forehead. With the assistance of another policeman (James Hastie, No. Ill), he was then placed on the barrow. One of the women, Mrs. Anderson, on his being raised, saw that he made no attempt to walk, FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 415 but that, as he was pulled away by the policemen, his legs were dragged or trailed after him. The second policeman, Hastie, on first seeing him, told Mitchell that it was not drink, but a fit, that was the matter with him. He lifted up his eyelids and found the eyes dull. He seemed sensible, and endeavoured to say something, but could not articulate. He was now slowly conveyed to the main police-office in the High Street, where he arrived about six o'clock. Mitchell told the police lieutenant on duty that, from the manner in which the man was lying, and from the loss of power in the legs, he now thought he was not intoxicated. At this period it would seem that, although the limbs were completely paralysed, the intelligence was still perfect, for he told the turnkey his exact address in the Canongate, in reply to a question. Dr. Tait, surgeon to the police force, was now sent for, and saw him about a quarter past six. In reply to a note which I addressed to him on this subject, he says :— " The first impression produced ou my mind from his appearance was, that he was in a state of intoxication ; he was then lying on his back, with his head and shoulders elevated upon a board we have in the office for that purpose. He was sensible when I spoke to him, and tried to turn his face towards me, and slightly raised his eyelids, but appeared unable to speak. His power of motion appeared completely prostrated, for when I lifted his arm, and laid it down, it lay where it was put; and when his arm- pits were tickled, he seemed to manifest a little sensibility, but could make no exertion to rid himself of the annoyance. There were occasional movements of the left leg, but they appeared rather to be spasmodic than voluntary. Several efforts were made to vomit, but these were ineffectual. His pulse and breathing were per- fectly natural. He had spoken to the turnkey a few minutes before I arrived. Heat of skin natural. I visited him again, about ten minutes before seven o'clock, at which time all motion of the chest appeared to have ceased; the action of the heart was very feeble, and the countenance had a cadaveric expression; pupils fixed. He was then sent to the Infirmary." He was conveyed to the Infirmary by Hastie and another policeman, M'Pherson. After being put on the stretcher, Hastie saw him draw the legs gently upwards, as if to prevent their hanging over the iron at its extremity. This was the last movement he was seen to make. On being carried into the waiting-room of the Infirmary, he was visited by the house-clerk on duty, who found him pulseless, and declared him, as previously stated, to be dead. This was shortly after seven o'clock p.m. Sectio Cadaveris.—Sixty-three hours after death. The body was well-formed and muscular. There were no external marks of vio- lence. The back and depending portions were livid from sugiilation. Head.—An unusual quantity of fluid blood flowed from the scalp and longitu- dinal sinus when divided. There was slight serous effusion below the arachnoid membrane, and about two drachms of clear serum in the lateral ventricles. The substance of the brain was soft throughout; on section presented numerous bloody points, but was otherwise healthy. No fracture could be discovered in any part of the cranium. Ciiist.—There were slight adhesions between the pleurae on both sides superiorly. The apices of both lungs were strongly puckered. On the right side below the puckering were two cretaceous concretions, the size of peas, surrounded by chronic pneumonia and pigmentary deposit. On the left side only induration, with hard, black, gritty particles, existed below the puckering. The structure of the lungs otherwise was healthy, although they were throughout intensely engorged with dark- 416 DISEASES OF THE NERVOUS SYSTEM. red fluid blood. The heart was healthy in structure, but soft and flabby. The blood in the cavities was mostly fluid, presenting only here an-1 th?re a few s nail grumous clots. Abdomen.—The liver was healthy ; the spleen soft, readily breaking down under the fingers. The kidneys were of a browaish-rej colour throughout, owing to venous congestion, but healthy in structure. The stomach contained a pultaceous mass formed of some raw green vegetable resembling parsley. Its contents weighed eleven ounces, and had an acid and slight spirituous oiour. The mucous coat was much congested, especially at its cardiac extremity. Here there were numeroiH extravasations of dark-red blooi, below the epithelium, over a space about the siza of the hand. The intestines were healthy, here and there presenting patches of conges- tion in the mucous coat. The bladder was healthy ; its inner surface much con"ested from venous obstruction. The Blood throughout the body was of a dark colour and fluid, even in the heart and large vessels. Commentary.—From the absence of structural lesion, and the general fluidity of the blood, I was induced to suspect that the vegetable matter found in the stomach was of a poisonous nature. On examining this more minutely, it was seen to be composed chiefly of fragments of green leaves and leaf-stalks. Although much was reduced to a pulp, a con- siderable quantity of both had escaped the action of the teeth. The same afternoon I carried as perfect a specimen of the fragments as could be found to Dr. Christison, who pointed out that they could scarcely be anything else than the lacinio of the Conium maculatum, or common hem- lock. Next day I bruised some of the leaves in a mortar, with a solu- tion of potash, when the peculiar mousy odour of couia was evolved so strongly that Dr. Douglas Maclagan and others, although previously unacquainted with its nature, at once pronounced it to be hemlock. Dr, Chri.-tison also procured a recent specimen of the Conium maculatum from Salisbury Crag-s, the botanical characters ot which, on being com- pared with the fragments found in the stomach, were proved to be iden- tical. No doubt could exist, therefore, that the man died from having eaten hemlock. Few cases of poisoning with this plant have hitherto been published, and none have been minutely detailed. The efLcts imputed to it hi the notices given of prior cases are very contradictory. In some it is said to have caused death, like opium, by stupor and coma. In others, con- vulsions of the frantic kind are symptoms stated to have been present. But the effects observed by Dr. Christison iu the lower animals, in his experiments with extract of hemlock and its alkaloid conia, are totally different, viz , "palsy, first of the voluntary muscles, next of the chest. lastly of the diaphragm ; asphyxia, in short, from paralysis, without insensibility, and with slight occasional twitches only of the limbs. On this account, as well as from the ciicumstance that considerable interest is connected with the question, as to whether the hemlock of moderu times be the KoWiov, or state poison ot the Athenians, great pains were taken to obtain a perfect history of the case. In preparing it, I eudeayoured to insure accuracy, by carefully interrogating all who * Treatise on Poisons, p. 855, 1845. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 417 saw him from the time of his eating the hemlock until the period when he was brought into the Infirmary. Fortunately, he was seen by many persons, and their several accounts are, on the whole, consistent, and render the case tolerably perfect. The time of day mentioned by the different narrators shows that the poison, shortly after it was taken, produced want of power in the inferior extremities, without causing any pain. This is proved by what took place in Wright's house. His gait, which at that time was faltering, afterwards became vacillating; he staggered as one drunk—at length, his limbs refused to support him, and he fell. On being raised, his legs dragged after him ; and lastly, when the arms were lifted, they fell like inert masses, and remained immovable. Perfect paralysis of the inferior extremities was ascertained to exist one hour and a half after the poison was taken, and that of the arms half an hour later. As regards the existence of sensibility, we have only the evidence afforded by tickling the arm-pits, which, according to Dr. Tait, seemed to excite it a little. The amaurosis, however, is a proof that one nerve of sensibility, at all events, was paralysed. This seems to have happened when perfect paralysis of the inferior extremities was manifested. The exeito-motory functions seemed also paralysed. Tickling the arm-pits failed in producing movements. He lost the power of deglutition. Dr. Tait says his efforts to vomit were ineffectual. There were no con- vulsions, only slight occasional movements of the left leg; and lastly, both inferior extremities were slowly drawn upwards, when placed over the iron of the stretcher. Three hours after taking the poison, the re- spiratory movements had ceased; the pupils were fixed. At this time the heart's action was felt very feeble. These also ceased about ten minutes afterwards. The intelligence remained perfect up to a very late period. When his movements were vascillating, he was seen to direct his steps from one fixed point to another. After paralysis of the inferior extremities was fully developed he gave accurate directions how he was to be taken home, and described his principal symptoms. Two hours after taking the hem- lock, when brought into the police-office, although he could not swallow, he gave his address; and a quarter of an hour afterwards, when seen by Dr. Tait, though he could not speak, he appeared sensible, and tried to turn his face towards him. Death took place about three hours and a quarter after eating the poi- son, and was evidently occasioned by gradual asphyxia from paralysis of the muscles of respiration. The appearances observed in the mucous membrane of the stomach were most probably caused by the unusual fluidity of the blood, and this, in its turn, by the gradual asphyxia. The phenomena, therefore, observed in this case fully corroborate the physiological action of hemlock, as described by Dr. Christison, from his experiments on animals.* It evidently acts upon the spinal cord, pro- ducing directly opposite effects to those occasioned by strychnia. Para- lysis of the voluutary muscles, creeping from below upwards, is the cha- racteristic symptom, unaccompanied by pains or derangement of the intellectual faculties. Some authors have described delirium and frenzy, * Transactions of the Royal Society of Edinburgh, vol. xiii. 418 DISEASES OF THE NERVOUS SYSTEM. and others giddiness and convulsions, to have been occasioned. But such symptoms were not observed in the case of Gow, nor in the experiments on the lower animals by Dr. Christison. Indeed, the symptoms described by Plato in the case of Socrates, resemble as nearly as possible those which appeared in Gow. We are told that Socrates was directed by the executioner to walk about after swallowing the poison, until his limbs should grow heavy. • He did so, and theu lay down. On his feet and legs being squeezed, they were found insensible; they were also pointed out by the executioner to be cold and stiff. When paralysis had pro- ceeded upwards to the abdomen, Socrates made a request to Crito, prov- ing that his intellect was then unaffected. In a short time after lie be- came convulsed, his eyes were fixed, and he died. Whether stiffness was present in Gow's case was not ascertained. The nature of the convulsions, whether violent or otherwise, is not stated in the account by Plato, but slight spasms were observed in Gow. It will be observed, that when Socrates felt paralysis coming on he lay down. Hence the staggering and falling in the street, observed in Gow, did not take place. The description of the effects of the KgWoi> given by Nicander, however, would iu this case apply with great accuracy. He says (I quote from Dr. Christison's paper):—" This potion carries destruction to the powers of the mind, bringing shady darkness, and makes the eyes roll. But staggering on their footsteps and tripping on the streets, they creep on their hands. Mortal stifling seizes the upper part of the neck, and obstructs the narrow passage of the throat. The extremities grow cold, the strong vessels in the limbs contract, he ceases to draw in the thin air, like one fainting, aud the soul visits Pluto." If we abstract the poetical parts of the description, and remember the loss of sight, staggering and tripping in the street, the difficulty of deglutition, and place the loss of the intellectual faculties last, this account of Nicander agrees very well with what was observed in Gow. A difference of opinion exists as to whether the Conium maculatum of modern botanists be the Kwaov of the ancient Greeks. Into the botani- cal controversy I do not feel myself qualified to cuter. But if the symp- toms ascertained to have existed in the case I have related be compared with the accounts of Plato and Nicander, I cannot help thinking that it will be found to favour the opinion of those who believe in their identity, Case XLV.*—Poisoning with Lead—Painter's Colic—Lead Paralysis—Partial Recovery. History.—Peter Taylor, aet. 50, a brewer's servant, admitted September 26th, 1851. At his occupation in the brewery he frequently uses half a hundred weight of white lead at a time, for jointing pipes, and is in the habit of painting with the same material. Twelve months ago had a severe attack of Colica Pictonum, from which he slowly recovered under medical treatment, and then resumed his work, being always subject, however, to transient twinges of pain in the bowels, as well as in the joints, which latter he attributed to rheumatism. Six weeks ago he first expe- rienced debility and want of power in both hands, which has gradually increased since. His speech also has become slightly affected. * Reported by Mr. Scott Sanderson, Clinical Clerk. FUNCTIONAL DISORDERS OF THE NERVOUS SYSTEM. 419 Symptoms on Admission.—He has at present no pain anywhere, and only com- plains of want of power in both wrist joints. Both hands drop down from the arms, especially the right, which forms a right angle with the fore-arm. He can flex them voluntarily when elevated by another, but cannot raise them himself. When the metacarpal bones are supported by the hand of another, he can extend the last joints cf the fingers. He has perfect command of the shoulder and elbow joints. His grasp of an object is little impaired ; there is no wasting of the extensor muscles of the arm, though they feel soft; and sensibility in the paralysed parts is normal. Bowels still somewhat constipated, but were opened freely yesterday. Speaks with unusual slowness, which he thinks has increased lately. All the other functions are healthy. Progress of the Ca^e.—October 1st. Since admission the bowels have been kept open daily by small doses of the sulphate of magnesia. The arms have been put up in splints, keeping the wrist and hand extended straight out. Galvanism has been applied tvice daily for several minutes in the course of the extensors, and frictions over them are occasionally employed in the interval by means of flannel cloths. Oct. loth.—He was ordered R Potass. Hydriod. 3ss; Aqua Cinnam.; Aquas font, aa z nj- ^- Siimal I j ter indies. To-day the splint was removed from the left arm, which still droops, but is more readily extended. Oct. 30th.—Has complained of numbness in the right arm, attributed to the bandage. The splint was, therefore, to-day taken off, but the hand droops as much as ever, although he can move the metacarpal joints and fingers a little better. Nov. lOtk.—There is a decided improvement in the power of motion in both wrist joints, especially the left. R Extract. Nucis Vomicas, gr. vj ; Cunfect. Rosar. q. s. utfiant pil. vj. Sumat unam ter indies. Nov. 21st.—The pills appear to cause occasional pain in the stomach and bowels, but have occasioned no spasmodic twitches in the muscles generally. The joints have not improved since last report, but he insisted on going out. He was therefore dismissed with the advice to txercise the wrists in pumping water. Commentary.—Lead, as a poison, appears to act first on the peripheral nerves of the body and subsequently on the nervous centres, its chief manifestations being in the nerves of the intestiues. causing colic, and those of the arms producing paralysis. Why this substance should espe- cially affect these parts, is as much unknown, as why any otlier poison should exert special influence on particular portions of the nervous system. It has been recently pointed out that the metal exists in the tissues (in the form of carbonate), and sulphur consequently has been recommended internally and externally, with a view of causing its more rapid decomposition and elimination as a sulphuret. For this purpose the sulphurous mineral waters have been recommended. Common alum was given by Gendrin, and an acidulated drink made with sulphuric acid by others. Theoretically, this treatment has its difficulties; for supposing the lead to be converted into a sulphuret, how is this in its turn to be removed from the tissues, any more than the carbonate, with- out being first rendered soluble, and therefore poisonous ? On the other hand, some physicians in France who have tried the chemical treatment extensively, and among others Andral, Sandras, Piorry, and Grisolle, assort that it has no influence whatever, and that patients abandoned to themselves get well just as soon. In most cases the disease yields to time and slow elimination of the poison from the economy. Iodide of potassium also is said by Melsens to have decomposing and eliminating 420 DISEASES OF THE NERVOUS SYSTEM. powers. The latter was employed in the above case, but with no great success. Dr. Christison informs me, that <; long ago, when there was a white lead manufactory at Portobello, I used constantly to have in the Infir- mary a case or two of lead colic or lead palsy and neuralgia. Every case of colic I saw got speedily well by the alternate use of opium and aperients, and every case of paralysis by generous living, stomachic tonics, warm baths, and especially support and regulated exercise of the arms. One man I well remember, who was three times under my care in consequence of his always returning to the factory—had colic, palsy, and also neuralgia; but he got well in no long time by attention to the above means." M. Duchenne has pointed out the great advantage of applying gal- vanism not generally to the arm, but more especially to the muscles affected, which in these cases are most commonly the extensores digi- torum, and not the lumbricales nor interossei—hence why the first pha- langes only cannot be extended, whilst when these are supported, the second and third phalanges can be voluntarily raised without difficulty.* * For a case of Poisoning by Aconite see Aneurism, case of Henry Smith. SECTION Y. DISEASES OF THE DIGESTIVE SYSTEM. Under this head I include derangements of all those parts which are concerned in the primary digestion—that is, not only the different por- tions of the alimentary canal strictly so called, but the liver, pancreas, and peritoneum. The lesions of the spleen I shall consider in the section devoted to diseases of the blood, as there can be little doubt that this, with the mesenteric and other ductless glands, is not only concerned in the formation of blood, but is most commonly disordered during its un- healthy states. i DISEASES OF THE MOUTH, PHAKYNX, AND (ESOPHAGUS. Case XLVI.*—Tonsillitis. History.—Christina Slater, set. 22, a well-nourished servant girl—admitted May 6th, 1857. Three weeks ago, after exposure to cold, during the family washing, she experienced rigors, headache, and thirst, with a sense of dryness and swelling in the throat, especially on the right side ; could with difficulty swallow either solids or fluids, the latter occasionally regurgitating through the nostrils. These symptoms continued to increase till the night before admission, when she felt something give way in her throat. She spat up some matter, and thereafter felt general relief. Symptoms on Admission.—Pulse of moderate strength and frequency ; no cardiac hypertrophy nor abnormal murmurs. Respirations easy and not hurried. The voice is soft and natural, but articulation is indistinct and hissing. The jaws are so immo- vable as to be separable only to the extent of a quarter inch ; neither by the finger, therefore, nor by inspection, can the tonsils be examined; but there is tenderness on pressure, and considerable fulness in the right sub-parotidean and sub-maxillary regions. The tongue, as far as can be exposed, is covered centrally with a thick white creamy coat; the edges being of a bright red colour. Can now swallow fluids ; appe- * Reported by Mr. W. Guy, Clinical Clerk. 422 DISEASES OF THE DIGESTIVE SYSTEM. tite returning; bowels regular. The urine is non-albuminous, slightly hyperphosplmtir, with a mucous sediment. The other functions are normal. Pr'ogress of the Case.—Poultices were applied from time to time ; on Ma>/ llth she was able to open her mouth to the full extent. Both tonsils were then seen to be enlarged, the one on the right side being the size ©f a walnut. Anteriorly it pre- sented two or three ulcers, with dense yellow margins, about the size of split peas. Lunar caustic is to be applied to the ulcers, and she is to use an astringent gargle. The right tonsil still continuing enlarged, was scarified May 21sr, with marked relief and diminished slightly in size afterwards, under the action of tincture of iodine applied locally. The diminution being very slow, and patient otherwise in good health, she was sent, June 8th, to Mr. Syme, who excised one half of the gland. June 10th.— Was dismissed cured. Commentary. — Hypertrophy of the tonsils is so common in youDg children as scarcely to demand notice, unless suspicions of croup are entertained, when they should invariably be examined. I have frequently seen the fauces almost closed from the contact of enlarged tonsils, so as to cause croup-like breathing, and give rise to great alarm. Painting them with the tincture of iodine is the best remedy, and excision may be practised if much permanent inconvenience be occasioned. In the above case, all the three lesions which affect the tonsil were produced, namely, abscess, ulceration, and enlargement. The former bursts, the two latter were treated successfully by local applications of the solid nitrate of silver, and subsequently half the gland was excised. Case XL VII.*—Follicular Pharyngitis. History.—Peter M'Donald, set. 42, a hammerman in an engine foundry—admitted December 1st, 1856. Four months ago, being previously healthy, he was attacked with severe sore throat, difficulty of deglutition, and subsequently deafness in the left ear. He could not swallow sufficient food, became weak, and in a fortnight gave up work. He ascribes his attack to the sudden changes of temperature to which he was exposed. The dysphagia did not continue, but he still is weak, feels a dry- ness in the throat, with frequent desire to swallow his saliva, but great difficulty in so doing. Symptoms on Admission.—The voice is hoarse. On examination with a spatula, numerous red bodies, of a somewhat spherical shape, about the size of a large pin's head, are seen scattered over the mucous membrane of palate, fauces, and pharynx. The mucous membrane of the fauces aud pharynx is of a deep red colour; no ulcers visible; no cough; no expectoration. Digestive, respiratory, and other symptoms are normal. Progress of the Case.—Under local application to the pharynx with a sponge, of the nitrate of silver solution ( 3 ss of crystallized nitrate to ^j of distilled water) the sense of dryness and the difficulty of swallowing saliva were relieved; hb strength im- proved under good diet, and he was dismissed Dec. 29th. Commentary.—Pharyngitis is generally indicated by a high degree of redness with thickening of the mucous membrane ; and in certain specific forms of it, ulceration is likely to occur. For a kuowledge of follicular pha- * Reported by Mr. Alexander Turnbull, Clinical Clerk. DISEASES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. 423 ryngitis, and its importance in relation to diseases of the larynx, we are indebted to Dr. Horace Green of New York. There can be no doubt that many cases of chronic cough, generally denominated bronchitis, chronic laryngitis, or clergyman's sore throat, are dependent on this lesion, and as little that they are to be cured or greatly alleviated by appropriate applications made to the part. For an account of these, however, I must refer to what is said under the head of Laryngitis. Case XLVIIL*—Stricture of the (Esophagus from Epithelioma. History.—William Porter, a>t. 68, a brassfounder—admitted May 2d, 18.55. Two years ago a cab ran over his abdomen, across the epigastric region. He vomited a considerable quantity of blood for a few days after, and felt a pain in the back. From the pain then felt he soon recovered, and enjoyed ordinary health till four months before admission. He then for the first time experienced a sense of obstruction to the passage of food at the lower part of the gullet. The dysphagia had gradually increased, and has latterly been attended with pain. He has had no cough, and no hsemoptysis. Symptoms on Admission.—Skin dry, patient greatly emaciated; pulse, 68 per minute, weak and irregular; the tongue is covered with white fur. The fauces are natural; his food consists of bread or biscuit steeped in tea, milk, or water; he does not dare to swallow more solid food. That which he takes (in the presence of the clerk) is returned within two or three minutes. The patient believes that the food vomited has not entered the stomach; being asked to point to the spot where he feels it stop, he puts his finger on the sternum, at the level of the fifth costal cartilage. He feels pain when the food reaches this spot. Three weeks ago, for a fortnight, the pain was felt constantly, even when no food was being taken. The smaller portion of food, which passes the obstruction and enters the stomach, is retained with only slight uneasy sensations. There is no tumour to be detected in the epigastrium; the hepatic organ is normal in size; the abdominal walls are easily excited to rigidity. The bowels are costive; no blood has ever been passed by stool. Nervous and other systems normal. Nutrients to be taken in small quantities, in a liquid form, often repeated. Progress of the Case.—May 4th.—Tongue clean; pulse 68, stronger than on admission. Vomiting appears to be longer delayed. May 8th. —A probang passed readily along the oesophagus to-day; there is less uneasiness, but no greater power in swallowing. May 9th.—Complains of extreme weakness; asks for beer, which is granted. May 10th.—About 2 p.m., while taking a mouthful of beer, he suddenly fell back; the mouth open; the neck stiff; the pupils slightly contracted; the eyes turned upwards; incoherent muttering, without consciousness. His face was pale; he lay gasping for breath; there was a tracheal rale, and a fremitus was felt over the whole chest. An ineffectual attempt to vomit was followed by increased distress. He rapidly sank, and finally expired at ten minutes to three o'clock. Sectio Cadaveris.—Twenty-two hours after death. Chest.—There was a little recent soft yellowish lymph over the pleura, cohering the lower part of the left lung. The subjacent pulmonary tissue felt firm, was of a dark colour, and presented a granular section; it was also friable, and portions of it * Reported by Mr. G. M. Reid, Clinical Clerk. 424 DISEASES OF THE DIGESTIVE SYSTEM. sank in water. About two inches above the cardiac extremity of the oesophagus there was found an epithelial ulcer, nearly encircling the tube. On slitting it up, this ulcer was seen to be of a circular form, an inch and a half in diameter. Its surface was raised about one-eighth of an inch above the level of the mucous membrane, and pre- sented the appearance of a pultaceous mass, of a dirty white matter, resembling gruel. On scraping a portion of it, its base was seen to be composed of a whitish curdy matter easily breaking down when pressed between the fingers. The muscular coat below was incorporated with the ulcer, and much thickened, so as to produce a stricture of the tube, through which, however, the forefinger could be readily passed. Above the stricture the oesophagus was dilated into a pouch the size of an orange. All the other organs were healthy. Microscopic Examination.—The ulcer presented the usual structure of epithe- lioma, as described and figured p. 177. Case XLIX.*—Epitheliomatous Ulceration of the Oesophagus, communicating with the Lung.—Pneumonia terminating in Gangrene. History.—John Fraser, set. 55, a flesher—admitted September 19th, 18.">5. States that for five or six years previous to admission, his health had been excellent; and that he took his food without any sense of uneasiness, until three or four weeks ago. He then for the first time felt as if a ball of wind rose from his stomach to meet the food, and the food in its passage also gave him pain. The pain was gnawing and paroxys- mal. During the last eleven days he has brought up his food after abortive attempts to swallow it, and for four days he has lived on gruel, not being able to swallow any solids. Symptoms on Admission.—Tongue covered with white fur; fauces natural; ap- petite reported to be good ; thirst not great; food consists of gruel or bread and biscuit soaked in fluid. Says that the food in passing down into his stomach gives him great pain opposite a point half an inch above the lower end of ensiform cartilage; it is re- turned from the stomach in a few minutes, again causing him pain at the same spot. He adheres constantly to this declaration. Has no nausea; never vomited blood or dark-coloured matter. Abdomen is everywhere tympanitic. No tumour can be detected. Dulness of the liver normal. The bowels are very rarely opened. The pulse is 82, rather small aud weak. Respiratory and other symptoms are normal. To have nutritive diet in a fluid form, in small quantities often repeated. Progress of the Case.—From September 22d to October 2d. Has been taking thrice daily the following powders:— IJ Bismuthi Trisnitrat. 3 j. Pulv. Opii gr. ij. M. et divide inpulveres duodecem. The dysphagia continues unrelieved; the pain over ensiform cartilage is felt as formerly; and there has been also a sharp internal pain over the mammary regions. October 11th.—Describes a pain, as if his flesh were being torn away, passing from the lower dorsal vertebrse to the epigastrium. Ex- perienced temporary and partial relief from a blister applied to the epigastrium. Oct. 16th.— Ordered three ounces of sherry wine daily, and scruple doses of the hyposulphite of soda. N»\ 8th.—No diminution in the pain, dysphagia, or vomiting. Ordered one drop of Fleming's tincture of aconite thrice daily. Nov. 13th.—Vomiting, pain, and weakness continue. The aconite is discontinued and naphtha medicinalis m ten- drop doses, with compound tinct. of cardamoms, is substituted. On the 26th Nov. this mixture was also stopped, and ice was ordered. Dec. 7th.—Strong beef-tea w|ec- * Reported by Messrs. G. M. Reid and R. P. Ritchie, Clinical Clerks. DISEASES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. 425 tions per rectum are now ordered night and morning. Dec. 16th.—To-day vomited round masses looking like blood, and under microscope, blood corpuscles are recog- nised in them. Dec. 23d.—Blood corpuscles are found in the vomited matters to- dav. Pulse small, weak, 120 per minute. Dec. 28th.—Has had a hiccup for a few days past; pulse, 100, very feeble, sometimes intermitting. Thirst, which he did r.ot feel on admission, has lately been urgent. Jan. 4th.—Has slight pain over right hypochondrium; increased on pressure; fine moist, rales are audible over base of right lung posteriorly, with inspiration. The • urine is not coagulable, but is defi- cient in chlorides. Jan. 5th.—Deficiency of chlorides confirmed to-day. Dulness, increa.sed vocal resonance, and crepitation with inspiration, are detected over lower two-thirds of right lung posteriorly. Pulse weak, small, and scarcely perceptible. To have z U- of wine additional. Jan. 7th.—Same signs as in last report. Chlorides are more abundant. Weakness extreme. Jan. 8th.—Chlorides again decreased; the pulse is imperceptible ; the skin cold; in the evening vomited three ounces of bright red blood. He died almost immediately afterwards at 9 p.m. Sectio Cadaveris.—Sixty-two hours after death. The body was much emaciated. Throat.—The larynx, pharynx, and cervical portion of oesophagus were natural. Thorax.—The heart was natural. There were a few adhesions in the left pleura, but the lung was healthy. On the right side of the chest there were firm adhesions superiorly, and on the external lateral aspect. In attempting to remove the lung a fungating growth situated over the spinal column was broken into. This growth (connected with the oesophagus) was found to have involved a portion of the tissue of the right lung near its root. On removal of the oesophagus, it was seen that a portion of it, about three inches in length, commencing a little above the root of the lung, and going down to about an inch above the diaphragm, was converted into a fungating substance of soft cheesy consistence. A part of anterior wall of the oesophagus had been broken down and removed in taking out the right lung; the whole of the internal aspect of the affected portion of the oesophagus presented a fungating ulcerated surface. The calibre of the tube must in consequence have been much diminished. The lower end of the oesophagus, as well as the stomach and pylorus, were natural. In the stomach there were three ounces of a . brownish fluid resembling coffee grounds. On removing and cutting into the right lung, a cavity about the size of a walnut was found in its posterior part, a little above the root of the lung. This cavity was filled with a brown foetid fluid, and the surrounding pulmonary tissue was softened, hepatized, and broken down. Higher up were two smaller cavities, presenting similar characters, and surrounded by a layer of condensed pneumonic substance. The abdominal organs were natural. Microscopic Examination.—The fungating mass presented all the usual appear- ance of the epithelioma, containing embedded in the deeper friable portion of the growth, numerous masses of concentricallv arranged cells, such as are represented Fig. 212, p. 177. Commentary.—Epithelioma of the oesophagus was present in the two cases above recorded in different degrees. In Case XLVIII., the disease was limited to a patch about one and a-half inch in diameter, causing at that point a stricture of the tube, and immediately above it a considerable dilatation. ' From the impossibility of taking nourish- ment, extreme debility was induced, of which he died. In Case XLIX., the epithelioma was more extensive, surrounding the ceso- 426 DISEASES OF THE DIGESTIVE SYSTEM. phagus internally over a space three inches in depth, causing great thickening of the tube extending through all the coat, and even affect- ing the root of the right lung. The whole of the involved tissues were of the consistence of soft cheese, and here and there pulpy and even diffluent. It was evident that at length a communication was formed between the oesophagus and the lung, the occurrence of which was indicated by a pneumonia, with all the physical signs and general symptoms characteristic of that lesion. Case L.*— Carcinomcrtous Stricture of (Esophagus—Cancer of the Liver—Pulmonary Emphysema and Tubercle—Pneumonia. History.—John Currie, set. 53, a cooper—admitted 18th February, 1857. Was accustomed to drink heavily till within the last half year. Was well fed, strong, and healthy. Has had rheumatic fever thrice, the last time being twelve years ago, without any cardiac symptoms which he can remember. Had inflammation of the chest eighteen years ago. Had general dropsy nine months ago; entered the hospital and was discharged cured in three weeks. It is about six months ago since the patient first experienced pain in the epigastrium after taking food, with pyrosis and anorexia. For three months he continued in this, state, losing flesh and becoming weaker. Three months ago he began to vomit his food, at first in the evening, and subsequently during and after all his meals. He has vomited a little blood on three or four occasions. The character of the vomited matters is reported by him to have been as at present. Symptoms on Ai'mission.—The tongue is clean; there is no pain nor any diffi- culty in swallowing till the food reaches a point which he indicates as beneath the lower part of the sternum and the epigastrium. He has to rest after each mouthful till the food passes this point. If it passes, he has no further pain; but the greater part does not pass, and causes him great pain till it is dislodged by vomiting. The matter vomited consists of undigested food and clear mucus. Fluids and solids are equally troublesome for him to swallow. He has often hiccup while eating, and brings up flatus with great relief. He feels a constant " working" at his stomach. There is a fulness and resistance on palpation over epigastrium; but little tender- ness, and no tumour. The area of hepatic dulness vertically below the nipple mea- sures three inches, and laterally three and a-half. No splenic enlargement detected. No abnormality on examination of abdomen. Bowels are rather costive. The cardiac dulness at the level of the nipple is If inch. The apex is felt and distinctly seen beating in the sixth intercostal space, and it is seen also in the fifth intercostal space. These two pulsations alternate, or are not exactly synchronous. At the apex, over a limited area of about one square inch, a short, blowing murmur, not loud, is heard with the first sound, the second sound being healthy. At the base, both sounds are feeble, but free from abnormal ii urmur. The pulse is 76; irregular in rhythm. The respiratory system is normal, with the exception of a few snoring rales posteriorly. The urine is high-coloured, sp. gr. 1027; not albuminous. Progress of the Case.—I took charge of this case on the 1st of May, up to which time his symptoms had continued the same, notwithstanding careful regula- tion of his diet and the administration of morphia, tr. ferri muriatis, creosote, wine, and the application of a blister. The report on May V2th is:—No improvement; pain in the epigastrium still severe. He is weaker, much emaciated, and destitute * Reported by Messrs. J. T. Walker and W. H. Davies, Clinical Clerks. DISEASES OF THE MOUTH, PHARYNX, AND (ESOPHAGUS. 427 of appetite. May 30th.—Patient's diet now consists of arrow-root twice daily, beef- tea tea and bread, and § iv of sherry wine. He is unable to take any other nourish- ment. Since admission has been rarely out of bed. June 10th.—No change in symptoms. Continues same diet. July 1st.—For the past week the strength has gradually increased. He has been up out of bed for several days, and to-day he ven- tured into the green for a short time. Has some calf's foot jelly. July 19th.—Has relapsed; he now feels a constriction higher up in the oesophagus, opposite the lower part of his throat, and is unable to swallow even the little he has hitherto taken. Is greatly emaciated. Weakness extreme. July 27th.—Complains now wholly of the restriction superiorly. Beef-tea enemata with port wine have been ordered four times a day. July 30th.—Enemata discontinued from the resistance of the patient. He is able to swallow wine, which he relishes. Aug. 2d.—Since last report, in same state, but more feeble ; lies very much on his left side ; groans at intervals, his voice being comparatively strong ; but articulation is very indistinct. Has no cough nor apparent dyspnoea. Not taken any food for four days. Aug. 3d.—Died apparently from ex- haustion at 10.30 p.m. Sectio Cadaveris.—Thirty-nine hours after death. Bodv presented the last stage of emaciation, the abdominal wall at the umbilicus bein" so retracted as to be in contact with the vertebral column. Thorax.—The pericardium was universally adherent; the adhesions were old and firm. The lower half of each aortic valve was thickened and almost rigid; but on trial there is no incompetence. The heart weighed nine and a half ounces, the left ventricle being slightly thinner than usual. Both lungs were emphysematous anteriorly; and throughout the spongy portion, indurated nodules could be felt, vary- ing in size from a coffee bean to that of a hazel nut. On section, these presented aggregations of miliary tubercle of a yellow colour, for the most part of cheesy con- sistence, but here and there softened, forming purulent collections and small abscesses the size of a pea. Iu the left lung, the posterior third of the lower lobe presented all the characteristics of red, in one or two places passing into grey, hepatization. In the right lung, posteriorly, were two or three masses of red hepatization the size of a walnut. Digestive Organs.—The posterior third of the tongue presented a tuberculated appearance ; the mucous membrane on section was found thick, dense, almost carti- laginous, of greyish colour, and yielding on pressure a thin greyish-white juice. The mucous membrane of the pharynx was natural. In the oesophagus, an inch and a half above the bifurcation of the trachea, there existed a stricture admitting only the point of the little finger. When opened, the mucous membrane appeared natural, the sub-areolar tissue somewhat thickened. Lower down the cardiac orifice was felt excessively contracted, so that nothing larger than a crow's quill could be passed through it. The stricture extended along nearly two inches in length, being strictly limited to the oesophagus. The liver and stomach being removed together, a large mass of greyish-white colour and firm consistence was found projecting from the posterior surface of the liver, and firmly adherent to the cardiac portion of the stomach just where the oesophagus enters it. From the surface of the liver there projected other rounded masses of greyish-white colour, with central depressions, and so firm as to creak under the knife. On laying open the stricture the mucous membrane was found not ulcerated; but in the sub-mucous tissue was deposited hard, cancerous matter, not separable by any margin from the similar substance al- ready described as projecting from the liver. The stomach was contracted, but other- wise healthy. Abdomen.—The kidneys felt indurated; but when examined, appeared natural. 428 DISEASES OF THE DIGESTIVE SYSTEM. The spleen weighed only two ounce.s; its structure was natural. Other organs healthy. Microscopic Examination.—The cancerous masses in the liver and in the cesopha- gus contained numerous large cancer cells in all stages of development, embedded in a fibrous stroma. The tubercles in the lungs exhibited the usual appearance of miliary tubercle in various stages of disintegration, associated with pus. The red and grey hepatization was composed of an exudation in the air-cells and smaller bronchial vessels, which presented various stages of transformation into pus, being most recent in the former, and most perfect in the latter. Many of the pus cells contained fatty granules, and exhibited different degrees of disintegration. Commentary.—This man literally died of starvation, from the utter impossibility of introducing nourishment into the system. The cancer- ous mass originally formed in the liver, had surrounded and compressed the oesophagus and cardiac orifice of the stomach, so as to reduce the canal to the size of a crow's quill, a stricture that extended through a curved line, nearly two inches long. A second stricture, but not to so great an extent, existed above this in the oesophagus. It is not surpris- ing, therefore, that at last no kind of nourishment could pass these ob- structions, the absence of contractile power in the diseased oesophagus above being insufficient to propel even fluids through the stricture below. What appears to me, however, the most remarkable feature in this case, is the occurrence in the same individual of recent cancer, tubercle, aud pneumonia. Whether th:; tubercle or the cancer was first formed, it becomes exceedingly difficult to determine, but certainly the nodulated groups of miliary tubercle in the lungs were in every respect similar in general appearance and structure to what is observable in phthisical cases. It is true there was no especial accumulation of tubercle at the apex of either lung, neither was there cough, nor any symptoms of pulmonary disease shown throughout the whole course of his disease. But as a decided form of exudation its presence was undoubted. The pneumonia must have come on during the latter days of his life, when he was in a state of extreme weakness. But it occasioned no active symptoms, and though conjoined with great emphysema anteriorly in both lungs, produced no dyspnoea. The pathological fact, however, of the occurrence of these three forms of exudation in one individual is, though undoubtedly rare, well calculated to demonstrate the fallacy of all exclusive views as to their production in individuals of a peculiar diathesis. Temporary dysphagia occasionally occurs in cases of hysteria or of spinal irritation, but when permanent it is always the result of organic disease of the pharynx or oesophagus. In the great majority of cases it is owing to some growth, cancerous, epitheliomatous, aneurismal, or of some other form, which, by attacking the parts themselves, induces stricture of its walls, or by compressing them from without, causes a mechanical ob- struction to the tube. In a few rare cases it has depended on pouch-like, or spindle-form dilatations, which, by becoming impacted with food, have caused the impediment. In all these cases the cure will depend on the means at our disposal of removing the obstructing cause, such as exter- nal tumours compressing the part; but if it depend on disease of the pharynx or oesophagus, the treatment must be for the most part pallia- FUNCTIONAL DISORDERS OF THE STOMACH. 429 live. There may be a simple stricture, which may require surgical in- terference by bougies or catheters, but more generally as observed by the physician, it is the result of cancer or epithelioma, as in the cases nar- rated. Under such circumstances, the treatment must be directed to support nutrition by unirritating food, given in small quantities and in a form that the patient can most easily swallow. Remedies of various kinds to alleviate or check the vomiting may be tried, but are seldom of permanent benefit. Very rarely, an effort at healing is set up by nature, which for a time causes diminution in the more distressing symptoms, of which Case XIII. is a remarkable example. FUNCTIONAL DISORDERS OF THE STOMACH. Case LI.*—Dyspepsia. History.—James Scott, set. 51—admitted 27th September, 1852. He states that about two months previous to admission, he experienced severe shooting pains dart- ing from the left scapula to the epigastrium and left hypochondrium. For many years back he has been much addicted to intemperate habits, and latterly his appetite for food has been considerably impaired. Symitoms on Admission.—On admission, the tongue is furred, and cracked in the centre; he has almost constantly a sour taste in the mouth, worse in the morn- ing after taking food ; frequent acid eructations; bad appetite, and considerable thirst. About a quarter of an hour after meals he experiences a feeling of heat and pain in the epigastrium, with acid eructations and flatulence; the latter also troubles him during the night, when the stomach is empty. These symptoms continue generally for about an hour and ahalf, when they gradually abate, and soon after disappear entirely. He then again takes food, and the symptoms return in about a quarter of an hour afterwards, as already noticed. He does not think that one kind of food disagrees with him more than another. He has often much nausea and loathing of food, but no vomiting. There is some tenderness on pressure at a point about the centre of the epigastrium, where he states there is always more or less pain, gene- rally of a dull, heavy character, but sometimes occurring in sharp twinges, shooting to the left scapula, and somewhat increased on pressure. There is no unusual hard- ness or tumour to be felt; and there is no dulness on percussion. There is no ten- derness or enlargement of the liver; urine normal. He is of a very desponding dis- position, and does not sleep well at night. Other functions normal. R Potassm bicarbonatis, 3 ij; Tina. Gentian Co. § i; Infus. Gentian Co. § v. M. ft. mist. Half a wine-glassful to be taken thrice a-day. Progress of the Case.—December 31st.—Still complains of flatulence anc1 distension of the abdomen; considerable pain in the epigastrium, increased on pres- sure. Applicenlur hirudines quatuor epigastrio et postea foveatur. Jan. 3d.— Appetite improved; still acid eructations, with sour taste in the mouth; pain in the epigastrium relieved after the application of the leeches and warm fomentations. He is very desponding about his complaints, which he much exaggerates. Jan. 10th.—The sour taste and flatulence diminished; pain and uneasiness in the stomach much relieved; no tenderness on pressure; appetite much improved; no sickness * Reported by Mr. James D. Maclaren, Clinical Clerk. 430 DISEASES OF THE DIGESTIVE SYSTEM. or vomiting; bowels regular; stools natural. Dismissed in order to return to his work. The diet ordered has been of a gentle, unstimulating, but nutritious kind. Commentary.—In this case derangement of digestion depended on intemperate habits, and was accompanied by excess of acidity in the stomach. The treatment was directed to counteract this condition by alkalies, vegetable bitters, and a regulated diet, which, to a certain extent, succeeded. But all such cases require exercise, regular habits, and moral control, without which medical treatment is unavailing. Case LII. *—Dyspepsia— Oxaluria. History.—John Millar, set. 28, a typefounder—admitted December 2fith, 18">2. He states that he had always enjoyed good health, with the exception of occasional palpitation of the heart, until about eight months ago. Vertigo came on suddenly when he was at work, but disappeared in a few minutes. Since then he has had many attacks of the same kind; and of late, these have been accompanied with pain and palpitation of the heart, and tinnitus aurium. Some years ago he was much addicted to drink, but for the last four years he has been more temperate. Symptoms on Admission.—On admission, the heart was found to be healthy, and the pulse natural. The tongue was dry in the centre, moist and white at the edges, with numerous transverse fissures. He had a disagreeable taste in his mouth in the morning, and no appetite for food; had never vomited, nor experienced pain in the stomach; bowels constipated. There was an anxious, haggard expression of countenance, and an evident tendency to exaggerate his symptoms; he complained of vertigo, tinnitus aurium, and muscae volitantes. The urine, after standing some time, exhibited a slight deposit, in which numerous large crystals of oxalate of lime were visible on microscopic examination; sp. gr. 1028; otherwise normal. The other functions were normal. R Acid nit. ; Acid muriat. aii 3 iss ; Tinct. gent. co. Z i: Infus. gent. co. ? v. M. A table-spoonful to be taken three times a-day. Progress of the Case.—January 8th.—Since last report, the oxalates have dis- appeared, the appetite has improved, the cardiac and cerebral symptoms are removed, and he is to-day dismissed cured. Commentary.—Dr. Golding Bird was the first to point out that oxaluria, associated with dyspepsia, was a very common disorder, and that its treatment by nitro-muriatic acid was the most successful one. The oxalic acid is probably derived from urea or uric acid, and its pre- sence in the urine is often associated cr alternates with these compounds. No doubt the tonic treatment practised in the above case is the best mode of relief, but here also a regulated diet, with exercise and meutal occupation, are necessary to render the benefit permanent. Case LIIL-j-—Dyspepsia—Hypochondriasis—Oxaluria. History.—Thomas Pollock, set. 24, hawker—admitted 25th December, 1852. He says that, three years and a half ago, when stooping down in a field during a dark night to evacuate his bowels, he felt a sharp, hard body, like the stump of a shrub, * Reported by Mr. James D. Maclaren, Clinical Clerk. \ Reported by Mr. William Calder, Clinical Clerk. FUNCTIONAL DISORDERS OF THE STOMACH. 431 penetrate his anus, causing acute pain, which continued for a fortnight, and has occa- sionally returned ever since. No blood passed at the time, but he has been under the care of various medical practitioners, and undergone numerous kinds of treatment. He has never had diarrhoea ; but is addicted to masturbation. He has consulted the numerous works advertised in the papers on manly vigour, etc., but has derived no benefit from them. Symptoms on Admission.—On admission, tongue moist, but furred, cracked, and fissured in the centre ; says he experiences a feeling of load after taking food, with occasional nausea. He has no vomiting, but an acid and sometimes disagreeable taste iu the mouth; frequent flatulence and constipation, for which he is in the habit of taking aperient medicine. On placing the hand on the epigastrium, he says that there is soreness beneath the xiphoid cartilage, increased on pressure. Has occasional involuntary emissions of semen. The urine contains a slight sediment on standing, which is crowded with large and small crystals of oxalate of lime ; sp; gr. 1020 ; otherwise normal. Sleepless at night; anxious and desponding about his complaints, which he attributes to the accident formerly mentioned, although it produced no local effects at the time, nor any structural change since. Says that he has frequent vertigo, tinnitus aurium, muscse volitantes, and cephalalgia. The other functions are normal. IJ Acidnitrici; Acid, muriat. aa 3 i; Tinct. gin',, co. § i; Infus. gent. co. 3 v- M. A table-spoonful three times a-day. Progress of the Case.—January 3d.—ne has continued to take the acid mix- ture, but does not admit that he is in any way better. On the 2d, the oxalates dis- appeared from the urine, and were replaced by a copious deposit of amorphous lithates. thnitta'.ur mist. acid. R Liquoris potassa, 3 ij ,' Tine, cardamom, co. ^i; Infus. quaxsiw, 3 vii. M. Ten table-spoonfuls night and morning. Jan. 4th.—As he still continues to complain of pain in the sacral region, which he attributes to the accident, a blister, three inches by four, teas ordered to be applied there. Jan. 10th.—Since the application of the blister the pain in the sacrum has disappeared. He expresses him- self as being much better, and was now dismissed. Commentary.—In this case the presence of oxalates in the urine was associated with the same class of symptoms as in the former one, but the tendency of the patient to exaggerate his complaints was more marked. He had also a firm belief in their being caused by an acci- dent, which possibly never happened, and even if it had, could not have occasioned his symptoms. The acid and tonic mixture removed the oxalates, but lithates took their place in the urine, which, in their turn, were got rid of by alkalies. Still, the fixed idea as to the cause of the disease continued, and he seemed no better. A blister was now applied to the sacrum, and he readily adopted the idea that his local complaints disappeared with the pain of the blister, and became cheerful and well. No case could better illustrate the effects of mental depression on the digestive organs than this. For a period of three years he had been the subject of delusion and genital irritations, heightened by the study of tlmsc publications, which, to the disgrace of the newspaper press, are daily advertised to the people as the only means of restoring vigour to the constitution. At length, satisfied with their inefficiency, he entered the Infirmary; the error of his practices was kindly pointed out to him, nutritious1 diet, regular habits, and tonic treatment were obviously bene- ficial ; and fortunately his hypochondriasis yielded to the simple expe- dient of substituting real for supposed pain, and leadiug him to imagine that the one had cured the other. 432 DISEASES OF THE DIGESTIVE SYSTEM. General Pathology and Treatment of Dyspepsia. By dyspepsia (from oW7re7TTGj. I digest with difficulty) is generally understood, all those functional derangements of the stomach which are primary in their origin, that is, not dependent upon, or symptomatic of inflammation or other disease in the economy. Such a disordered con- dition is exceedingly common, and often constitutes the despair of the physician, arising, as it frequently does, from causes which are obscure or, if discovered, are beyond his control. This will become apparent by considering, in the first place, those circumstances which require to be united to secure a healthy digestion. These are—1st, A proper quantity and quality of the ingesta. 2d, Sufficient mastication and insalivation. 3d, Active contractility in the muscular coat of the sto- mach. 4th, Proper quantity and quality of the gastric, biliary, and pancreatic fluids. 5th, A consecutive and harmonious action of the in- testinal canal. Dyspepsia, or indigestion, may be produced by any cause which occasions derangement of one or more of these conditions; and hence it is why so many different circumstances may produce some- what similar symptoms, and why so many different remedies have been found effectual in various cases. Notwithstanding that you will fre- quently meet with instances which baffle all preconceived rules, there can be no doubt that a careful attention to the essential physiological conditions above enumerated will, in the great majority of cases, conduct you to a successful rational treatment. Thus— 1. Of all the causes of dyspepsia, excesses in eating and drinking are the most common. An over-distended stomach, or too rich a meal, not unfrequently induces a feeling of weight or fulness in the epigas- trium, nausea and eructation of acid, bilious, or gaseous matters, with a loaded tongue, headache, and other general symptoms. This is acute dyspepsia, or the embarras gastrique of the French. Occasionally, there is more or less vomiting of bilious matter, when the attack is vulgarly called a bilious seizure. If called to see such a case, immediately on its occurrence, and before the ingesta have left the stomach, as determined by the sense of load at the epigastrium, and by percussion, an emetic should be given; and if vomiting be present, it should be assisted by warm diluents. As soon as the stomach is quieted, or, if you have been called in at a late period, when the ingesta have passed into the intes- tines, a purgative should be administered, consisting of four grains of calomel, with four of compound extract of colocynth, followed in a few hours by a draught of salts and senna. If necessary also an enema may be given. The purging, with a day or two's confinement to farinaceous food, will generally get rid of such an attack; but their frequent repeti- tion leads to the chronic form of dyspepsia, in which careful regulation of the diet, with exercise, must constitute the chief treatment. Hence the advantage of what is called " change of air," and much of the benefit which is derived from watering places. Chronic dyspepsia, however, is far more commonly caused by excess of spirituous and vinous drinks, than by eating, and, in such cases, abandonment of the evil habit is a sine qua, non in the treatment. Tea drinkers are very liable to the dis- FUNCTIONAL DISORDERS OF THE STOMACH. 433 ea8e, and its frequency among female servants is probably owing to over indulgence in this beverage. 2. Tt may frequently be noticed, that those who have acquired the habit of eating rapidly are more or less dyspeptic. I knew a journey- man printer, who had been much tormented w th indigestion, but who was cured by changing his residence. The reason of this cure was for some time a mystery; on again changing his house the disease returned; Btill no apparent cause could be discovered. I ascertained, at length, that it depended not on the locality per se, but on its distance from the printing house. When far off he ate his dinner with his family rapidly, having only just time enough to walk home and back within the hour. When he lived near, the time otherwise spent in walking was occupied in eating, or in cheerful converse with his wife and family. Sinca I made this observation, it has often occurred to me that the distance of the resideuce of artisans from their place of employment may be the occasional cause of the dyspeptic symptoms they frequently suffer from. The exact object of the saliva in the process of digestion, whether it be to convert the farinaceous compounds of the food into glucose, or by its viscidity to mix up air with the portions swallowed, is uot positively determined; but its necessity for digestion is shown by what happens in cases where the under lip has been lost by accident or disease, or where salivary fistulae have formed; in such cases dyspepsia is generally pre- sent, aud in some the disordered digestion has been cured by operations that, by restoring the parts to their normal condition, prevent the escape of saliva. Again, persons habituated to the dirty habit of spitting, are for the most part dyspeptic. In all cases where dyspepsia can be traced to this source, the treatment becomes obvious. 3. The contractile movements of the stomach which, by kneading the ingesta, and keeping them in constant motion, secure their intimate admixture with the gastric juice, and the rapid transference to the duo- denum of such portions of it as are transformed into chyme, are evidently of great importance to the proper performance of digestion. The experi- ments of physiologists have shown that digestion goes on in gastric juice taken out of the stomach much slower than in the stomach, and that section of the pneumogastric nerves, by arresting the contractile move- ments, permits only the circumference of the mass in contact with the secreting surface to be digested. These facts at once explain the well- known influence of mental emotions upon the stomach. Contentment and hope are as favourable, as dissatisfaction and despondency are inju- rious, to good digestion. Nothing is more common than dyspepsia among literary men who overtask their mental faculties; among young persous of very excitable minds ; and among individuals of a melancholy temperament, hypochondriacs, etc., etc. It is in such cases that cheerful society, active and appropriate occupations, change of scene, removal from mercantile or literary employments, variety in trains of thought, and so on, are beneficial. Hence also many of the good effects of travel, visits to watering places, etc, etc. 4. Our knowledge with regard to the offices performed by the gastric , 434 DISEASES OF THE DIGESTIVE SYSTEM. biliary, and pancreatic juices in digestion has of late years been much advanced. Thus, the gastric juice operates more especially on the albu- minous, and the pancreatic juice on the fatty compounds of the food. The function of the bile is more obscure; it probably acts as a means of precipitating or separating some of the excretory matters from chyme and so facilitates assimilation of the nutritive portions. Digestion may be deranged by all those causes which increase or diminish too much the secretion of these three fluids. Thus excess of acidity in the stomach is one of the most common causes of dyspepsia, and is associated with that form of it which accompanies scrofulous and tubercular diseases. It may be in such excess as to neutralise the alkaline action of the pan- creatic juice, and render it incapable of emulsionising fatty matters. In such cases the alkalies, with bitter tonics and the direct introduction of animal oils in excess, are indicated. On the other hand, the gastric juice may be diminished in quantity, as frequently occurs in persons who sud- denly overtask the powers of the stomach at feasts, or in old persons with feeble digestion. The sense of load after eating is generally indi- cative of slow digestion from this cause. In acute cases, a stimulant rouses the stomach to increased action, and hence the moderate use of drains and generous wines after dinner is occasionally useful. In old persons the sense of load and feebleness is best removed by giving up tea, and drinking at night a little weak brandy and water. Iu chronic cases, acids are indicated, especially muriatic acid. The Tr. Ferri co. of the pharmacopoeia is a useful preparation in chlorotic females. The pre- pared gastric juice of the calf has been lately recommended as a remedy in these cases; and is undoubtedly in some cases of much service. We have no distinct means, as far as I am aware, of rousing the pancreas into action, and yet many cases are on record in which fatty matters have passed undigested through the alimentary canal in conse- quence of obstruction to the pancreatic duct. In such cases, and in all those in whicii fatty matters are difficult to digest, alkalies, especially the socio bicarb, with vegetable tonics, are indicated. When the bile is deficient, constipation and dyspepsia are usual results, and are to be relieved by gentle mercurial purgatives, with extract of taraxacum, and by remedies, such as rhubarb, and especially the compound rhubarb pill, which by acting on the duodenum, also favour the flow of bile into the upper part of the alimentery canal. Dr. Clay of Manchester has recommended in such cases the administration of ox-gall, a remedy which, although not extensively given, is evidently rational, and calculated by its purgative action to be highly serviceable. Excess of bile, on the other hand, ought to be treated by drastic purga- tives, diuretics, and diaphoretics, according to circumstances, to cause excess of excretion. Exercise should also be insisted on to call the lungs into action, and thus relieve the liver in its office of separating hydro-carbon. 5. A derangement of the consecutive and harmonious action of the alimentary canal is another frequent cause of dyspepsia, for it is as necessary that those portions of the food which are not assimilable should be removed out of the economy, as that the nutritive materials should be absorbed. Hence, whatever impedes the contractility of the FUNCTIONAL DISORDERS OF THE STOMACH. 435 intestinal canal, whatever alters the structure of its mucous membrane or whatever mechanically obstructs its calibre, induces dyspeptic symp- toms. The removal of these various conditions, whether by stimulating the nervous centres by appropriate diet, or by purgatives and astringents, need not be more particularly dwelt upon here. I would only observe that the constant use of laxatives, however they may temporarily relieve, cannot cure, and that in all chronic cases a proper action of the bowels must be obtained as much as possible by means of dietetic and hygienic regulations. In many cases of dyspepsia, two or more of these classes of causes may be combined so as to render the indications for treatment complex and apparently contradictory. In other cases, one or more causes may- exist, although from the indications present their nature cannot be deter- mined ; in such cases, our treatment must always be more or less vath.—Complains now of diarrhoea. Habeat Enema c. Tr. Opii min. xl. Dec. 26th.—Diarrhoea continues; early this morning took the following draught:—R Sol. Mur. Morph. m. xv; Tinct. Catechu, Z ss; Syrup. Limonum, Zj-M- No change in the febrile symptoms, dyspnoea, or the pulmonary physical signs; has no pain; pulse 124, weak; skin clammy; states that she felt very cold during the night. Dec. 27th.—Diarrhoea continues. To have an enema of starch and opium. Dec. 28th.—Diarrhoea has ceased; dyspneea and febrile symptoms increased; no pain; face* pale and anxious. Dec. 29th.—Evidently weaker; breathing laboured; pulse 140, weak and thready; countenance of a yellow waxy tinge. There was profuse sweating this morning; other symptoms unchanged. Dec. 30th.—She ORGANIC DISEASES OF THE STOMACH. 443 continued to sink, and died this morning at 3 a.m., death having been preceded by repeated vomiting of dirty brownish-green matter. Seetio Cadaveris.—Thirty-three hours after death. Head not examined. Thorax.—Two drachms of clear serum in the pericardium ; heart healthy; the right lung healthy, but its lower lobe and the diaphragm on that side were con- siderably pushed upwards by an abscess containing nearly a pint of pus, situated above the liver and below the diaphragm; the left lung also healthy, with the exception of a gangernous ulcer, the size of a shilling, in the centre of the lower lobe inferiorly, where it rested on the diaphragm. This ulcer presented a brownish, broken up, sloughing surface, and was surrounded by red hepatization, occupying the pulmonary substance to about the extent of a hen's egg. Abdomkx.—On reflecting the integuments, a considerable quantity of pus escaped from the abscess above alluded to on the right side, immediately below the diaphragm and above the liver. This abscess contained nearly a pint of pus, and was situated in a circumscribed pouch formed by the diaphragm above, the liver below, the peritoneum anteriorly and externally, and false lymph of considerable tenacity internally. Lymph also glued these parts and the small curvature of the stomach together. On reflecting the integuments, the anterior wall of the abscess was removed, and so the pus escaped. The stomach, transverse colon, and coils of intestine in the superior third of the abdomen, were all glued together by bands and flakes of lymph, which, though of tolerable tenacity, were gelatinous in con- sistence, and could be readily torn through by the fingers. In the left hypochondrium there was a layer of this lymph half an inch in thickness, softened, purulent, and gangrenous in the centre, situated above the spleen, and communicating, by a slonghened opening, with the ulcer and hepatization iu the lung formerly described. On cutting open the stomach, in the line of its large curvature, there flowed out a dirty, greenish-brown, grumous liquid, containing coagulated masses, apparently of milk, tinged of a dark-red colour by port wine. In the posterior part of the stomach, about its centre, was observed an oval ulcer, the size of a five-shilling piece, with smooth, thickened edges, and surrounded by puckered folds of the mucous mem- brane, which was otherwise healthy. The ulcer was adherent to the pancreas behind, which constituted its base; but the adhesions round its superior half were composed of the same gelatinous lymph as has been previously alluded to. On dis- secting the ulcer from its attachments, it was seen to have completely perforated the coats of the stomach, although the opening behind, viewed on the serous surface, was not above the size of a shilling. On removing the intestines from the pelvis, flakes of purulent lymph were observed between several of the coiis and on the serous membrane of the pelvic cavity. All the other organs healthy. Commentary.—All the facts connected with this case were obtained with great accuracy, and left us in little doubt, from the commencement, that we had to treat a chronic ulcer of the stomach, which, on the morning of the day she was admitted, had perforated the organ, and induced the violent pain she complained of. The peritonitis, which may have been induced by the perforation alone, was undoubtedly augmented by the brandy and water administered to rally her from the state of collapse into which she was thrown by the immediate effects of the accident. On entering the house also about five hours 444 DISEASES OF THE DIGESTIVE SYSTEM. after she became ill, a stimulating and anodyne draught was adminis- tered by the clerk to rouse her from her depressed condition. As this was followed by no increase of local pain, but by improvement of the vital powers, we may fairly conclude that the practice, though highly questionable, was not productive of injury. Nothing, indeed, is more natural on the sudden occurrence of violent pain in the epigastric region with a feeling of syncope, than to have recourse to stimulants, for perforations of the stomach are rare occurrences, and it is not every one who at such a moment, even among the profession, has sufficient coolness and discrimination to detect the real nature of the disease. Hence, why so frequently these perforations are fatal, not so much from their own natural results as from the stimulating reme- dies administered, which pass through the aperture into the abdominal cavity. Indeed, had not brandy and water been given in this instance, there is every reason to suppose that the perforation might not have occasioned much mischief, for it occurred early in the morning, before breakfast, and long after her evening meal, and consequently when the organ w7as empty; and, besides, it is to be observed that such perforations have a great tendency to become re-closed by the rapid formation of fibrous lymph round their edges. In this case, however, extensive peritonitis was already occasioned when I first saw her, and the subsequent treatment was directed—1st, To prevent the intro- duction of further matters into the stomach; 2d, To rally her from collapse by stimulating and nutritive enemata; aDd 3d, To conduct the inflammation to a favourable termination by local fomentations and opiates largely administered in the form of enemata, and subsequently in pills by the mouth. This treatment was attended with apparent success, so that on the fifth day nourishment was cautiously adminis- tered by the mouth, and also with tolerable benefit. On the eighth day, however, rigors appeared, followed by fever, whicii was attributed to a pleurisy on the right side, where increased thoracic dulness was discovered inferiorly, with loud friction and cegophony. Circumscribed pneumonia evidently also existed on the left side, as indicated by crepitation. This formidable complication was attempted to be relieved by gentle salines, and topical bleeding by leeches. It was soon appa- rent, however, from the appearance of dyspnoea and other symptoms, that there was now little hope of recovery, and notwithstanding tho liberal administration of stimulants, the patient sank on the twenty- third day. Dissection exhibited exactly what was anticipated with regard to the stomach and peritoneum, but showed that the signs of the presumed pleurisy were occasioned by an abscess, which, by pushing up the diaphragm and occupying the lower portion of the thoracic space on the right side, had given rise to all the physical signs of pleuritis. On the left side there was limited pneumonia, as was expected, the lung communicating by a gangrenous ulcer iu the diaphragm, with the lymph exuded above and around the spleen. The edges ol the ulcer of the stomach were firmly united to the pancreas, so that the patient undoubtedly died from the extensive peritonitis. ORGANIC DISORDERS OF THE STOMACH. 445 Case LIX.*—Chronic Ulceration in the Stomach—Perforation occasioned by a Fall (?)—Recovery. History.—Barbara Ferguson, servant, aged 51—admitted January 6, 1853. States that she enjoyed excellent health till about eight years ago, when she first bean to complain of her stomach—suffering from pain of a cutting or grinding char- acter, always worse after taking food. Her appetite has all along continued good, but she often experienced considerable thirst; has never had nausea or vomitin°\ She believes that she has been getting worse lately, but has had no distinct exacer- bation. On January the 4th instant, stepping upon a chair, her foot slipped, and Bhe fell with the stomach across the back of it. She was immediately seized with intense pain in the epigastrium, rapidly extending over the whole abdomen. She did not faint, and was still able to speak, but had to be carried to bed. The accident ■ occurred about 9 r. m., three hours after she had taken any food, which had consisted of somo coffee, with a few mouthfuls only of bread. She was immediately ordered a one-grain pill of opium, which was to be repeated every four hours. On the next day, as the acute pain still continued, four leeches were applied to the epigastrium, followed by warm fomentations. She has had nothing by the mouth except the opium pills, up to the date of admission. Symptoms on Admission.—On admission she appears very weak and nervous, and in a state of partial collapse ; the countenance is saliow; pulse 100; weak; heart sounds normal; no headache, but a feeling of vertigo on attempting to rise or change her position ; tongue clean, moist; no nausea or vomiting; appetite gone; considerable thirst; pain in epigastrium, which, with the whole abdomen, is exces- sively tender on pressure; she has had great dysuria and pain on micturition ever since the accident. All the other functions are normal; ordered to have no food by the mouth, but an enema of beef-tea, with the yolk of an egg, immediately, to be followed in two hours by an opiate enema, with 40 minims of tincture of opium ; to be kept quiet, and not to get out of bed. Progress of the Case.—January 7th.—Was almost free from pain yesterday evening, and felt altogether much better, having slept a good deal during the after- noon. The beef-tea enema, with yolk of egg, has been repeated at intervals of four hours, and she had another opiate at 4 a.m., after which she slept well. To-day she feels easier; pain, or rather tenderness, in epigastrium somewhat diminished; and con- siderable pressure may now be exerted without causing uneasiness. She has still thiri-t; tongue dry ; very little inclination for food ; pulse 100, soft. Jan. 8th.—Was considerably easier last night, and expressed a desire for some food ; the pulse was of better strength, 90. To-day is still improving ; complains of no pain when lying quiet, but still pain on pressure in epigastrium; she expresses fear and pain when other parts are touched, but not to the same extent; pulse 95, of moderate strength. 6he has had th- beef-tea, etc., enemata as before, with an opiate enema every 10 or 12 hours—to have beef tea and milk by the mouth, in tablespooufuls at a time, repeated every five minutes if the patient desires it. Jan. 9th.—Felt rather uneasy after taking the beef-tea and milk, which occasioned a sense of " working " in the stomach. An opiate enema was ordered in about two hours, aud in the evening she expressed herself as free from uneasiness, and rather refreshed from the beef-tea. To-day she feels not quite so well, and her general appearance is more depressed. She has con- tinued the beef-tea, but has had an egg and beef-tea enema twice a day in addition; pulse 88, of good strength; bowels have not been open since admission ; to have a worm water enema, with an ounce of castor oil, followed, if necessary, by an opiate one. * Reported by Mr. F. S. B. F. de Chaumont, Clinical Clerk. 44G DISEASES OF THE DIGESTIVE SYSTEM. Jan. 10th.—Felt rather weak and exhausted after bowels were opened; the opiate enema was administered two hours afterwards, and she has felt better since; had some tea, with a little toast, by the mouth this morning; takes beef-tea for dinner but cannot eat rice or any farinaceous food; no bad effects have followed taking food by the mouth; pulse 88, of good strength; little pain complained of, and she can now sustain considerable pressure on epigastrium without suffering. Slept less last night than before; urine clear, sp. gr. 1020, contains phosphates. Omit the enemata. Jan. 24th.—Since the last report she has been doing well, and gradually o-aiuing strength. Dismissed. Commentary.—Many cases are on record of evident perforations of the stomach, which have been cured by judicious treatment, and the one just narrated seems to me to be an instructive example of this favourable termination of the lesion. The symptoms at the commencement were very like those of Case LVIII., but were induced by a blow on the epigastrium instead of coming on after straining at stool. Violent pain, tenderness on pressure, and collapse were the immediate effects. For- tunately, I saw the patient immediately after the accident, and took care not to administer brandy, or stimulating draughts. A grain of opium in the form of pill was administered every four hours, quietude enjoined, and complete abstinence insisted on. Next day the local pain continued, and on the following morning I sent her to the Infirmary. Nourishment was administered by enemata, and on the fourth day was cautiously given by the mouth, and no untoward symptom ensued. From this time she slowly recovery. Of course we have no positive evidence that there was a perforation in this case. For eight years, however, she had been sub- ject to severe attacks.of pain in the stomach, increased on taking food, but there had been no vomiting. It is possible, that the blow may have been sufficiently strong in itself to induce the pain and subsequent symptoms, although, from all the inquiries I could make, it did not ap- pear to be so. Oue of her fellow-servants indeed maintained that it must have been trifling. Wherever anatomical evidence fails, there must be more or less uncertainty hanging over the history of those cases which recover; but, taking all the circumstances into consideration, I cannot help thinking that had brandy and water been given in this as in the former instance, there is every chance that here also fatal peritonitis would have been occasioned. From what I have observed of post-mortem examinations in the Royal Infirmary of Edinburgh, it does not appear to me that chronic ulcer of the stomach is a common disease here. Without having made any exact calculation, nothing positive can be said, but I do not think that the disease exists in more than 3 per cent, of those examined; whereas in the Copenhagen and some German hospitals, it is said to vary from G to 13 per cent.* This frequency of it has been thought to be dependent on habits of intemperance and particular diet; and, if so, we might have anticipated that the habit of drinking raw whiskey would have rendered it more common in Scotland than it appears to be. Its morbid anatomy was first admirably described and figured by Cruveilhier.t The ulcer is "'■ See an able Memoir on the subject by Dr. Brinton. London, 1857. t Anat. Pathologique. Liv's x. et xx. ORGANIC DISEASES OF THE STOMACH. 447 chronic, of circular or oval form, generally varying in size from a fourpenny to that of a crown piece, having an abrupt, slightly thickened margin as if it had been punched out, and an indurated smooth base. It may be shallow or deep, and frequently perforates all the coats of the stomach, in which case the external is larger than the internal aperture. It has a great tendency to contract adhesions by its external borders to neigh- bouring viscera, more especially the pancreas, immediately over which, in the posterior wall of the stomach, the ulcer is most commonly situated. "When it, occurs in the anterior wall, it less readily contracts adhesions, and therefore is more likely to induce perforation. The ulcer may heal at any period of its progress, leaving a cicatrix, which varies in appearance according to the amount of tissue previously lost. Sometimes there is a mere scar, at others a stellate puckering. Occasionally there is a dense thickening, with rigid folds, causing contractions in one place, and pouches in another, and this contraction may even be circular, causing a stricture of the organ. Mineral deposits are now and then found adherent to the cicatrix. The three leading symptoms of chronic ulcer of the stomach are pain, increased on pressure, vomiting after taking food, and haematemesis. Of these, the last is the most important in a diagnostic point of view, because its presence renders certain, what would otherwise only be conjectural. The disease, however, may exist without as yet having so injured a blood- vessel as to occasion hemorrhage. Hence the symptoms of chronic dyspepsia, with vomiting after food and fixed pain, if long continued, should invariably give rise to the suspicion of an ulcer, and lead to an appropriate treatment. The remedies I have found most efficacious, in simple chronic ulcer of the stomach, are quietude, careful regulation of the diet, bismuth and opium pills or powders, and sometimes warmth, at others cold applied locally. It may frequently be observed that the mere coming into a hospital and remaining quietly in bed has a favourable effect in modify- ing the distressing symptoms. I have also remarked that those patients who are always getting up and walking about suffer much more than those who remain in bed, especially at the commencement of the disease. Hence, repose in an easy position should be enjoined. The diet should consist of farinaceous pulpy substances, occasionally mixed with beef-tea, or milk, given in small quantities, frequently repeated. If the stomach will not tolerate the food warm, it should be given cold. When, despite this treatment, vomiting continues, it is best to suspend all nourishment for a day or two, and give nutritive enemeta. As the patient gets better, the amount of solid food should be very cautiourdy increased. Thirst is a distressing symptom in such cases, and is best allayed by allowing ice to dissolve in the mouth slowly, or sipping, at intervals, milk and lime- water, mingled in equal proportions. The pain is alleviated best by bis- muth and opium, combined in the form of pill or powder. Sometimes local warmth, but more frequently pounded ice, mixed with salt in a bladder, applied over the part, will give relief. Two or three leeches, or a counter-irritant, may succeed when everything else fails, and should be tried. Quietude and suspending all ingesta for a time, I believe to be the best remedies for hemorrhage, and where exhaustion from want of food exists, nutrient enemeta, with wine, must be administered. When a 443 DISEASES OF THE DIGESTIVE SYSTEM. perforation occurs, I have already pointed out the great importance of avoiding the giving of stimuli by the mouth (Cases LVIII. MX.), and have stated the practice which should be perseveringly followed, namely, the administering of opium in the form of pill, quietude, avoidance of purgatives, and nourishing at first by enemeta, and then cautiously by unirritatiug substances, given in small quantities by the mouth. Case LX.*—Cancer of Stomach, Pancreas, and Mesenteric Glands—Cystic Atrophy of Right Kidney. Historv.—Thomas Gaffney, oet. 50, married, a labourer—admitted November 24, 185U. States that up to twelve months ago he was in good health, but since that time he has been troubled with pyrosis and occasional vomiting, with diminished appetite. Three months ago, feeling much pain in the epigastrium, he noticed that he had a tumour in that region. It was very sore, continued to increase in siz3, and became more and more painful. At present he is very emaciated, and suffers severe pain in whatever position he places himself. Symptoms on Admission.—Teeth and gums dry; tongue dry, with a longitudinal fissure down the centre. Thirst only occasionally felt. Has no appetite. Has no difficulty in swallowing; but complains of constant pain in the epigastrium. It is not distinctly increased on taking food. The food cannot be retained on his stomach, coming up in mouthfuls from an hour to an hour and a half af.er ingestion. The vomited matter is described as resembling ia colour coffee grounds. On examining the epigastrium in the mesial line, two inches bslow the ensiform cartilage, and three inche-s above the umbilicus, there is felt a small tumour about the siz3 of a walnut of an irregular margin superiorly. The convex surface looks outwards and down- wards. It may be moved upwards and to the right, but not downwards or to the left. In left half of epigastrium, over a space of two square inches, there is dalness on percussion, and on palpation, a deep seated strongly-resisting tumour is felt, with a distinct margin to the right side. It appears to pass upwards under the superior part of left hypochondrium, where percussion gives forth a comparatively dull resonance. Percussion elsewhere over abdomen, tympanitic. 'Over the hepatic organ and over the tumour there is great tenderness on percussion. Occasionally the tumour is felt more distinctly, and is then rough and nodulated. The chest is barrel- shaped. Percussion is unusually resonant. Respiration is feeble anteriorly and is harsh posteriorly, the expiratory murmur being prolonged. No dyspnoea. Sputum scanty. Prascordial region unusually resonant on percussion. Transverse dulness, two and a quarter inches. Cardiac sounds healthy, but feeble. Apex of heart cannot be felt. Pulse small and weak, 68 per minute. Sleeps but little. Urine normal. Th'. d'ut it to be carefully regulated; small quantities of nutritive food and wine to be taken at frequent intervals. A mixture of snow and salt put into a bladder is to be applied over the tumour. To take two of the following pills every night:—R. Morph. Acet. gr. iss ; Conserv. Rosar. gr. xij. Fiat massa in pilulas sex dividenda. Progress of the Case.—December 1st.—The local application of cold has afforded him considerable relief, so much so that he does not like to be without it. He is unable to take a sufficient amount of aliment, and is gradually getting weaker. Dec. 4th.—The pills at night continue to lull his pain. His diet consists of strong beef-tea, three half pints per diem ; bread and milk; milk and rice pudding; with six ounces of wine. Patient always vomiti after eating, however little, and continues to sink. Dec. 5th.—Died at 10.30 a.m. * Reported by Mr. William Guy, Clinical Clerk. ORGANIC DISEASES OF THE STOMACH. 449 Sectio Cadaveris.—Twenty-eight hours after death. Abdomen.—Permission could only be obtained to examine the abdomen. On opening the stomach it was seen to contain a considerable quantity of yellow pulta- ceous substance, being half digested food tinged with bile. The pyloric orifice was compressed by a mass of cancerous exudation, seated in the smalhr curvature, and projecting into the stomach; this mass was about 5 inches in diameter, rounded at the margins; nodulated internally with two projecting portions, so situated as to act as valves in front of the pyloric orifice, through which a finger could be easily passed behind them. The thickness of this mass was in one place two inches, gradually diminishing towards the margins to half an inch. The tissue was friable, easily breaking down under the finger, but not yielding cancerous juice. The pancreas was generally healthy, but an inch of the duodenal extremity was involved in the can- cerous tumour. The cardiac orifice, which was half an inch from the maro-in of the canrerous tumour formerly described, was quite healthy, as was the rest of the stomach not involved. Several mesenteric glands in the neighbourhood of the pancreas were enlarged, nodulated, and filled with cancerous exudation. Anteriorly the stomach was strongly adherent to a portion of the liver, which below, over the tumour de- scribed, felt hard and nodulated. In the position of the right kidney was a cyst, the size of the human head, containing yellow serum. Internally it presented a smooth serous surface, here and there interrupted by circles and fragments of circles leading into pouches. Some of these openings were perfectly circular, with smooth abrupt margins, and were about the size of a fourpenny piece ; others were about the size of a half crown or five shilling piece. Here and there, on the surface of the serous mem- brane, were corrugated indurated lines with black calcareous plates upon them the result of cicatrizations. Externally the pouch was smooth, covered with shreds of cellular tissue; at its inferior portion was an induration, measuring two inches in length, and being cut into four, was found to consist of cortical renal substance about one-sixth of an inch in thickness. Immediately behind this renal substance was a cyst, communicating with one of the pouches previously described, about the size of half a crown. No trace of tubercular structure could anywhere be seen. A portion of lung was also removed about two inches square; it was spoix'v throughout, but presented gelatinous-looking masses, about one-sixth of an inch in diameter, scattered through its substance. They could be squeezed and compressed between the fingers, but had a certain amount of firmness. On section they pre- sented a smooth surface of grey colour. Microscopic Examination. —The cancerous mass in the stomach presented cancer cells in all stages of formation, with granule cells here and there embedded in masses of molecular substance. The mesenteric and epigastric glands on being cut presented a fragile surface, from which a glutinous substance could readily be scraped. This contained, when examined microscopically, large cancer cells multiplying endogenously ; here and there granule cells, with a tew fibres and numerous molecules. The rounded nia^es in the lung were of the same structure. Case LXI.»—Colloid Cancer, with Perforating Ulcer of Stomach—Peritonitis. HisTouy.—James Douglas, ajt. 55, a porter—admitted Sept. 15, 1854. About fourteen weeks ago, being previously quite healthy, he began to experience a burning pain m the epigastrium, more severe after taking food, and also a sensation as of a ball rising in his throat. For three weeks he continued to work, but gradually grew worse : * Reported by Mr. Robert Rhind, Clinical Clerk. 29 450 DISEASES OF THE DIGESTIVE SYSTEM. eight weeks ago, he vomited, for two days, dark coloured matter like coffee grounds Has since been troubled with pyrosis, has lost his appetite, and become weaker and thinner. Symptoms on Admission.—Is greatly emaciated. Tongue moist, slightly furred • appetite bad; no dysphagia ; feels pain in the epigastric region constantly of a burning character, more severe after taking food; no vomiting, but has eructations of a thin watery fluid. The epigastrium feels hard on palpation; in the region of the umbilicus there is a distinct tumour stretching across the abdomen; movable under the integu- ment; not very tender to the touch. Bowels habitually costive. Has no cough. Pulse 56, weak. Urine not coagulable, of sp. gr. 1019. Other systems normal. Progress of the Case.—September 15th to October 9th.—The patient has been treated by the administration of antacids, bismuth and magnesia; by the injection of nutritive enemata; by occasional opiates at night; by suitable aperients, and careful regulation of the diet. He has gained no strength; is indeed much weaker; at present he has a burning sensation along the whole course of the oesophagus. Oct. \3th.— This morning experienced acute pain in the abdomen, which is now distended, and generally painful on pressure and deep inspiration. Pulse 84, pretty fircn. Eight leeches were applied to the abdomen, followed by warm fomentations, and opium in grain doses Oct. 14th.—Has had much vomiting, this morning, of dark coffee- coloured fluid; pulse is feeble, and extremities are cold. While eating his dinner to- day, he fell forward, and immediately expired. Sectio Cadaveris.—Twenty-two hours after death. Body very much emaciated. Thorax.—Thoracic organs normal. Abdomen.—On opening the abdomen a large quantity of dark coloured fluid was found, iu which were suspended flakes of white lymph. To the inner surface of the peritoneum pieces of soft recent lymph were attached, but it was quite free of small round nodules. The stomach and the intestines were loosely glued to each other, and to the parietal peritoneum, by soft lymph. The fingers alone were sufficient to sepa- rate the bowels. On examining attentively the anterior surface of the stomach two or three small perforations could be detected. The largest was nearly an inch long on the outer surface of the stomach, and corresponded to an ulceration about 2 k inches in extent internally. The pyloric half of the stomach was transformed into a large, intensely hard, glue-like mass, and was abo,ut the size of a cocoa-nut, or two closed fists. On opening the stomach, the mucous membrane, towards the cardiac extremity, was perfectly sound, but at the pyloric end it had undergone ulceration at several points, especially near the smaller curvature and the pylorus. The pyloric orifice was of sufficient diameter to admit easily the little finger. The pancreas, liver, and surrounding organs were healthy. The texture of the growth was as hard as cartilage, and creaked under the knife, but on section presented the usual characters of colloid cancer. (See p. 136.) The mucous mem brane of the intestines was perfectly healthy. The other abdominal organswere normal. Microscopic Examination.—The colloid cancer presented the characteristic struc- ture described and figured p. 136. Commentary.—An indurated swelling in the epigastric region, pain and vomiting after food, are the usual symptoms of cancer in the stomach; and they were all present in the two cases just noticed. There was, besides, haeinatemesis, indicating ulceration in Case LX., aud. in ORGANIC DISEASES OF THE STOMACH. 451 addition, sudden pain, with peritonitis, in Case LXI.. pointino- out the occurrence of perforation. The vomiting did not appear so soon in the last as in the first case, and it will be noticed that in it the pyloric con- striction was not great. On the other hand, ulceration was more exten- sive with pyrosis, and led to perforation with fatal peritonitis. The atrophy of the right kidney, which was converted into a fibrous sac, had not apparently in Gaffney produced any complaiut whatever during life. All the symptoms observed in this man, with the exception of hamiate- mesis, may be produced by a tumour outside the stomach, as well as by disease of the stomach itself, pressing on the organ, and nothing is more difficult (if indeed it be ever possible) than to diagnose the former condition from the latter, which, however, occurs rarely. (See p. 474.) In many cases the lesion hitherto described as scirrhus of the pylorus or stomach seems to be a simple hypertrophy of their muscular and fibrous coats, which may or may not be associated with cancer of the neighbouring glands. A simple stricture of the pylorus may in this way produce more or less thickening of the stomach, in consequence of the chronic vomiting excited by it; or by increasing the muscular power Fig. 397. Fig. 393. Fig. 399. necessary to overcome the obstruction, just as happens in the intestines, bladder, and other hollow vi-ccra, when the parts below them are stric- Kig. 397. Appearance of the gastric glands in recent catarrh of the stomach. Their external outline is irregular, and they arc filled with enlarged secreting cells.— ( WUson Fnx.) rig. 398. Commencing cystic formation iu a gastric follicle, which is constricted m some places (6, c,) and swollen at others, a, Shows the thickening of the limitarv membrane, and d, slight fatty degeneration of the epithelium.—( Wilson Fox.) ^ tig. 31)9. A cyst in the pyloric portion of the stomach, composed of a fibrous envelope, and contents wholly eomposed'of cylindrical epithelium. At a, the limitary membrane of the gastric glands commences to be thickened ; aud at b, their contents nave undergone the fatty degeneration, so common in chronic catarrh.—( Wilson Fox.) 340 diam. 452 DISEASES OF THE DIGESTIVE SYSTEM. tured. (See Figs. 140 to 148, p. 153.) I have recorded four cases of this kind in my work on " Cancerous and Cancroid Growths." (Edin- burgh, 1848, p. 40, et seq.) In all such cases it is observable, that the same emaciation and cachectic appearances are present as in instances of undoubted cancer—a circumstance which is attributable to the impeded nutrition of the body rather than to a supposed cancerous diathesis. On this account I have long ceased to place any confidence in the so-called " cachectic appearance " as diagnostic of cancer, attributing it either to imperfect nutrition, or to wearing down of the body from excessive pain. This cachexia is often present in many other forms of morbid growth, and frequently absent when the disease has been proved to be cancerous by a microscopic examination. Of all forms of cancerons disease, that of the stomach is perhaps the most distressing; it cuts off the supply of nourishment which should enter the system, aud induces (in addition to the wearing-down pain) loss of sleep, loss of blood, and more or less constant vomiting. Our duty in such cases is to relieve and support the system; and to this end opiates in large doses, nutritive enemata, careful regulation of the diet, and ice allowed to dissolve in the mouth, are the best remedies. A local frigorific mixture, as recommended by Dr. J. Arnott, aud the application of a few leeches to the epigastrium, are also occasionally beneficial. In Case LX. the cold application was of marked service. The histological changes which occur in various disorders of the Fig. 400. Fig. 401. Fig. 402. stomach were first investigated by Dr. Handfield Jones, who has described and figured the appearances presented by the follicles, their contained cells, and other minute structures under a variety of circum- Fig. 400. The gastric glands in chronic catarrh of the stomach, the breaking down of the upper portion being probably due to post mortem change, a, A mass of pig- ment ; 6, b, free fat drops; c, thickened limitary membrane; d, d, d, complete fatty degeneration of the epithelium.—(Wilson Fox.) 240 diam. Fig. 401. Chronic catarrh of the stomach, with hypertrophy of the fibrous tissue between the glands. The section has been treated with acetic acid, which exhibits more distinctly the nuclei of the nervous tissue, and gives a cloudy appearance to the follicular epithelium.—(Wilson Fox) Fig 402. Fatty degeneration affecting the upper layer of the follicular epithelium, c, and fibrous connective tissue, a, a, producing erosion of the surface; b, tatty degeneration of the epithelium and sub-mucous fibrous tissue.—( Wilson For.) ° l 340 diam. DISEASES OF THE LIVER. 453 stances.'* There may be hypertrophy and atrophy of the solitary glands; atrophy of the glandular tubes; fatty degeneration; wasting and black discoloration of their epithelial contents ; fibroid thickening, etc. His researches have been for the most part confirmed by Dr. F. Schliipfert and Dr. Wilson Fox.J The latter observer has added some important facts connected with chronic catarrh of the stomach, thicken- ing of the limitary membrane, and cystic degeneration of the glands. Dr. Haber^hon,^ as well as Dr. Fox, points out the rapid changes which take place in the glands of the stomach after death, and the great cau- tion therefore required in forming conclusions, when examination of the minute structure is too long delayed. As a guide to the clinical student and practitioner, I give the more important morbid changes which have been observed in the gastric glands, from the excellent representations of Dr. Fox. Dr. Jones has the great merit of having laid the founda- tion for a clinical history of these lesions, although the observatious are as yet far too few to enable us to connect them with diagnosis and treatment at the bed-side. From what is known on this subject, I must refer to the works I have named, hoping that before long these researches may be extended by clinical histologists. aud ultimately lead to a more exact knowledge of the dyspeptic and organic diseases of this important organ. DISEASES OF THE LIVER. Notwithstanding the obscurity which still rests upon the functions of the liver, the progress of histological pathology has tended to make us better acquainted with the minute changes which occur in many diseases of the organ. The nature of fatty enlargement, of cirrhosis, and of the disintegration of cell-texture following obstruction of the bile-ducts, is now understood, but much research is still necessary. A careful com- parison of the structural changes observed in the liver after death, with the clinical history and symptoms observed during life, is what is greatly desired to advance our knowledge of hepatic diseases. This knowledge, however, can scarcely be hoped for until medical men, and especially such as^ practice in the East, become efficient histologists. It is the application of therapeutics to these diseases, however, and a correct appreciation of the class of remedies called cholagogues, which, in the present state of medicine, requires most to be determined. Such an in- vestigation necessitates physiological, histological, and chemical know- ledge, added to good powers of clinical observation. But of all the sub- jects of research now open to the young investigator, I know of none in which patience and exactitude, based on a scientific rather than an empirical system of inquiry, is likely to yield more useful results. * Pathological and Clinical Observations respecting; Morbid conditions of the Stomach. London, 1845. (t Virchow's Archiv. H. 7, p. 158. 1854. tMedico-Chir. Trans, of London. Vol. XLI. 1858. fe On Diseases of the Alimentary Canal, p. 52. 8vo, bound. 1857. 454 DISEASES OF THE DIGESTIVE SYSTEM. CaseLXIL*—Acute Congestion of the Liver—Hepatitis?—Recover)/. History.—Thomas Russell, aet. 38, labourer at a gas work—admitted January 26th, 1S55. States that about three weeks a^o, after indulging freely in the use of ardent spirits, he experienced general shivering and pain in the right Iiypochondrium with tinnitus and a sense of faintness. Subsequently he felt pain in the right shoulder, and at length he was obliged to leave off work. His comrades, who went home with him, told him that he looked yellow in the face. At night he became very hot. He returned to his work on the following day, and continued at his employment for a fortnight, but was very weak, and suffered much from the pain in his side, and in the shoulder. Since then he has been confined to bed, under medical care, applying coun- ter-irritants locally, and taking pills which have made his mouth sore. Symptoms on Admission.—On admission, he complains of pain in the right hypo- chondrium and right shoulder, in the former of which situations it is permanent and increased by pressure, while in the latter it is only occasional. The tongue is covered with a moist, white fur; the breath has a mercurial fcetor; the gums are painful; appetite good. Bowels open. Pressure and percussion over the liver painful. Ver- tical hepatic dulness 4£ inches. Pulse 72, soft. Sleeps little in consequence of the pain. Urine normal; no jaundice. Other functions well performed. To apply sir leeches to the right hypochondrium, and the parts afterwards to be fomented. To take two compound rhubarb pills every night. Progress of the Case.— February 1st.—The leeches and fomentations have in no way benefited the pain, which to-day is as severe as on admission. Bowels still open. Stools darker than formerly, but healthy. Feb. 3d.—Since last report all pain has left him; he declares himself to be well, and at his own request was dis- charged. Case LXIlI.f—Acute Jaundice—Albuminuria—Recovery. History.—Walter Halliday, set. 51, tailor—-admitted July 6th, 1857. States that he has generally been a temperate man, although, occasionally, he has taken spirits moderately. On the first of this month, when working below an open window, he was suddenly seized with rigors, followed by great thirst, heat of skin, and headache. Next morning he went to work as usual, but was obliged to desist in the middle of the day, and go home. The rigors have returned occasionally ever since, and he has experienced obscure pain in the lumbar region. The skin became jaundiced on the second day of his illness, and the yellow tint has been increasing in intensity since. He has occasionally vomited. Symptoms on Admission.—The tongue is moist aud covered with a whitish fur. No difficulty in taking food nor paiu afterwards. Xo tenderness or pain in abdomen ; but feels a pain in the lumbar region, which sometimes darts round the right side towards the umbilicus. Appetite impaired. Bowels costive. Vertical dulness of liver on percussion 4 inches. The skin over the whole body is of a deep yellow tint, dotted with spots of purpura the size of pin heads; but is cool and moist. The urine is deep coloured, like Madeira wine. It is very albuminous on the addition of heat, and contains a large quantity of bile. Pulse 88, small and weak. Other organs healthy. $. Pota I^S"-] °^^?'; ^Q ° natural meatus urinarius was occluded. «(V * Sy $oQ < ^ o Microscopic Examination.—On crushing a small °^Oc'1j . ;SCJL:'-- '■•"' piece of the liver between glasses, and examining it under &.>'■•'■-•■ -'-' a power of 250 diameters linear, it was found to consist F'S- 403- of a multitude of fatty molecules and granules, with larger globules of loose oil. Many of the cells seemed to he broken down and disintegrated, but such as were entire were more or less distended with bile pigment.—Fig. 403. Commentary.—The symptoms present in this case on admission, viz., the jaundice, local pain, the rigors, and fever, were indicative of obstruc- tion in the common bile-duct connected with some inflammatory action going on in the liver or its neighbourhood. Hence the topical applica- tion of leeches, and afterwards warm fomentations, were ordered. As the blood and urine were evidently loaded with bile, diuretics and purgatives were also given to assist the excretion of that product. These remedies proving of no avail, and the constitutional symptoms increasing, mercury, conjoined with opium, was actively administered, but failed to produce its physiological or any useful therapeutical result. After death, perito- nitis surrounding the gall-bladder and common duct was discovered; but death evidently resulted from the poisoning of the system through the absorption of bile, the excretion of which was prevented by the firm impaction of a calculus in the common bile duct. The benefit of mer- cury in such cases, though strongly recommended as a means of altering the constitution of the bile, appears to me very doubtful; for, supposing it to possess the effect ascribed to it, and to act as an alterative and cholagogue, its action in obstruction of the gall-ducts must be to distend them still further, and thus increase the pressure on the hepatic cells, and consequently the disintegration of the hepatic texture. Most of the , examining class were in favour of the trial of mercury in this case; and considering how uniformly it has hitherto been recommended by experienced practitioners, I did not think it right to deprive the patient Fig. 403. Disintegration of the hepatic structure following obstruction of the biliaiy ducts. 250 diam. 458 DISEASES OF THE DIGESTIVE SYSTEM. of any chance which might arise from its use. At the time, I expressed my want of confidence in its virtues, an opinion which the progress of the case fully justified. In the present state of science and art of medi- cine, there is no one point in therapeutics which so urgently requires thorough re-investigation as the real value of the medical properties attributed to mercury. The effect of the long-continued over distension of the gall-ducts on the liver was a partial disintegration of its cell elements, and an accu- mulation of bile in such of the cells as remained perfect. This lesion is remarkably well described by Dr. Budd, in the third chapter of his work on the liver, where he treats of fatal jaundice. It admits of question how far this destruction of the hepatic cells may not, by impeding the secreting power of the organ, at length induce that condition described by Dr. Alison, where the biliary principles are not eliminated. It must, I think, be certain that jaundice, produced primarily, as in the present case, by a mechanical obstruction, must be kept up by the altered condi- tion of the cell-structure afterwards induced. This case was instructive to all who observed it, with regard to a sup- posed pregnancy she laboured under. The abdomen was certainly some- what prominent; but the investigation of the existence of this state was uever gone into, for the simple reason, that it no way affected the dia- gnosis or treatment. When the woman was dying, however, the husband applied to me, with a view of ascertaining whether it might not be pos- sible to save the child. On this point I requested the opinion of Dr. Simpson, who, on examining the woman, declared her not to be pregnant. This circumstance then is an illustration of how women who have pre- viously had children may be deceived as to the existence of a subsequent pregnancy, and how important it is for the practitioner, as a general rule, to satisfy himself of the reality or falsity of such a state in all cases. When formerly delivered in India, she said instruments were employed, and that she sustained some injury. This account is rendered highly probable by the existence of the recto-vaginal and urethro-vaginal fistula?, aud the remarkable vaginal stricture, found after death. Case LXV.*—Jaundice—Compression of ihe Ductus Communis Choledochus from a Cancerous Tumour, composed of Epigastric and Lumbar Glands—Occlusion of Cystic Duct—Enlargement of Gall Bladder—Cancer of the Pancreas—Biliary Congestion of the Liver—Cancerous Exudation into various organs—Slight Leu- cocythemia. History.—William Dodds, set. 23, ploughman—admitted December 8th, LS">J. He states that four weeks ago he was seized with pain in the lower part of the abdo- men, accompanied by unusual costiveness. Some days afterwards he commenced to vomit his food a few hours after taking it. The vomiting continued for a fortnight, and then suddenly ceased. But it returned about four days ago as before, and hasxon- tinued up to the time of admission. Symptoms on Admission.—The tongue is loaded with a thick white coat, but moist. Appetite bad. After taking food he has feeling of a great load and dis- tension in his stomach. No flatulence, but has frequent eructations of a watery * Reported by Mr. Robeit Rhind, Clinical Clerk. DISEASES OF THE LIVER. 459 fluid, which is neither acid nor of disagreeable taste. Usually vomits it about 4 o'clock a.m., and for some time afterwards experiences considerable relief; has con- stant severe pain and considerable tenderness over the epigastrium. A tumour can be felt towards the pyloric end of the stomach, of a rounded form. It measures two and a half inches vertically, its upper and lower margins being distinctly tangible, its lateral margins, however, cannot be determined. The hepatic dulness in the right hypochondrium was normal. All the other functions are healthy. Diet to be care- fully regulated Progress of thf; Case.—December 10th.—Has been much better since admis- sion, not having vomited till this morning at five o'clock. He then brought up a large quautity of brownish pultaceous matter, which, on microscopic observation, was found to consist of half-digested muscular fibres, starch and oil globules, and epithelial cells. Has considerable pain and tenderness in the epigastrium. Eight leeches to be applied, followed by warm fomentations. Dec. 18th.—There have been remissions in the epigastric pain, which, however, still continues. The vomiting also has not been permanent, having been suspended for two days by eating ice, and again on the 16th, by a morphia draught. The constipation has been relieved by domestic enemata. It was observed to-day for the first time, that the skin has a decided though very slight yellow tinge. Dec. 23d.—Since last report has expe- rienced great pain at times in the abdomen generally, for which he was ordered a draught at night with Tr. Cannabis Ind. Z ss. Six more leeches were also applied on the 20th, but without lessening his sufferings. There has been considerable fever, with thirst and loss of appetite. Iced Lemonade for drink, and warm fomentations to the abdomen, give most relief. Yesterday the jaundice was decidedly more pro- nounced, and has increased still more to-day. There has latterly been constant vomiting, shortly after taking food. He is more emaciated, and the tumour formerly alluded to can now be felt hard and nodulated through the integuments. The stools are of a clay colour, and the urine loaded with bile so as to resemble porter. Pulse 120, \ cry weak. fyPH. Opii vj. One to be taken immediately, and repeated in four hours if there be no alleviation of the pain. To have wine f iv daily, and ice to dissolve in the mouth. Continue the warm fomentations to the abdomen, and to inject slowly ; iv of strong beef tea into the rectum. From this time he continued sinking. The skin assumed a greenish tinge. On the 24th he vomited blood, and passed black tarry matter by stool. Brandy and stimulants were freely administered, but he died Dec. 26th. Sectio Cadaveris.—Fifty-one hours after death. The body considerably emaciated. The whole surface, and all the tissues, includ- ing the cartilages, were stained of a greenish-yellow colour. Thorax.—Both lungs were emphysematous anteriorly, especially the left. Pos- teriorly they were engorged, and on section were cedematous, with scattered nodules of cancerous matter in their substance, of cheesy consistence, but occasion- ally very soft, and varying in size from a pepper-corn to that of a small hazel-nut A continuous layer of cancerous matter also here and there surrounded the bronchial tubes. From the universal predominance of bile-pigment, these cancerous masses closely resembled to the eye tubercular matter. Immediately under the upper part of the sternum, and over the ascending aorta, was a mass of lymphatic glands, about three inches long and two inches thick, of a fleshy colour and pulpy consistence, easily breaking down under the finger, and infiltrated here and there with a yellow- ish-white cheesy deposit, exactly resembling tubercle. The bronchial glands at the root of the lunga were greatly enlarged, and presented a similar appearance. The 460 DISEASES OF THE DIGESTIVE SYSTEM. heart was healthy. The ventricles contained sjmi-r-oagulated blood, the veins black fluid blood. Abdomkn.—In the cavity of the peritoneum there was about 8 oz. of dark brown clear serum. The liver weighed 3 lbs. 12 oz., was of a light olive green colour, approaching to brown, soft in texture, and on section was seen to contain a few whitish yellow masses, varying in size from a millet-seed to that of a small pea, of tolerably firm consistence. The gall-bladder projected about an inch and a half below the lower margin of the liver. It was considerably enlarged, and was distended with thick black bile. The cystic duct was completely closed a little above its junction with the hepatic, which was quite free. The calibre of the common duct was much diminished ; and although a probe could be pushed through it, it was evidently com- pressed by the tumour to be described immediately. The spleen weighed 5 oz., and was healthy, with the exception of a cancerous mass in its centre, about the size of a coffee-bean, similar to those in the lung. Surrounding the pyloric end of the stomach, and projecting from below the liver towards the left side, was an agglom- erated, indurated, and nodulated mass of enlarged and cancerous lymphatic glands, of the size and form of a cocoa-nut. This was the tumour which, during the life of the individual, was felt in the epigastrium. It pressed upon and completely occluded the ductus communis choledochus. The aorta passed through the left third of this mass, and was so compressed as scarcely to admit the little finger. On section, this mass presented very much the appearance of some specimens of pudding stone, consisting of rounded or oval yellowish-white masses, varying in diameter from £ to 1-J- inches, and united together by highly congested areolar tissue, of a deep purple colour, with here and there extravasations of blood in its substance. The affected glands were friable and easily crushed between the fingers, but yielded no juice on pressure. The mesenteric, mesocolic, and lumbar glands generally were similarly diseased. The right extremity of the pancreas was converted into a firm mass by cancerous exudation, and closely connected to the tumour just described, of which it formed an integral part. On opening the stomach, it was seen to contain a quantity of tenacious, brown, glairy mucus, closely coherent to the mucous membrane. Its walls at the pylorus were found thickened; and from this point the thickening gradually diminished, until it ceased at a convex margin, somewhat irregularly nodulated, and elevated above the rest of the mucous surface. The diseased portion occupied about one-third of the area of the organ. The mucous surface covering it was of a dirty-white colour, and was ulcerated at one point with softened ragged edges over a space the size of a shilling-piece. The healthy two-thirds of the mucous surface was of bright rose-pink colour, from vascular congestion. The cut edge of the pylorus was a quarter of an inch thick, dependent on hypertrophy of the muscular coat to the extent of one-sixth of an inch, and of an infiltration of firm whitish exuda- tion, in the submucous areolar tissue. The intestines, kidneys, and other organs, were healthy. Microscopic Examination.—The whitish-yellow masses in the lungs were prin- cipally composed of molecular matter, but with numerous delicate nucleated cells apparently forming. In the bronchial glands, the whitish-yellow matter was com- posed of a few cancer cells only, evidently in a state of disintegration, associated with multitudes of fatty molecules and granules. The fluid squeezed from the fleshy and pulpy matter from the same glands, contained, 1st, numerous round and oval nucleated cells, about one-thousandth of an inch in diameter; 2d, many gra- nule cells of varying size ; 3d, multitudes of gland nuclei; 4th, blood corpuscles; oth, a large quantity of molecular matter. The pulp of the epigastric glands contained, 1st, large cancer cells, some containing three included cells ; 2d, a very few granule cells; 3d, numerous molecules. The blood contained a decided increase of colour- DISEASES OF THE LIVER. 461 less corpuscles. The cells of the liver contained a quantity of biliary matter, giving them under the microscope, a bright yellow colour. Commentary.—The nature of this case was tolerably evident from the first; the epigastric tumour, pain, and vomiting after taking food, indi- cated obstruction of the pylorus produced by a cancerous growth. Later, when jaundice appeared, it became clear that the common duct was obstructed. Treatment could, of course, only be palliative. On dissection, it was singular to observe the resemblance which the cance- rous masses in the lungs and in the glands bore to tubercle. Some persons who were present, indeed, judging from the youth of the patient, their friable consistency and yellow colour, maintained that the glands were scrofulous; and it would have been difficult to undeceive them without the assistance of the microscope. All the tissues were tinged of a deep yellow, aud the hepatic cells were gorged with bile, so that the absorption of this excretion into the blood must have been very great. The insensible manner in which so much cancerous matter de- veloped itself is worthy of observation, as it was only four weeks before admission that he experienced any inconvenience. Then came on the effects of obstruction—first, of the pylorus, and, secondly, of the common duct—from the combined effects of which he died. Case LXVL*—Jaundice—Cancerous Tumour of the Pancreas, comprising tlie Ductus Communis Choledochus—Dilatation of the Gall-bladder, and passage of the Gall- stones into the Gall-bladder—Cancer of the Liver and Kidneys. History.—John M'Donald, set. 50, tailor—admitted November 29, 1853. Four weeks ago he was seized with a gnawing pain in the epigastrium. On the 13th he was over-worked, and went home much exhausted. On the following day, there was drowsiness, loss of appetite, and anorexia. On the 27th, the skin was slightly tinged yellow. He applied at one of the dispensaries, and was then suffering from intense grinding pain in the right hypochondrium. One of the clinical students who saw him there advised him to come into the Infirmary. Symptoms on Admission.—He has no pain, no difficulty in taking food, though it excites nausea. Tongue slightly furred ; moist. No appetite. Considerable thirst. Vertical dulness of liver is 3| inches. No abdominal tenderness. Xo tumour to be felt in epigastrium. Bowels constipated. Stools of a dark green colour ; but he says they were white when the attack came on. Urine is of a dark brown colour, like weak porter, from the presence of bile ; unaffected by heat. Pulse 60, regular. Skin of a deep yellow colour. Other organs and functions normal. H PH. Hydrarg.; Pil. Rhcei Co. aa 3 ss. M. et divide in pil. xii. Two to be taken every night. Progress of tiii: Case.—December 3d.—The stools are now of a lead colour. 7b have gr. v. Pil. Hydrarg., and of Ext. Taraxaci every night. Dec. 10th.—Com- plains of acute grinding pain in t he region of the liver. Bowels have not been open for some days. Skin of a deeper yellow. To have gr. v. of Pil. Rhwi Co. in addi- tion to the others. Dec. 12th.— Had an asafcetida enema yesterday. The bowels have been well opened ; pain much relieved. Stools still of a lead colour. Omittant. Pil. H Pil. Rhai Co. 3j; Calomel, 3j; Olco Ci.inamomi, guttas iv. M. et divide * Reported by Mr. Almeric Seymour, Clinical Clerk. 462 DISEASES OF THE DIGESTIVE SYSTEM. in pil. xij. Two to be taken every night. Dec. 14th.—Is now free from pain, but feels very weak. Stools of a dark green colour. Otherwise the same. Cannot take food. I£ Liq. Potasso3 Z ij ; Sp. jEther. Nit. 3 ss; Infus. Gentian. Co. 3 v. M. 7>„ table-spoonfuls to be taken three times a day. Dec. 17th.—Much weaker. Takes no nourishment. Skin of a dark green tint. Tongue dry, and covered with a dark brown cru*t. Bowels open. Stools of a dark leaden tint. Pulse 120. very weak. To have -" vj of wine. Dec. 19th.—"Whisky has been liberally administered; but he continued to sink, and died at two o'clock a.m. Sectio Cadaver is.—Thirty-four hours after death. Extreme jaundiced appearance of the whole body, and yellowness of all the tissues. Thorax.—With the exception of slight emphysema of the lungs, all the thoracic organs were healthy. Abdomen.—On opening the duodenum, there was seen at the point where the common duct enters it, a tumour bulging inwards, and compressing the duct. The growth was the size of a walnut, and presented all the characters of scirrhus. It was formed in the right extremity of the pancreas ; and the rest of the organ was indu- rated, and contained several small cysts filled with a gelatinous fluid. The portion of the common duct which passed through the tumour was an inch and a half long, and barely admitted a small probe. Behind the constriction, the common, cystic, and hepatic ducts were greatly enlarged, the common duct having a calibre nearly equal to the size of the thumb. The gall-bladder was much enlarged, and distended with dark-coloured bile. It contained two small gall-stones of bile pigment, but none could be found in the ducts. The liver weighed 3 lbs. 9 oz., was of a green colour, with the centres of the lobules congested. The bile-ducts were everywhere dilated throughout its substance. Scattered throughout the liver were white cancerous masses, varying in size from a pea to that of a hazel-nut. Similar small cancerous masses existed in the cortical substance of the kidneys. On opening the intestines, a considerable quantity of black blood was found mingled with the fceculent matter, both in the small and large intestines. Other organs healthy. Micuoscopic Examination.—The cancerous masses in the pancreas, and liver, and kidneys, contained numerous characteristic cells. The hepatic cells were loaded with yellow bile, whicii became of a cherry-red colour on the application of Petten- koi'er's test. They contained no fat. Commentary —It appeared, from careful examination of this man's case, that he had suffered from two attacks of grinding pain in the right hypochondrium, such as are commonly felt during the passage of gall- stones. After death, two biliary calculi were found in the gall-bladder, having all the appearance of those which are usually formed in the liver. It is almost certain, therefore, that the painful attacks were coincident with the passage of these calculi from the liver to the gall-bladder, a> their escape into the intestines was prevented by the constriction of the common duct, by the cancerous mass in the pancreas. Since the researches of Bernard as to the functions of the pancreas were made known, I have carefully sought, in a great number of cases, for the passage of fatty matter in the alvine evacuations, but iu vain. In several instances of jaundice, such as the present, I have found the head of the pancreas diseased; but in none <>f them did the stools pre- sent the characters described in the cases of Bright, Lloyd, Elliotson, and others. It is true that in this case the common duct was not abso- DISEASES OF THE LIVER. 463 lutely obliterated, but it appeared to me that the pancreatic duct was so involved in the tumour, that its fluid secretion was incapable of passing. But, as no special anatomical investigation was made in reference to this point, we are not entitled to suppose that the supply of pancreatic juice was entirely cut off. In other cases, however, where the common duct has been obstructed (Case LXIV.), or where, from disease of the head of the pancreas, the pancreatic duct has been obliterated (Cases LX. and LXV.), there has been uo proof whatever that the fatty elements of the food have not been emulsionized. Such facts indicate that the function attributed by Bernard to the pancreas must also be performed, under certain circumstances, by the alimentary canal alone, independent of that organ. Case LXVIL*—Enlargement of the Liver—Ascites—Albuminuria—Recovery. History.—David Harper, ast. 30, painter—admitted into the clinical ward Feb- ruary 18th, 1852. Four months ago, was .seized with diarrhoea and vomiting, which have continued more or less ever since. The liver was first observed to be enlarged in the beginning of December last, and it has gradually increased in size up to the present time. He has taken numerous remedies to check the diarrhoea and vomiting, but with little effect. Symptoms on Admission.—On admission, the liver is found to extend from one inch below the right nipple above to within an inch and a half of the anterior supe- rior spine of the ilium below—a depth of nine inches. From this point it> margin could be felt ascending obliquely upwards to the most depending portion of the ninth rib on the left side, crossing about an inch above the umbilicus. There is distinct fluctuation to be felt throughout the rest of the abdomen, indicating ascites. In the right lumbar region the enlarged liver is tender on pressure. The abdomen measures 32\ inches in circumference at its widest part. Spleen of normal size. Tongue moist, slightly loaded. There has been no vomiting for some days, but the diarrhoea is very severe. Says he has frequently passed blood by stool. Skin not jaundiced, but rather dry. Respiratory, circulatory, and other systems normal. R> Pil. Plumb, et Opii xij. Sumat unam ter indies. Progress of the Case.—March 4th.—Has had occasionally vomiting and diar- rhoea since last report, for which he has been taking at times the naphtha mixture, morphia draughts, and gallic acid. To-day the urine is somewhat scanty, and slightly coagulable on the addition of heat and nitric acid: spec. grav. 102-1. R Acetatis Potassie, Z j ; Sp. JElh. Nit. Z 'j ; Syr. Aurantii, %j ; Aquas, § v. M. Sumat 3 j ter indies. March 12th.—To-day the urine was ascertained with the microscope to contain numerous casts of the tubes and isolated epithelial cells loaded with fatty granules. The vomiting and diarrhoea continue. Habeat suppositorium opiatum octavd qudque hord. April 6th.—The diarrhoea was for a few days somewhat checked by the suppositories, but gradually returned, and is now very severe; the bowels having been opened twelve times yesterday. The urine has continued albuminous, and loaded with desquamative casts and fatty tubes. To-day its spec. grav. is 1007. There is now great debility, and occasional stupor and drowsi- ness. May 12th—The drowsiness has disappeared. For the last few days has been taking 3j of the potass, bitart. with the mixture of acetate of potash and nitric lether, and he now passes a larger amount of urine, which is free of tubular ca.-ts. The abdomen is less tense. About the middle of May the vomiting and diarrhoea * Reported by Mr. J. A. Douglas, Clinical Clerk. 464 DISEASES OF THE DIGESTIVE SYSTEM. first abated, and was soon after checked. In August his health was so much improved that he was allowed to go out of the house for the benefit of air and exer- cise. He was re-admitted September 13th, having enjoyed tolerable health in the interval, although the hepatic swelling is about the same size. He was now ordered, R Hydrarg. Proto-iodidi, gr. vj; Pulv. Opii, gr. ij ; Ext. Taraxaci, ; ss; Conserv. Rosarum, gr. v. fiant pil. xx. Sumat unam ter indies. Tliese pills on the 20^ produced salivation, when they were discontinued, and an astringent gargle was ordered. The abdomen now measures thirty-six inches in its broadest circum- ference. Oct. 25th.—Complaints of oppression on walking, of shooting pains through the chest and abdomen. Ascites seems once more to be increasing. Tr. Iodini to be painted over the abdominal surface. Nov. 21st.—Since last report the liver has greatly diminished in size, and his complaints have ceased. The urine presents a slight hazy albuminous appearance on the addition of heat and nitric acid, but is voided in natural quantity. Dec. 13th.—The liver is now so reduced in size that its lower margin is only two inches below the false ribs in front, and one inch on the right side. All his functions are apparently healthy, the urine healthy, and his strength appears perfectly re-established. Dismissed. Commentary.—The enlargement of the liver which existed in this man was probably simple hypertrophy, which, by pressing upon the large abdominal veins, caused ascites. It is worthy of remark, that it underwent a sensible diminution under the local application of Tr. of Iodine, having resisted mercurial action and various other remedies. The occurrence of Bright's disease, and the presence of numerous de- squamative casts of tubuli uriniferi, more or less loaded with fat, aud of albumen in, with diminished density of, the urine, were considered for- midable complications. But here, also, under the use of strong diuretics, the renal symptoms subsided, the casts disappeared, and the urine became perfectly healthy. He has since been seen by the clerks walk- ing about the town, and has informed them that he is (mite well, and carries on his occupation without any inconvenience. Cask LXYIIL*—Fatty Enlargement of the Liver. History.—James Grant, set. 29, blacksmith—admitted October 14th, ls.H. His occupation consists in watching an apparatus worked by steam, in a room of elevated temperature; he has no heavy labour, though constantly standing on his feet; he drinks whisky to a large amount. Since September, 1849, he has been three times in the house for various periods, from which he has been as often dismissed relieved. The liver began to enlarge two years ago, and has been very slowly increasing ever since. Symptoms on Admission.—On admission, he labours under slight -diarrhoea, having had two or three stools daily for several weeks past. He has, moreover, a dull heavy pain in the abdomen, extending to the lumbar region. The belly is evidently enlarged at its upper part, wher3 a firm tumour exists, forming a protu- berance in the epigastric region. The girth of the abdomen at this place during expiration, is 34 inches. The hepatic dulness extends from two inches below the right nipple, down to a transverse line drawn one inch above the superior spine of the ilium. The whole of the right and part of the left hypochondriac regions are * Reported by Mr. \V. M. Calder, Clinical Clerk. DISEASES OF THE LIVER. 465 dull on percussion. The tympanitic sound of the stomach is audible in front, the organ being evidently pushed forward by the enlarged liver behind it. The whole surface of the tumour feels smooth, and presents no tenderness. The splenic dulness measures 5$ inches vertically; skin dry; no oedema of the legs ; general appearance pale and cachectic ; occasionally he has frequent desire to micturate, but the urine has always presented ite normal characters; considerable breathlessness on exertion, but the lun^s and heart, on examination, were apparently quite healthy ; other functions well performed. He was ordered a mixture containing the Iodide of Potassium, six srrains of which were to be taken three times a day. Frictions with the Unguent. iodinii were also to be employed daily. Progress of the Case.—Towards the end of October the bowels became regalar, and his general health was somewhat improved. Frequent micturition, with dis- charge of pus in the urine, now came on, which subsided in a few days. From this time although the size of the liver underwent no diminution, his bodily strength gradually improved. He occasionally had slight return of looseness in the bowels, which was checked by appropriate remedies. The difficulty of breathing after exer- tion also slowly left him ; and he was dismissed greatly relieved, January 26th, 1852. Commentary.—Fatty liver was first shown by Mr. Bowman to depend on the secretion of a large quantity of oil, which is stored up in the hepatic cells. These cells are, uuder such circumstances, frequently enlarged and contain oil varying in amount from a few granules to a large mass, which occupies the whole of their cavities. Not unfrequently livers,' which to the naked eye appear healthy enough, may still be demon- strated under the microscope to con- tain an unusual number of fat granules, and there can be little doubt that considerable variations may exist in this respect quite compatible with a state of health. Almost all stall-fed animals that do not labour, possess a large amount of fat in their hepatic cells. It is only where the organ is much enlarged, altered in colour, and pressing upon neighbour- ing viscera, that its fatty degeneration can be said to interfere with the vital processes. Fatty degeneration of the liver has been observed to be very common in drunkards who are continually taking alcoholic liquids. Of 13 indi- viduals who died from Delirium Tremens, 6 had very fatty liver, in 3 the organ contained little, in 2 none at all, and in 2 there was cirrhosis (Frerichs.) In such cases, the quantity of carbon taken in the form of spirits being too great in amount to be excreted from the lungs as car- bonic acid, and from the liver as bile, is stored up in the liver as fat. In tropical climates, the same pathological condition comes on under differ- ent oircumstances. A high temperature, and a rarified atmosphere, indispose persons to take bodily exercise; and Europeans, instead of living according to the simple manner of the natives, too often continue Pig. 404. Hepatic cells in various stages of fatty degeneration. On the right of the figure, yellow granular pigment is also contained in the cells, which were taken from a cirrhosed liver. 250 diam. 30 466 DISEASES OF THE DIGESTIVE SYSTEM. to consume the food habitual to them in their native country. But the excretory power of the lungs being, at the same time, diminished, the excess of carbon in the tissues and food is thrown upon the liver and there converted into fat. Dr. Macnamara* found that, among the first regiment of European Bengal Fusileers, during seven years, the mor- tality among the officers was 11 per cent., and among the men SO per cent. so that the whole of the fighting men in the regiment were changed about once in every ten years. From the circumstance that the great majority of these men were young, healthy, and vigorous, when they left home, and other circumstances, he attributes the deaths to high feeding, indulgence in spirits, and to slothful habits, causing fatty degeneration of the textures. The manner in which the livers of geese are made fatty at Strasburg is as follows :—The geese are confined in close cages, in a heated atmo- sphere, and largely supplied with food. Want of exercise and heat diminish the respiratory functions, and cause that of the liver to be dis- ordered, and the result is an enlargement of the organ from accumula- tion of fat. Iu the case before us, the cause of the disease seems to have been exactly the same. A man is kept stationary watching a steam- engine, in an elevated temperature, consuming his usual food, and indulg- ing in alcoholic drinks. Fatty liver is also common in cases of phthisis pulmonalis. Here- the excreting function of the lungs is more or less interfered with, and the carbonaceous matters, not separated as usual by this channel, are stored up in the liver in the form of fat. The hepatic disease is especially observed in those consumptive patients who, while they are capable of assimilating a certain amount of food, are prevented by languor, breathlessness, or other causes, from taking exercise. According to Frerichs, of 117 cases of pulmonary tuberculosis, examined after death, there were 17 which presented fatty liver in the highest degree, whilst there were G2 others with the hepatic cells loaded with oil globules. On the contrary, in other diseases of the pulmonary organs, he found fatty liver to occur very seldom. This view of the pathology of fatty liver has been objected to on the following grounds :—1st, That the connection between fatty liver and disease of the lungs is not general; 2d, That there is no evidence that a fatty liver does not excrete bile as usual; and 3d, That as a considerable portion of bile is absorbed into the blood to be excreted from the lungs, the liver must be considered as preparing material for these organs. Hence it is argued, that it would be a strange compensation if the func- tions of the liver were to be increased, while that of the lung is dimi- nished by disease (Budd). But if fatty liver be not always conjoined with diseased lung, it will be found associated with some circumstance which diminishes the function of that organ, in relation to the work it is called upon to perform; for instance, the diminished exercise and great heat of tropical climates. Further, although it be granted that the liver may in health prepare carbonaceous matters for pulmonary excre- tion, it must be clear that if the lungs cannot accomplish this function, such matters must be thrown back or retained in the liver, and consti- tute a powerful cause of fatty degeneration of that organ. On the y Indian Annals of Medical Science, 1855, p. 170. DISEASES OF THE LIVER. 467 whole, therefore, we must regard excess of carbonaceous matters in the system, and the diminution of pulmonary action, as the chief causes of fatty degeneration of the liver ; a view which has the merit of pointing out to us as remedies a diminished diet, a temperate climate, appropriate exercise, and an endeavour to promote the functions of the lungs and of the skin. » There is another structural alteration of the liver, which, from its colour and general resemblance to bees'-wax, has been called " waxy," and sometimes " brawny " liver. This disease has been confounded with fatty liver, but an examination of their minute structure shows that the hepatic cells present a very different character in this condition. Instead of being enlarged and filled more or less with oil globules, they are colourless, shrunken, and for the most part destitute of contents, and the nucleus disappears. (See Fig. 295.) I have previously described this lesion as one of the forms of albuminous degeneration. (See p. 214.) Its clinical history will be given under the head of Phthisis. (See case of Margaret Clark.) Case LXIX.*—Cirrhosis with Atrophy of the Liver—Ascites. History.—John Harper, set. 28, farmer, from Caithness—admitted June 24th, 1832. Six years ago, after recovering from measles, his health was greatly deranged. He was weak, and perspired profusely at night, or when performing any unusual exer- tion. A short time afterwards, he was exposed to cold and wet, and he observed that the abdomen gradually enlarged, and dyspnoea supervened. On two occasions para- centesis abdominis was performed; at the first operation a quart, and at the second a pint, of fluid was removed, without producing much relief. He has had considerable pain in the epigastric region at times, and latterly the appetite has been diminished, and the bowels costive. Symptoms on Admission.—On admission, the abdomen is slightly swollen, and evidently contains fluid. Round the umbilicus it measures 39 inches. No anasarca. The hepatic dulness extends three inches downwards on the right side, commencing two inches under the nipple. Tongue is furred; appetite diminished ; no epigastric pain or uneasiness ; bowels irregular, but at present costive. There is slight dulness on percussion under the right clavicle, with harsh inspiration, prolonged expiration, and increased vocal resonance; urine scanty, depositing lithates. The other functions are well performed, and he appears to be a strong, well-nourished person. PitoGitEss of the Case.—The treatment consisted of diuretics (Sp. JEthcr. Nit. and Tr. Digitalis) and sudorifics (Pulv. Doveri); but feeling the confinement of the Hospital to disagree with him after his usual active occupations, he insisted on going out, which he did July 6th. Commentary.—The diminished extent of the hepatic dulness, the ascites, and the chronic nature of the disease, point out this case to be one of cirrhosis. This morbid change in the liver consists of the forma- tion of fibrous tissue between the lobules of the organ, whereby its secreting cells are compressed and atrophied. As a further result, the large venous trunks are also compressed, and their commencing ramifi- * Reported by ilr. John Matthews, Clinical Clerk. 468 DISEASES OF THE DIGESTIVE SYSTEM. cations so congested that effusion into, or dropsy of, the peritoneal cavity is induced. Notwithstanding the extensive organic changes which are frequently observed in this disease, danger is not so much to be appro- hended from them as from the ascites, which, by distending the abdomen and compressing the lungs and liver, so interferes with those important organs as to destroy life. Case LXX.*—Cirrhosis with Enlargement of Liver—Hypertrophy of Spleen—Sliqld Leucocythemia—Jaundice—Construction of Arch and descending Aorta. History.—James Kerr, aet. 28, a labourer—admitted July 22, 1S">2. This man first had jaundice, with swelling of the abdomen, between four and five years ago; and since then he has been several times in the Infirmary. The treatment has con- sisted of various alteratives internally, with the occasional application of the Tr, Iodinii, blisters, and leeches externally. The swelling, however, has continued to increase very slowly, and for the last two years he has been incapacitated from working. The blood for some time has contained an excess of fibrin, and a slight increase of the colourless corpuscles ; and he has been troubled at intervals with attacks of epistaxis and occasional diarrhoea. For two years past there has been an increased impulse, with a rough blowing murmur, loudest with the first sound under the manubrium of the sternum. Symptoms on Admission.—On admission, the hepatic dulness commences an inch below the right nipple, and extends down to the umbilicus, measuring twelve inches vertically. The splenic dulness reaches from the lower margin of the fifth rib to a transverse line drawn an inch below the umbilicus, and measures eight inches verti- cally. The liver presents a protuberance anteriorly, which extends in the form of a ridge, four inches broad, from the epigastrium backwards towards the false ribs. The girth of the abdomen over this ridge is 42 inches. The inferior border of the spleen and liver can- be distinctly felt through the parietes of the abdomen. The heart's action and sounds are normal. An increased pulsation is distinctly visible at the root of the neck, and can be felt above the clavicles and under the top of the sternum. Here there is a loud rough murmur synchronous with the systole of the heart, and accompanied by a distinct impulse. There is a slight cough, with a little mucous ex- pectoration, hut auscultation and percussion of the lungs reveal nothing abnormal, Urine rather scanty, high coloured, spec. grav. 1026, contains some biliary matter, and deposits on cooling a pretty copious pinkish sediment of lithates. The integuments and conjunctivae are still tinged of a light bile yellow colour. There is considerable tenderness over the liver in the right hypochondrium. He says slight epistaxis returns about once a week. The bowels are open daily ; no diarrhoea. After walking or un- usual exercise oedema of the legs comes on. On examining the blood microscopically, the colourless corpuscles are not so numerous as when he was last in the house, Four leeches to be applied to the right hypochondrium. Progress of the Case.—This man left the house in August. He was re- admitted November 9th, having in the interval suffered from an attack of pleurisy on the right side. Latterly he has been in the Dundee Hospital, and says that five weeks ago he passed considerable quantities of dark grumous matter from the bowels In other respects his condition is the same as formerly reported. November llw.— Vomited about nine or ten ounces of blood. 29th.— Hematemesis returned yesterday afternoon with great violence, and at intervals he brought up in all 132 ounces o blood. His strength is now greatly diminished; pulse 101, full. The abdominal * Reported by Messrs. Douglas and Dewar, Clinical Clerks. DISEASES OF THE LIVER. 469 swelling and aortic signs as formerly reported; but the breathing is laboured, with dyspneea at night, considerable cough, and muco-purulent expectoration. No dulness on percussion <>&.t lungs ; but sibilant and sonorous rales are heard at the base of the right lung on ausaultation. From this period his general health evidently began to fail. Ascites first came on, followed by oedema of the legs and general anasarca. The dyspneea became more urgent, with a sense of oppression in the chest, and there was occasional vomiting of blood. On the 21st of December there was considerable hematemesis, and discharge of blood by stool, which was followed by exhausting diar- rhoea. He died December 25th. Sectio Cadaccris.—Fifty-three hours after death. Body generally anasarcous. Thorax.— Extensive chronic adhesions between the pleura on the right side. On the left side about four ounces of serum in the pleural cavity. Lungs cedematous. Slight emphysema of the. left lung anteriorly. Posteriorly both lungs congested, and here and there compressed. The ascending portion of the aortic arch was of normal size, but its transverse and descending portions, as well as the descending aorta generally,' were unusually small in calibre, so that the little finger could with difficulty be in- troduced. In structure the vessel was healthy, but in consequence of this formation a pouch was formed immediately above the sigmoid valves. About two ounces of serum in the pericardium. The heart healthy. Abdomen.—About twenty ounces of serum in the peritoneal cavity. The stomach was about half full of brownish-black blood, containing soft coagula. Mucous coat healthy. Brunner's glands much enlarged, about the size of millet seeds. The intestines everywhere healthy. Mesenteric glands slightly enlarged. Liver weighed nine pounds one ounce, was of a pale gamboge colour throughout, speckled here and there with rounded masses, the size of a pea, having a darker ochrey tint. On sec- tion, it offered considerable resistance to the knife, and the fresh-cut surface present- ed a dense, whitish-yellow fibrous structure, with the lobules of the organ atrophied and embedded in it, and of various tints of yellow, varying towards white. In short the last stage of cirrhosis. Spleen weighed 3 lbs. 6 oz., and is enlarged from simple hypertrophy. Kidneys, larynx, oesophagus, and other organs healthy. Fig. 405. Structure of a thin section of liver in the last stage of cirrhosis. 250 diam. 470 DISEASES OF THE DIGESTIVE SYSTEM. Microscopic Examination.—On making a thin section of the liver with a Valen- tin's knife, and examining it with a power of 2."i0 diameters, the appearance was seen represented in the woodcut. (Fig. 405.) The stroma of the organ'was composed of fibrous substance, surrounding and compressing the hepatic lobules, many of which presented pale cells, more or less filled with yellowish pigment; in some the cells were more or less fatty, and in others waxy. Here and there the spaces were empty, the contents having apparently lost their cohesion, or having been dragged out by the knife. Commentary.—The lesion which I presumed to exist in the liver of this man during his life was that of a simple hypertrophy, a disease fre- quently associated with enlarged spleen and excess of colourless cor- puscles in the blood. But on dissection, the liver presented all the structural characters of the last stage of cirrhosis, associated with great increase of size in the organ. The fibrous structure especially was very large in amount, the lobules much compressed, and so altered, that, while the cells in many of them were loaded with pigment, some had undergone the fatty, and others the waxy, degeneration. The cirrhosis must have occasioned some obstruction to the perfect excretion of bile, as the jaundice, though slight, was uniform for more than four years. There had also been epistaxis, haematemesis, and frequent diarrhoea, symptoms very common in connection with enlarged liver and spleen, and probably dependent on the congested condition of the gastro-intes- tinal mucous membrane, produced by pressure on the portal veins. For a long time he suffered no inconvenience from the abdominal swelling, except from its bulk and occasional tenderness, unless indeed dyspnoea be taken into consideration, which was attributed partly to an aneuris- mal dilatation of the aortic arch. A dilatation in point of fact did exist, and. a certain obstruction was occasioned from the state of the parts described, sufficient to produce all the physical signs and functional symptoms of aneurism of the aorta. The origin of the excessive hemor- rhages is involved in mystery, the most careful examination of the body having failed to detect lesion of any vessel, or of any part of the mucous membrane. Some years ago I opened the body of a man whose stomach was found filled with a firm coaguluni of blood, so that, when the organ was opened, it could be turned out, presenting a cast of its interior, weighing between two and three pounds. Yet the most minute inspec- tion did not enable me to discover the slightest lesion to which such ex- tensive hemorrhage could be attributed. Such lesion, however, must have existed; for no one can now conceive the possibility of blood cor- puscles passing through the vascular walls by transudation, as was for- merly imagined. "We may, I think, theoretically ascribe them to the excessive congestion occasioned, and to the rupture of capillaries which escape detection after death. Another fact worthy of observation in the case of Kerr was, that the excess of colourless corpuscles in the blood (leucocythemia), which existed when he first came under my notice, had entirely disappeared during the last few months of his life. The treatment in cirrhosis must be purely palliative, and directed to diminish the ascites by means of diuretics and diaphoretics. The ques- tion of drawing off the fluid by paracentesis is one which may arise, in case the swelling is very great, and the embarrassment to the pulmonary DISEASES OF THE LIVER. 471 % and renal organs extreme. Even then, although temporary relief maybe obtained by the operation, there is every reason to believe that, iu the majority of eases, life is in no way prolonged. A. condition of the liver is frequently seen, and which has been called the nutmeg liver, from the resemblance it presents to the fresh-cut surface of a nutmeg. That is to say, it exhibits bright red or brown points, surrounded by a whitish or slightly yellow substance. On making thin sections of such a liver, it will be seen, that whilst the ves- sels of the lobules, and especially their central parts, are distended w margins of the lobules have undergone the fatty supposed by some that this condition is an iuc an incipient fatty degeneration of the organ. cases the fatty cells are formed at the circum- ference of the lobule, iu immediate relation+ to the portal capilla- ries, which are loaded with blood. It has been called interlobular fatty degeneration, but is in fact fatty degene- ration of the cells at the circumference of the lobule. Wedl has pointed out that in some rare forms of this lesion there is a deposit of pigment in the cells nearest the hepatic ca- pillaries, and occupy- ing the centre of the lobule, without any fatty degeneration wdiate ith blood, the cells at the degeneration. It has been ipient cirrhosis, by others Certain it is, that in such vcr. Pigment, may also Fig. 4Gl>. Peii lobular fatty or nutmeg liver, a, Fatty degeneration around the lobules; 6 and c, Centres of the lobules with the vessels congested.—( Wedl.) Fig. 407. Pigmented nutmeg liver, a, Lobule with the central vein divided at +, containing amorphous pigment; 6, Lobule with the central vein healthy ; c, The cen- tral veiu filled with pigment. The radiated central pigment is owing to its being de- posited iu that portion of the hepatic cells nearest the capillaries.—( Wedl.) 90 diam. 472 DISEASES OF THE DIGESTIVE SYSTEM. occur in the veins themselves. At other times the fatty and pigmentary degenerations of the liver may be more or less combined, the former existing at the periphery, and the latter at the centre of the lobule. We have no clinical history of these forms of nutmeg liver, nor, so far as is yet known, do they occasion any symptoms, susceptible of being recog- nised in the living body. Case LXXL*—Cancerous Exudation into the Liver—Cancerous Ulceration of (Eso- phagus—Simple Stricture of Pylorus—Profuse Hematemesis—Aneurism of TJioracic Aorta, bursting into the left Pleura. History.—Thomas Stewart, ast. 54, bookseller—admitted November 28, 1841). States that about six years ago he had an attack of hemoptysis, but, with this excep- tion, he always enjoyed good health till about four months ago. At that time his appe- tite began to fail, and he felt sick after eating, occasionally vomiting his food. Since then the sickness has been increasing, and about three or four weeks ago, he began to vomit blood. He has also been affected with pain in the throat on attempting to swallow, and a sense of constriction in the oesophagus, opposite the superior border of the sternum. He states, that he can very seldom take food without exciting vomiting; but occasionally, when he succeeds in retaining it for half an hour, the sense of sick- ness passes off. He further states that he vomits blood mixed with clots of dark-brown masses. This does not occur after eating, but generally between three and five in the morning ; occasionally, however, it occurs during the day, and is then preceded by a fit of coughing. He has been losing flesh lately to a great extent, and is now very thin, having formerly been of a stout and robust habit of body. Symptoms on Admission.—On admission he appears pale and emaciated. Com- plains of great general weakness. Tongue much furred, and the superior surface fissured. He has pain and constriction on attempting to swallow. Is sick, and gene- rally vomits after every meal, and this whether his diet be solid or fluid. Vomits a great deal of florid blood, mixed with dark grumous masses, and clots of a black colour. On examining this fluid under a microscope, it is seen to consist chiefly of blood cor- puscles and epithelial scales; no cancer cells can he detected. He states that on Friday last (Nov. 23), he vomited about half a gallon of blood, and on the following day even a larger quantity. There is great tenderness over the region of the stomach; and on examination, a hard lobulated oval tumour is discovered on the right side of the epi- gastric region, measuring four inches transversely, and two inches from above down- wards. The appetite is bad, and has been getting worse of late. Bowels usually regular. He complains of cough, which has existed for about four months; no dyspneea. On percussion, the chest sounds well, except that there is dulness over the lower third of the left lung posteriorly. On auscultation, the expiration is prolonged anteriorly, and crepitation is heard over the part where dulness is elicited on percus- sion. Pulse 90, of tolerable strength. Complains of occasional palpitation, and the impulse of the heart is somewhat increased; but on auscultation, the hearts sounds are normal. Urine, sp. gr 1020, natural in quantity, not coagulable; deposits, on cooling, an abundant lateritious sediment of lithate ot ammonia. Complains of giddiness, and is unable to walk well, owing to weakness. Four leeches to be applied over the tumour in epigastrium. R. Pulv. Opii gr. ij; Extract. Hyoscyam. gr. xii. M. et divide in pil. iv. One to be taken morning and evening■ ty. Naphthie Medicin. 3i; Mist. Camphorce, § iij. M. Half an ounce to be taken every three hours. * Reported by Mr. Hugh Balfour, Clinical Clerk. DISEASES OF THE LIVER. 473 Progress of the Case.—December 1st.—Pain and tenderness are somewhat relieved by the leeches. Still vomits, but not to so great an extent as formerly. From this time he went on with occasional exacerbations and remissions, but on the whole became manifestly weaker. Every now and then he vomited large quantities of florid blood, and on one occasion the quantity amounted to thirty-six ounces. Gallic acid and acetate of lead and opium were given at these times. After each attack of hematemesis, for some hours small quantities of blood came welling up into his mouth, and were expectorated. On December 14th, it is noted that the weakness is increasing, and appetite diminishing. He was then ordered eight ounces of wine and beef-tea enemata. 17th.—Extremely weak, and quite unable to take food, evidently sinking. 18th.—Died this morning at four a.m. Seetio Cadaver is.—Twenty-one hours after death. The body was livid and greatly emaciated. On reflecting the integuments from the thorax and abdomen, a nodulated portion of the liver, nearly separated from the rest, very movable, containing a large mass of cancerous exudation, and measuring four by two inches across, projected as a distinct tumour into the epigastrium, and was evidently the same swelling as had been felt during fife, through the in- teguments. Thorax.—The cavity of the left pleura contained about a pound and a half of recently coagulated blood. The pericardium contained about six ounces of clear straw-coloured serum. Heart much contracted. The whole of the thoracic viscera, together with the trachea, and great vessels, were removed en ?7iasse. The blood in the pleura was then seen to have issued from between the lobes of the left lungi through a laceration of the pleura, at the external and back part of that organ. The aorta being slit up, was found to be somewhat rough internally. At the outer part of the arch, where it joins the descending aorta, the left side of the vessel was perfo- rated by a nearly circular aperture, two inches in diameter, with smooth edges, which led into an aneurismal sac, the size of a large cocoa-nut, filled with a soft coaguluni. The aneurismal sac pressed and encroached on the left lung inferiorly, and communicated with the pleural cavity through a recent ragged laceration in the pleura costalis, three inches in length. Here and there immediately round the sac, the lung was infiltrated with blood, and greatly softened. In these places it was very thin, and preLented several perforations, through which hemorrhage into the lung must have taken place. No communication could be discovered between the aneurismal sac and the stomach or oesophagus. The whole arch of aorta was slightly dilated; the valves healthy. Between the thoracic aorta and the oesophagus there were two masses of glands, greatly enlarged from cancerous infiltration. The oesophagus itself was ulcerated about its middle, and the enlarged glands before men- tioned projected into its cavity. This ulceration surrounded the tube internally, and extended about three inches from above downwards, presenting a soft pultaceous sur- face, the result of disintegrated cancerous exudation. The lung presented throughout a number of small irregularly-shaped masses of exudation, not larger, in most instances, than four or five lines in diameter, and resembling masses of crude tubercle, but somewhat softer, and slightly redder in colour. There were also one or two larger masses, nearly globular in form, from one-fourth to three-fourths of an inch in di- ameter, of soft consistence, yielding a cream-coloured juice, and marked with one or two red vessels and reddish points. The bronchial glands were infiltrated with black matter, and mostly contained masses of cancerous exudation similar to, but smaller than, those in the lung. Abdomkx.—The peritoneum covering the diaphragm, as well as that in the pelvis and several other places, showed fungus-like projections and nodules of irregular 474 DISEASES OF THE DIGESTIVE SYSTEM. form—the largest two inches in diameter, flattened on their surface, of a Yellowish- white-colour, mottled with numerous red vessels externally. Internally thev were of a similar colour and appearance—crossed by fibres, which included matter of the consistence and general appearance of boiled ground rice. In the pelvic cavitv, at its most depending parts, there were about two ounces of bloody pus and lymph, infil- trated with blood, and here and there these existed in small patches on the surface of the intestines and parietal peritoneum. The liver was much enlarged, and weighed six pounds ten ounces. It contained numerous nodular masse*, which on the surface were cup-shaped. The largest were nearly four inches across, and were usually softened in their centre. On section, they presented the ordinary appearance of encephaloma of the liver, with the exception, that in many place* their substance was partly diffluent, and on section excavations or cavities were left in the mass. Some of them contained a creamy yellowish fluid, mixed with red, and others olive- coloured serum, with a large amount of flocculent and granular pinkish debris. Here and there, also, masses of reticulum were infiltrated among the whitish and greyi-h cancerous exudation. The liver itself was pale fawn coloured and very fatty. The stomach was perfectly healthy; but there was a simple stricture at the pylorus, which with difficulty admitted the introduction of the little finger, and which depended on hypertrophy of the areolar tissue between the muscular and mucous coats. The intestines were • extremely contracted; the colon not being above one-half inch in diameter. Kidneys pale, containing numerous small cysts. The epithelium, however, was nearly healthy, exhibiting under the microscope only a small quantity of granular matter. The mesenteric and lumbar glands were healthy. Microscopic Examination.—A small portion of the white and tolerably con- sistent cancerous exudation in the liver presented numerous cancer cells, varying greatly in size and shape, but none exceeding the l-50th of a millimetre in its longest diameter. Many were nucleated, and several were evidently breaking up and disintegrating. They were associated with some free nuclei, aud a multitude of molecules and granules—(Fig. 323). The recticulum was wholly composed of fatty molecules and granules—(Fig. 324). The broken down matter on the surface of the oesophagus, where it was ulcerated, closely resembled "that represented in Fig. .'!22, but was even more disintegrated. The milky juice squeezed from the glands between the thoracic aorta and the oesophagus, presented large cancer celh, which presented the various appearances characteristic of their undergoing the fatty dege- neration—(Fig. 323). Commentary.—During life, the pain in the stomach, the vomiting after food, the black bloody coagula rendered, and the distiuct nodulated and somewhat movable tumour in the epigastrium, left little doubt iu the minds of all those who examined the case, that we had to do with cancer of the pylorus. On examination after death, however, the tumour whicii had previously been felt, was found to be a nodule of cancerous exudation developing itself in the liver, a part of which had beeu pushed forward so as to occasion the swelling. As the rest of the liver was entirely hid under the ribs, it was not possible to have suspected this occurrence during life. The simple structure, however, that really existed in the pylorus, conjoined with the pressure exercised by the tumour on the valve, caused the vomiting that formed the principal fea- ture of the disease. The appearance of the matters rendered by the mouth proved that they must have come from the stomach; because, although a con- DISEASES OF THE LIVER. 475 siderable quantity of red blood was evacuated, this was commonly min- gled with rusty brown, and even perfectly black, coagula. Besides, on one occasion, he was actually seen by the clerk to render the blood by the act of vomiting; and the same thing was repeatedly observed by the nurse. At first, then, I considered that the cancer of the stomach had ulcerated internally, and poured out the blood evacuated; but lat- terly, from the large quantities discharged, my suspicions were fixed on the presence of an aneurism pressing on the lung, and communicating with the trachea, in which case he must have swallowed the blood. This supposition seemed to be confirmed by the existence of limited dulness on the left side, and by crepitation—an almost invariable con- comitant of aneurism so situated. On attempting, after death, to ascertain by what means the blood entered the stomach, I could not find any direct communication between the aneurism and that viscus, or the oesophagus. It may have resulted from the blood, in the first instance, having been infiltrated into the substance of the lung, tben passed through the bronchi, trachea, and laruyx, into the pharynx, and so been swallowed. More probably, how- ever, it was caused by intense portal congestion, producing hemorrhage from the capillaries. This man presented in a very marked degree the so-called peculiar Fig. 403. cachectic aspect of malignant disease. I have always noticed that this aspect is best marked in individuals labouring under cancer of the Fig. 408. Remarkable carcinomatous cyst in the liver ; a, part of diaphragm.- \Ogle.) Half the real size. 476 DISEASES OF THE DIGESTIVE SYSTEM. stomach, so situated as to interfere with the process of nutrition. It is stated in the report that he had previously been stout and fat—a condition I have pointed out in another place* to be favourable to the development of cancer generally. I am inclined to think that this malignant aspect, so much dwelt on by practitioners, is the mere result of emaciation from interference with the nutritive processes, or from pain and want of sleep, and is in no way distinctive of cancer in organs where such effects are not occasioned. Cancer of the liver may occur iu two forms—1st, That of distinct nodules, which have been so well described by Baillie and Farre; 2d, More or less infiltrated in minute grains throughout the hepatic tissue. The former is by far the most common, and when it presents projections from the surface of the organ, these constitute the only positive proof during life of its being affected with cancer. In some rare cases I have seen these two forms run into one another. Softening of the cancerous masses was well observed in the case just recorded, as well as its trans- formation into the fatty substance which forms the so-called reticulum. Dr. Oglef has recorded a case in which a cancerous mass in the liver presented on section the remarkable form of a cyst with thick walls, closely resembling a small cocoa-nut full of fluid. The walls exhibited the usual appearance and structure of encephaloma, and the fluid which occupied the centre was slightly turbid and contained shreddy particles of cancer and some fatty matter. In the majority of cases of cancerous liver, other organs of the body are similarly affected, rendering the dis- ease more or less complicated. (See Cases LXV. and LXXVI.) The treatment must be entirely palliative. DISEASES OF THE INTESTINES. Case LXXII.^:—Diarrhoea—Recovery. History.—Mary Gordon, set. 21, a thin weak-looking woman, lately employed as a herring-curer—admitted in the afternoon of July 25th, 1855. She has for the last two days been much exposed to cold and wet, and early this morning was seized with violent pain in the epigastric and lumbar regions, accompanied by shivering, sickness, and vomiting. At nine o'clock the bowels were freely opened, and since then she has had several fluid stools, with griping pain in the abdomen, and violent tenesmus. The matters discharged from the bowels she describes as watery, mingled with slime. She has taken some brandy, which caused slight relief. Symptoms on Admission.—On admission the tongue is white, appetite impaired, great thirst, no nausea nor vomiting at present, no tenderness over stomach or abdo- men. Bowels still loose; the matter discharged consists of a dirty yellow fluid, in which masses of mucus are floating. No blood nor pus. Pulse 84, full. Says she has occasional palpitations. Countenance slightly flushed. Considerable lumbar pain. Urine healthy. Other functions well performed. R Tr. Opii Z j; Conf. Aromal. 3j ; Mist. Cretct comp. § iij ; M. Half an ounce to be taken every three hours. * On Cancerous and Cancroid Growths. Edinburgh, 1849. f Trans, of Patholog. Society. Vol. ix., p. 238. % Reported by Mr. Shimon Mutakisna, Clinical Clerk. DISEASES OF THE INTESTINES. 477 Progress of the Case.—July 26th.—To day feels weak, but the diarrhoea ceased after the second dose of the mixture. July 21 th.—Still very exhausted. To have nutrients with wine § ij. daily. She rapidly recovered, and was discharged August 2d. Case LXXIIL*—Diarrhoza—Recovery. History.—Frederick Lyons, ast. 4—admitted December 19th, 1854. The mother says he has been fed regularly, if not plentifully, and up to two months ago he was quite healthy. He was then sent to school, ever since which he has had diarrhoea, the bowels being generally open five or six times a day. He has been losing strength up to the present time. Symptoms on Admission.—The child is now very thin, is always picking his nose. Tongue clean. Abdomen tumid and tender on pressure. Has had six stools within the last twenty-four hours, of fluid consistence and clay colour. Pulse 96, weak. Has never been known to pass worms. Other systems normal. Habeat 01. Ricini 3 ij. Nutritious diet. To remain in bed. Progress of the Case.—Diarrhoea diminished. Stools of a more healthy colour. Takes rice and milk greedily. From this time he rapidly recovered. All diarrhoea had ceased on the 24th. On the 27th he was allowed to get up ; there was then no tenderness of abdomen, and the tumidity had nearly disappeared. Discharged well, January 8th. Commentary.-^-The cases of diarrhoea here recorded are examples of the two most common forms of this disorder, the one originating from exposure to wet and cold, the other from irregularities in diet. In the first case the discharge was checked by opium and chalk, in the second by a mild aperient, proper nourishment, and rest. Many varieties of diarrhoea, or excessive discharge from the bowels, have been described by systematic writers, but pathologically they may all be referred to two causes, namely :—1st, A disturbance of the healthy conditions of the blood, leading to increased eliminating action of the intestinal mucous membrane, in various acute inflammatory diseases— when it may be critical—as after exposure to cold or wet, occasioning suppressed transpiration; in cholera; in leucocythemia; and so on. 2d, From irritating substances in the canal itself derived from food or drink ; from an increased amount of bile or other secretion; from struc- tural disease of the mucous membrane, as in dysenteric, tubercular, or typhoid ulcerations ; from worms or foreign bodies impacted in the gut, etc., etc. The indications for treating those two forms of diarrhoea are very different. In the first it may be sanative in itself, and only symp- tomatic, or the natural termination of a general disorder which it would sometimes be injurious and even dangerous to check. In the second, the diarrhoea is always hurtful if long continued, and our hopes of cor- recting it will mainly depend on our capability of removing the local irritating cause. Thus if, as very commonly happens, improper diet be the cause, this must of course be better regulated. If any special irritating substance has been taken, and occasions griping with tenesmus, a, simple warm- * Reported by Mr. Arthur W. Moore, Clinical Clerk. 478 DISEASES OF THE DIGESTIVE SYSTEM. water injection, slowly introduced, so as to distend and wash out the rec- tum, may at once remove it. If not, a dose of castor oil, followed by an antacid and anodyne mixture, such as the compound chalk mixture with a little Tr. opii, generally succeeds. To this, if the discharge con- tinue, the various astringents may be added, and given by the mouth or by the rectum. Quietude is a very necessary part of the treatment, and confinement to bed in all severe cases is of the greatest importance. When diarrhoea is symptomatic of deranged liver, of intestinal ulcera- tions, of worms, or other irritating cause, the treatment resolves itself into the appropriate method of removing the original disorder. The opposite disease to diarrhoea is constipation, which is diminished, difficult, or suspended discharge from the bowels. This also may be the result of constitutional or local causes, and give rise to indications for treatment directed to overcome the one and remove the other. In most cases, however, there is torpor and diminished nervous energy affect- ing the contractility of the intestinal muscular coat. All that I think it necessary to say here is, that purgatives, although necessary to over- come temporary obstructions and give immediate ease, do not tend in themselves to remove the causes of, and therefore seldom permanently cure, a constipation. The best means for accomplishing this are appro- priate diet, the use of particular kinds of food, such as brown bread, stewed fruits, etc.; exercise, baths, pleasure-excursions, a course of saline waters, etc., etc. In constipation, as in diarrhoea, should any structural disease or mechanical impediment exist, its treatment must be regulated according to the circumstances of the disease of which it is sympto- matic. The use of purgatives in intestinal disease is a subject of great im- portance, and one which appears to me to have been much misunderstood. It has been supposed, for instance, that a good alvine evacuation once a day is necessary to the healthy state of the body, and that an individual who only has such an evacuation once in two days, and sometimes iu three, is constipated. This idea has led to the habitual use of purgatives, and is the principal cause of the enormous number of aperient pills annually sold with government stamps in this country. The fact is, that many persons naturally never have a motion above once in two or three days, and retain their health quite well. The rule ought to be that iu all such cases purgatives are unnecessary unless inconvenience, or some decided symptom, follow retention of the fceces. Again, it has been sup- posed that purgatives are antiphlogistic, and so far has their administra- tion been deemed beneficial, that there is scarcely a disease, the treatment of which at one time was not commenced by a smart aperient, with a view of cleansing out the bowels, in order to have a clear field, as it were, for future operations. But purgation can in no way benefit a distant part actually inflamed, whilst its employment at the commence- ment of many diseases, and more especially of typhus and peritonitis, is positively injurious. The chief uses of purgatives are to overcome tem- porary obstructions, to remove irritating substances; to solicit the flow of bile and other secretions at the upper part of the canal, and to excite watery discharges in certain cases of dropsy. For this purpose the practitioner must be acquainted with the properties of the different kinds of purgatives, and choose such only as, when properly administered, will DISEASES OF THE INTESTINES. 479 best effect his object. Everything like routine practice should be avoided. Case LXXIV.*—Acute Dysentery—Recovery. History.—Timothy Flinn, aet. 14, a hawker—admitted November 26th, 1852. States that on the 22d inst., when in Perth, he was suddenly seized with looseness of the bowels, griping pains in the abdomen, and tenesmus not preceded by shivering. He attributes the attack to having breakfasted on oatmeal porridge, a kind of food to whicii he was not accustomed, although he had been much exposed to wet, cold, and fatigue. On the first day of his illness, the calls to stool occurred several times in an hour. On the following day he observed that he was passing blood with the fceces, and sometimes nothing but small quantites of thick bloody matter of tough consistence like glue. Notwithstanding these symptoms, he walked from Perth to Edinburgh, the frequent bloody stools continuing, but the pain gradually abating. Symptoms on Admission.—Tongue is dry in the centre, the tip and edges being clean and moist. Appetite much impaired; thirst moderate. Thinks he has had twelve stools during the last twenty-four hours, which were mixed with blood. Has still tenesmus and much straining, complains of a constant and rather sharp pain at the lower part of the abdomen, which is greatly increased on pressure, and follows the course of the sigmoid flexure and rectum. This pain, he says, appeared on the second day of his illness, a few hours before the appearance of the blood. Pulse 92, small and soft. Urine diminished in quantity, but healthy. Other functions well performed. R Tr. Catechu zssi Sol. JIur. Morph. 3j; Mist. Cretos comp. ad I viij. M. Sumat \) tertid qudque hord. Progress of the Case.—The bowels have been opened twelve or fourteen times since yesterday's visit. Pain still very severe in the left iliac fossa. A considerable quantity of blood and mucus in the stools. Applicent. hirudines xij parti dolenti. Injiciatur Enema Amyli cum Tr. Opiii 3 i. November 28th.—Six stools since yester- day, very watery, with traces of blood. No tenesmus. Continuetur Mist. Nov. 30th. —Six stools, more fceculent, and without blood. From this time he rapidly recovered, and was dismissed quite well, December 9th. Case LXXV.f—Sub-Acute Dysentery—Recovery. History.—John M'Gee, set. 38, a mason's labourer—admitted June 29th, 1853. Says that last summer he was confined to his house for twenty-six weeks, in conse- quence of severe bowel complaint, and has been subject to diarrhoea every now and then ever since. He returned to his work last February, but was again obliged to desist nine weeks ago in consequence of the severity of the bowel complaint and weak- ness. Three weeks since he observed the stools to be tinged with blood. Six days ago he vomited a tenacious mass of the appearance of white of egg. He has been much addicted to the use of ardent spirits, and is very intemperate. The medicines he has taken have been of little benefit. Symptoms on Admission.—Tongue smooth and moist anteriorly, but somewhat loaded at the base. Appetite tolerably good. No fever. There is tenderness on pressure over the abdomen generally, and frequently griping pains. Has about * Reported by Mr. "Win. Calder, Clinical Clerk. \ Reported by Mr. J. D. Maclaren, Clinical Clerk. 480 DISEASES OF THE DIGESTIVE SYSTEM. thirteen stools a day, which are thin, of pale yellow colour, containing a quantity of pus. Pulse 80, weak. Other systems healthy. R: Pil. Plumb. Acet. Sumat unam quartd qudque hord. Habeat suppositor. cum Mur. Morph. gr. ss vespere. July \st.~ Increased pain in the abdomen. App'icent. hirudines vj. July 2d.—No change. Complains of thirst. Intermit. PH. Plumb. R Confect. Aromat. 3 ss; Sol. Mur. Morph. Z iss; Tr. Catechu 3 vj; Mist. Cretot 3 v. M. A table-spoonful to be taken every four hours. Habeat Enema Amyli cum Tr. Opii. min. xl. ty Lactis recentis 3 x; Aq. Calcis 3 viij. M. To be used as drink. July 4th.—Has now only six stools in the twenty-four hours. Complains of dysuria, and has only passed nineteen ounces of urine daily for three days. R Sp. JEther. Nit. § ss; Pot. Acet. 3 ij ; Syr. Aurant. z i • Aquos ? ivss. M. A table-spoonful to be taken three times a day. July 7th.— Has now only three or four stools daily, which are fceculent. No dysuria. Urine more copious. Considerable uneasiness in the epigastric region. Omit. mist, diure- tica. Applicet. Emp. Lyttm (3 + 4 ) epigastrio. Habeat Enema Opiatum vespere. July 25th.—Since last report has had about three stools on an average daily. He feels much stronger. Aug. 1st.—Has had occasional exacerbations of fever, with thirst accompanied by increased looseness, which have been checked by the Pil. Plumb. Opiat. From this date he continued slowly gaining strength, taking occa- sional exercise, but subject every now and then to relapses, for which he was ordered tannin with opium, and occasional suppositories. Gradually the pus disappeared from the stools, which became more fceculent and regular. He was dismissed quite well, September 20th. Case LXXVL*—Chronic Dysentery—Ascites and (Edema of the Legs—Leucocythe- mia—Cirrhosis of the Liver—Cancer of the Lung. History.—Thomas Crease, set. 28, single—admitted May 27th, 1857. Has been of intemperate habits. Since November 1856 has been troubled with violent cough. —sputum being tinged with blood; voice hoarse ; feet and legs more or less swollen, hot and tender, especially around the ankles. This attack dated from a definite day which he could not name in November 1856, after exposure to cold while crossing at Queensferry. He was under treatment in the Infirmary from March Gth to April 28th, 1857; there were present during that time cough, with bloody or rusty sputum, which, however, occasionally become frothy and mucous; a doughy and cedematous condition of the feet, and latterly of the hands ; an unusual temperature of skin, and a pulse more or less thrilling and hard. There was no diarrhoea. After leaving hospital he was for four weeks under quack treatment; getting steaks, ale, and brandy almost ad libitum. No relief was obtained; the heat of skin, thirst, and exhaustion continued, and the bowels became loose. The cough became less troublesome, aud the expectoration scanty. Symptoms on Admission.—Percussion note is rather flat on the right side 0. thorax anteriorly and over the upper half on same side posteriorly. The respiratory murmurs are very feeble. When audible they are harsh; no sibilus nor moist rale; vocal resonance increased under right clavicle; no dyspneea; no cough nor sputum to-day. Cardiac impulse weak; the transverse dulness is normal; the sounds are normal, hut a systolic blowing murmur is said by the clerk to have occurred for- merly at night. It is not now audible. The pulse 126, rather full and hard. The tongue is covered with fur; thirst great, appetite bad. Abdomen on palpation is natural; no dulness on percussion, nor tenderness on pressure. The bowels are re- ' ported loose, hut patient does not complain of their frequency. Urine is quite natural. * Reported by Messrs. John Lowe and Stewart Lockie, Clinical Clerks. DISEASES OF THE INTESTINES. 481 The skin over the body generally is of an unusually high temperature and dry. No lesion of the nervous system ; is exhausted, and is mentally despondent. Is ordered wine (1 iij) and saline diaphoretics. Progress of the Case.—May 31s/.—Sputum rather frothy, semi-transparent, gelatinous, slightly tinged with blood; pulse 114; febrile condition the same; the diarrhoea has not ceased. June 3d.—Diarrhoea continues; fceces of a light yellow colour and pea soup consistence, of an extremely fceculent odour, presenting on micro- scopic examination no blood discs nor other abnormal bodies. Ordered an astringent and cha-'k mixture. June 7th.—Febrile symptoms continue ; ordered 3 grains of qui- nine thrice daily. The diarrhoea slightly abated; continue the astringent mixture. June 11th.—Diarrhoea continues with much tenesmus; frequent calls (from 6 to 8 times) at night to stool; evacuations at each time are scanty; stools watery. Let him have an opiate suppository at night, and after every stool let the following enema be ad- ministered : R Plumb. Acetat. 3j ; Aq. Distill. § iss; Sol. Mur. Morph. 3 ss. June \",th.—Patient expresses himself as better, and the febrile excitement is diminished. June 24th.—The diarrhoea has not ceased ; the injections cause pain, and are speedily ejected ; they are now discontinued ; ordered half ounce of the decoction of the Indian Bael thrice daily. June 27th.—In additition to the decoction, let him have, thrice daily, one of the following powders : R Pulv. Cretat prep. 3 ij ; Confect. Aromat. 3 j ; Pulv. opii, gr. iij. M. et divide in chartulds duodecem. July 2d.—Febrile symptoms and diarrhoea much diminished ; skin cooler; pulse 86, of moderate strength ; oedema of the legs is much less than formerly. On the 4th, he becomes worse ; on the 5th, feels better; on the 8th, diarrhoea again more severe, and febrile symptoms renewed. On the 9th, the blood was microscopically examined, and an increase of white corpus- cles was detected (from 20 to 25 being visible in one field), and the red discs arranged themselves in irregular masses. On the 11th, the powders and decoctions are discon- tinued, and a mixture of Kino, Catechu, and Simarouba was given. On the 13th, the diarrhoea being persistent, the use of the powders is resumed, and at night an astrin- gent injection. On the 15th and 17//;, is better; on the 20th, is worse and seldom off the stool; on the 21st, is better, having had only three stools; on the 24/A, has six stools, skin being burning hot, pulse 120, hard, and apparently strong, but patient complains of great debility. July 26th.—Great thirst; pain over abdomen, which is relieved by a turpentine epithem. Abdomen is tense, with skin white, glistening, and dry; percussion very tympanitic anteriorly ; is slightly dull over the flanks. July 28th.—Patient is extremely weak ; feces are passed in bed. Urine is examined and found non-albuminous ; has been delirious this morning. July 29th.—No return of the delirium; swelling of abdomen increased; the diarrhoea and febrile state con- tinue; pulse 112; very weak; great thirst. July 30th.—Died this morning at 9.30 a.m. Sectio Cadaveris.—Forty-eight hours after death. Body.—Moderately emaciated ; oedema of feet and legs; face with a peculiar fever- ish expression. Thorax.—Heart was quite natural. The two upper lobes of right lung healthy: the lower lobe felt heavy, presenting a rounded prominence about three inches in diameter, projecting from its surface. On section it was found to be a mass of soft cancer, of an oval form, about the size of a fist; greyish or pinkish-white in colour, with some opaque yellow patches (reticulum) intermixed with it. It readily broke down under pressure, and part had already undergone softening. In its neighbourhood were two otlier masses of similar character, about the size of small marbles. In the lower lobe of the left lung there was a cancerous mass of the size of a filbert; other- wise the lung was healthy. The bronchial glands were natural. Abdomen.—The peritoneum contained nearly a gallon of a somewhat opalescent 31 482 DISEASES OF THE DIGESTIVE SYSTEM. serum. The liver was of small size, and presented a coarsely granular surface. On section it was found in a moderately advanced state of cirrhosis ; it weighed 2 lbs. 8 oz. The spleen was quite natural, and weighed 6 ounces. Kidneys healthy. Stomach normal. The coats of the small intestines were generally thickened and cedematous but there was no trace of ulceration. The mucous membrane of the large intc-tioes was found extensively ulcerated, chiefly in the transverse and descending colon. There were a few in the caecum and upper part of the rectum ; they ceased altogether about 3 inches above the anus. The calibre of the intestine was diminished. The ulcera- tions were of a very chronic character, there being no increased vascularity of the sur- rounding mucous membrane. They were generally arranged in a linear direction, parallel to the long axis of the gut. Many were nearly cicatrized, presenting in the base and margin an accumulation of dark-coloured pigment. There were pretty numerous slate-coloured cicatrices, indicating the position of former ulcers. No other lesion was found. Microscopic Examination.—The cancerous exudation in the lungs contained numerous cancer cells in all stages of development. Some of them were very large, and contained from three to five secondary cells. Several of them contained clear col- lections of fluid, as represented Fig. 126. Commentary.—The three cases now related present the same disease in different degrees of severity. In the first there is every reason to suppose that, though severe, it was not extensive. In the second it was more chronic, but ultimately the patient got well. In the third, it went on to such extensive ulceration, kept up such constant irritative fever, and so interfered with nutrition, as, conjoined with the other lesions under which the man laboured, to cause death ; on dissection afterwards it was seen that he had had chronic disease of the liver, which had caused ascites and oedema of the extremities. On this had supervened the inflammation of the lower bowel, especially of the colon, which had proceeded to ulceration, extending over a considerable portion of the mucous membraue. In many places the ulcers had healed, while in others there was exhibited a tendency to cicatrization; and it U very possible that a recovery might have occurred in this case, as in the one which preceded it, but for the hepatic disease, which, by keeping up con- stant congestion of the portal system, and therefore of the intestinal venous capillaries, must have opposed itself to all successful efforts at cure of the ulcers. The masses of cancer developed in the lower portion of the lungs, and which gave rise to many of the symptoms of pneumo- nia, especially cough and bloody expectoration, cannot be said to have had any influence in producing the fatal termination. In the case of Crease I employed, as an astringent, a decoction of the unripe fruit of the Indian Bael, commonly called the Bengal Quince. It is said to contain tannin, both free and in a combined state, aromatic principle, mucilage, aud a small amount of bitter principle supposed to be sedative. The decoction must be used fresh, and is prepared by sim- mering two ounces of the unripe fruit in a pint of water down to a fourth, of which from one to three tablc-spooonfuls constitute a dose. In the case of a gentleman under my care, whose obstinate diarrhoea had resisted all the usual means, this decoction checked the disorder permanently after a few doses; and I have since given it with great advantage in similar cases. In the case of Crease it was of no benefit whatever, in- deed it cannot be supposed that where actual ulcerations exist over a DISEASES OF THE INTESTINES. 4S3 considerable portion of the mucous surface of the colon, any remdies can produce an impression on the alvine discharges. These are the result of the organic lesion, so that medicines merely directed to the symptoms, unless they favour cicatrization, cannot operate with effect. This requires time, general health of body, avoidance of irritating food and mental excitement, quietude, a good atmosphere, pure water, etc. etc.—in short, local agents inust be combined with all those general remedies and hygienic conditions calculated to improve the vital powers, and favour regeneration of tissue. Diarrhoea and dysentery pass into one another; a great variety of lesions may induce the first, but the last is considered to be a true inflammation of the large intestines. Hence the symptoms of dysentery are local pain accompanied by fever, and attended with a discharge from the bowels, first of blood, and then of pus. The blood results from rupture of the capillaries consequent upon the congestion, and is mingled with the mucous discharge. Fluid exudation is at first poured out on the surface and passes away from the bowels with the excess of mucus and blood, but subsequently purulent matter is thrown off from the ulcerated surface of the mucous membrane. The character of the fcecal evacuations should be carefully attended to, not only in dysentery, but in all forms of intestinal disease. In health the fcecal evacuation consists of a soft solid mass, forming a mould of the outlet at the anus. It is mingled with bile, and presents a dark brown colour. Tts odour, though fcecal, is not putrid. Asa general rule, the more the alvine evacuation departs from its normal consistence, colour, and odour, the more violent in the cause which occasions the chauge. Thus, as regards consistence, the discharge from the bowels may be fluid, though fceculent, sometimes resembling pea-soup, the characteristic stools of active typhus. The discharge, again, may be watery through an excessive amount of serum, resulting from congestion of the vessels, or occasioned by saline and drastic cathartics. In cholera the discharge resembles rice-water, and is largely mingled with pure desquamated epithelium. It may consist of shreds of glairy mucus, which is very common in females with uterine disease, and sometimes of masses of recently coagulated exudation, or a substance like white of egg. In colour it may he paler than natural, to such a degree as to be clay- coloured or almost white, indicating a diminished quantity of bile. It may be red, reddish-brown, grass-green, or absolutely black, from the presence of blood, and according as blood has been poured into the intestine more or less near its outlet, or as chemical changes have occurred in it before being discharged. In otlier cases it may be of a dark leaden hue, or of a dirty yellow more or less resembling pus. If pus and blood appear in the stools almost pure, then these fluids have been poured out not far from the orifice; the more they are mingled with fceculent or fluid matter, the more is their origin distaut. Constant fluid stools of a uniform colour are generally derived from the small intestines. As to odour, the more offensive and putrid, the greater '■•* the indication of absence of bile in some cases, and prostration of the vital powers in others. In the examination of the fceces the microscope will be found of the greatest service. (See p. 83.) 484 DISEASES OF THE DIGESTIVE SYSTEM. The morbid anatomy of dysentery and of enteritis generally is a most extensive subject, for which I must refer you to the various special works which treat of it. It will suffice to say that the seat of the exudation is for the most part the areolar texture below the basement membrane but pressing principally on the mucous surface, and giving rise t > hemorrhages ulcerations, purulent discharges, etc. If the disease be chronic, the muscular coat becomes hypertrophied, causing thickening and rigidity of the intestinal tube. If violent gangrene occur, the mucous surfuce after death presents a deep red colour, wbich is caused by congestion of the vessels; sometimes bright green patches are mingled with the red and result from alteration in the colour of extravasated blood; then again, brown or blackish sloughs may be observed from decomposition of the injured texture. Typhoid enteritis will be subsequently described. (See Fever.) Tubercular enteritis is a common complication of phthisis, generally hurrying on the fatal result. Cancerous enteritis is by no means uncommon. The structural changes observed in the mucous membrane in cases of diarrhoea and dysentery are—1st, Degeneration of the epithelium; 2d, Congestion of the vessels and hemorrhage; od, Exudation; 4th, Morbid changes in the various glands. 1. The readiness with which the epithelium is separated from the basement membrane of the intestinal mucous membrane varies much in different animals. For instance, I have found it to be easily separable in dogs, while in cats it is very firmly adherent. This circumstance explains, to a certain extent, the different ideas put forth by experimen- talists as to the function of the epithelium in digestion. Some maintain that it is cast off so as to admit of endosinose through the naked villus; whilst others maintain that endosmose is carried on through the agency of the epithelial cells themselves in situ, which I believe to be the correct doctrine. In man the epithelial cells are easi- ly separated, and their separation constitutes a morbid state of great importance, because if, as I suppose, they be the organs of primary assimilation, their re- moval must interfere with nutrition. This I consider to be one of the reasons why chronic diarrhoeas, aud more especially cho- lera, in which disorder the rice-water stools consist chiefly of serum, containing desquamated Fig. 409. Vascular congestion and sugillation of the mucous membrane of the small intestine in cholera, a and b, Congested tortuous vessels in villi, which are deprived of epithelium; c, The veins only congested in four villi; d. Extravasation of blood below the basement membrane, and around the glands of Liebcrkuhn.—(II «»••) 50 diam. DISEASES OF THE INTESTINES. 485 epithelium, and so prostrating to the economy. Of course the inter- ference with nutrition so occasioned will be in proportion to the extent of mucous membrane affected. 2. Great congestion of the vascular plexus, which ramifies in the villi and around the glands, is one of the most common appearances seen after death in the intestinal mucous membrane; it is often associated with extravasations of blood more or less extensive. This lesion may be conjoined with all the others to which this texture is liable, and is at once visible both to the naked eye and on mi- croscopic observation. In all cases of acute diarrhoea, dysentery, and in cholera, this morbid change may be recognised. 3. Exudation may occur below the base- ment membrane, infiltrating the areolar texture between it and the mucous coat, occu- pying the villus and surrounding the various glands; or more rarely, it may appear on the surface of the mucous membrane, pre- senting adherent coagula. In the former case it undergoes the usual transformations, giving rise, according to circumstances, to purulent collections, fibrous growths, or ulcerations varying in extent, which mav or may not ultimately cicatrize. In the latter case the coagulated exudation rarely presents a fibrillated structure, but rather a dense aggregation of fibrinous amorphous substance, which disin- tegrates or passes into pus. Within the villi it often assumes an opaque brownish colour, and passes into granule cells, while the blood, which has been extravasated or arrested in the vessels, is transformed into black pigment (Fig. 410, b, c, and d). 4. The morbid changes in the various glands have been more especially studied in relation to ty- phoid fever, under which head I shall again refer to them. There can be no doubt, however, that the glands of Brunner and Lieberkuhn, as well as those of Paj'er, are constantly undergoing alterations, pro- bably similar to those so well described by Dr. Handfield Jones in the Fig. 410. a, Granular mass, in recent exudation on the surface of the intestinal mucous membrane; 6, Summit of a villus, containing black pigment, at +, in a vessel; c, Summit of a villus, containing a brown exudation: d. Another villus, with the exudation transformed into granule cells and masses.—( Wedl.) 2.10 dia,,,. .. *'ff- *H- A'i enlarged Payerian sac from the colon of a child, a, Glands of Lieberkuhn; 6, Macular layer; c. Sub-mucous tissue; d, Transverse muscles; e, Se- rous membrane ; /, Depre^ion of mucous membrane over the sac, g.—(Kolliker.) 50 diam. 486 DISEASES OF THE DIGESTIVE SYSTEM. stomach, although few histological and clinical researches have as yet been made regarding them. In children, in whom the intestinal mucous membrane is active and easily irritated, the shut sacs of Payer are often unusually large. (Fig. 411.) The treatment of ordinary dysentery, such as we meet with in this country, may be gathered from the cases recorded. It consists, 1st In careful regulation of the diet, which should be nutritive butunirritating- 2d, In confinemfent to bed ; 3d, In the use of antacids and astringents to check the discharges; and 4th, In the employment of leeches, fomen- tations, and poultices locally, and of opium internally to relieve pain and diminish irritability. It should not be forgotten, however, that, although in consequence of inflammation there may be abundant diarrhoea, this may be conjoined with a true constipation; in other words, the excrement which it is necessary for the body to throw out, may be retained in the coecum or upper part of the canal, in con- sequence of the contraction or irritability of the canal lower dowu. Hence it is necessary occasionally to administer a small dose of castor oil or other mild aperient, to secure the passage of effete matter from the system, a point in practice requiring great care and experience. Derangements of the alimentary canal constitute the great majority of children's diseases. In them this portion of the economy is actively engaged, not only in developing itself, but in producing, by means of digestion and assimilation, an excess of nutritive materials for the blood. During these processes of evolution, the functions of the alimentary canal are especially liable to be disordered, and frequently, as a result of the irritations thereby occasioned, various convulsive or diastaltic affec- tions arise. In all such cases the practitioner should endeavour to remove local irritations and support nutrition. The former object is best accomplished by antacid medicines, especially chalk and magnesia, and occasionally a mild aperient, such as castor oil; the latter, by careful attention to the diet, procuring a healthy nurse, etc. The constant flow of saliva during dentition, the vomitings from ovcr-distention of the stomach, and occasional diarrhoea in weak children, are often salutary discharges, which only require watching and hygienic regulation, aud will, it is hoped, no longer be mistaken for symptoms of an active inflammation which require antiphlogistic remedies. Case LXXVIL*—Obstruction of the Large Intestine—Cancer of Stomach, Lieer, Peritoneum generally, and Mesenteric Glands. History.—James Sturgeon, jet. 21, tax collector—admitted into the Clinical Ward of the Royal Infirmary, September 14, 1853. He noticed for the first time last January that his appetite had diminished, and that he was greatly troubled with flatulence, vomiting, and constipation. These symptoms continued until three months ago, when the abdomen became swollen, and gradually so distended, that he applied to Dr. Alison, under whose treatment ihe vomiting nearly disappeared. He then noticed several hard lumps in the abdomen, varying in size from a walnut * Reported by Mr. Wm. Calder, Clinical Clerk. DISEASES OF THE INTESTINES. 487 to a hen's egg. These, since then, have continued to increase in size, and have become very painful on pressure. Progress of the Case.—October 26th.—Since his admission the appetite has been gradually failing, and he has become daily thinner and weaker. He has expe- rienced considerable pain in the abdomen, combined with a feeling of tightness and constriction there. It has always felt tense, and contained more or less fluid, but until a fortnight ago, the tumours formerly mentioned could be felt very distinctly, separated from the walls of the abdomen by a thin layer of fluid. The bowels have been greatly constipated. The treatment has consisted in the administration of diuretics of every kind, with strong purgatives, enemata, warm fomentations to the abdomen, and occasionally anodyne draughts at night. On taking charge of this patient to-day I found his condition as follows :—Great emaciation ; complexion of a cachectic waxy appearance; skin cold and dry; tongue moist, with a brownish fur: breath offensive; very little appetite; only occasional vomiting; and no thirst. Bowels have not been opened for four days, a draught of castor-oil with a drop of crotnn-oil havinc merely brought away a few hard lumps of foeces of a dark colour. Purgatives do not cause griping. The abdomen is greatly enlarged, and tense, but with a distinct feeling of fluctuation. No tumours can now be felt, but during inspiration distinct friction can be felt by the hand, and heard by means of the stethoscope. Pressure only causes a trifling obscure amount of pain, but his chief complaint is from the sense of constriction. The pulse is 70 ; regular and feeble. A murmur is audible with the first sound cf the heart, at the base; action is regu- lar; no palpitation. There is dry cough and slight dyspneea. The respiratory sounds are feeble, but otherwise seem natural. Urine healthy. From this time he gradually sank. OZdema appeared in the inferior extremities; vomiting became more severe, and at length constant, whenever food or drink was taken. All kinds of medicines failed even as palliatives; emaciation became extreme, and he sank November 5, the bowels having been obstinately closed for ten days. Scctio Cadaveris.—Forty hours after death. Thorax.—Pulmonary tissue everywhere spongy and crepitant. On the superior lobe of the left lung there were two cicatrices, and on the right pulmonary pleura there were similar patches, more widely scattered, extending over the whole of superior, middle, and inferior lobes. Purulent mucus was easily pressed from seve ral of the bronchi. No carcinomatous nodules were found in the pulmonary tissue, but the whole intercostal pleura was studded over with small irregular plates of cancerous exudation, bearing a considerable resemblance to the eruption of small- pox. Heart small; muscular substance pale fawn-coloured. The pericardium shows on its external surface numerous cancerous nodules from the size of a pin's head to that of a small flattened coffee bean. Bronchial glands at the root of lung swollen, some of them the size of a pigeon's egg; all infiltrated with cancer, and some mingled with black pigment. Abdomen.—The liver was smooth on its surface. Inferiorly and laterally it was closely adherent to the diaphragm, the pleural surface of which was covered by lamina; of cancerous matter. On stripping off the diaphragm the peritoneal covering of the liver was seen infiltrated with cancer, in some places to the depth of half an inch. Substance of liver presented the usual appearance of the white tubercle of Farre; it was pale, soft, and very fatty. The spigelian lobe of the liver, the omen- tum, epigastric glands, spleen, and pancreas were united together, and formed a large irregular and whitish mass extending across the abdomen, and weighing 4 lbs. This mass formed, on the right side, a dense wedge pressing in the right iliac fossa upon the ascending colon immediately as it leaves the ccecum; this bowel was filled, 488 DISEASES OF THE DIGESTIVE SYSTEM. but not distended, with firm yellow fceces, but the ascending, descending, and trans- verse colon were empty and collapsed. The peritoiieum covering the intestine was dotted all over with nodular projecting masses, varying in size from a millet seed to a hazel nut, in colour from white to deep red, and even almost black, and in con- sistence from soft pulpy matter to nodules considerably indurated. The whole of the abdominal peritoneum was closely covered with similar irregular nodules for the most part of soft consistence, with here and there a little coagulated blood. There were two gallons of sanguineous serum in the peritoneal cavity. Spleen small, but healthy; it was closely adherent to the diaphragm above and the can- cerous mass below, and on section seemed to be surrounded by a thin layer of cancer infiltrated in the peritoneum superiorly, while inferiorly the cancerous mass all round it is 1^ inch in thickness. Stomach imbedded, and also compressed, in the cancerous mass, which was everywhere adherent to its peritoneal surface. Its mucous mem- brane, as well as that of the alimentary canal, was quite healthy. On section of the mass it presented the uniform appearance of white lard, giving to the finger a feeling of considerable firmness. It yielded no cancerous juice, but was friable, rea- dily breaking down under pressure. Microscopic Examination.—The whole of the cancerous exudation on the peri- toneum exhibited numerous cancer cells in some places mingled with fibres, in others associated with numerous oil granules and granular cells. The white ina.ws on the pleura; were principally composed of fibres, but on the addition of acetic acid might be seen to be crowded with cancer nuclei. Commentary.—In this case it was observable that the vomiting did not occur regularly after taking food, and that the ejected matters con- sisted of the ingesta, and were never mixed with recently extravasated or altered blood. This indicated that no ulcer or erosion of the stomach had taken place. That the peritoneum and mesenteric glauds were the principal textures involved, was indicated by the nodular swellings felt, and the friction sound audible over the peritoneum, and the abdominal distension from accumulation of fluid. The continued constipation also indicated some mechanical contraction of the gut, obviously owing to cancerous deposition in some way pressing on or constricting it,—all which suppositious were proved to be correct on examiuatiou of the body after death. Case LXXVTII.*—Strangulation of the Small Intestine from Inguinal Hernia—Gan- grene, Ulceration, and Perforation of the Intestine—Peritonitis. History.—Margaret Bruce, set. 47—admitted September 25th, 1848. Says that she has occasionally had a swelling in the left groin for the last nine years, that has always gone away on lying down and applying warm fomentations. On the 18th, while carrying a large bucket of water up stairs, she felt something give way in the left groin. On the following morning she suddenly awoke with rigors, shortly followed by nausea and vomiting. The left groin also felt painful, and she perceived a tumour there the size of a man's fist. Purgatives were now taken without causing any action of the bowels. The vomiting, however, became more intense, and the matter ejected more of a dark brown colour. In this condition she has continued ever since. Symptoms on Admission.—On admission she lay on her back, with the thighs * Reported by Mr. T. N. Fanning, Clinical Clerk. DISEASES OF THE INTESTINES. 489 flexed on the abdomen. The countenance was sharp, sallow, and expressive of great suffering. Extremities cold. Pulse 120, small and weak. Respiration difficult, especially during inspiration. Percussion and auscultation of the che.t elicit nothing abnormiil. Tongue white, but red at the top and edges. Bowels have not been opened for eight days, and there is frequent vomiting of matter like coffee. Skin of abdomen is hot and distended, and she complains of great pain in the umbilical and left iliac regions on the slightest touch. A fluctuating tumour, the size of an orange, occupies the left groin, over Poupart's ligament. Urine scanty but normal. Menstrua- tion has been irregular. Other functions normal. Mr. Syme was consulted, who opened the tumour, from which there was evacuated about § v. of foetid serum, mixed with dirty yellow purulent matter. Warm fomentations to be applied to the abdomen. To have one grain of opium in the form of pill, immediately. In the evening the symptoms were the same, with the exception of the abdominal pain, which is more violent, and appears as if she was cut with a sharp instrument. Has had three injec- tions of warm water, which return unaltered. To have Pulv. Opii, gr. ij. every hour. Progress of the Case.—September 26th.—No change. The opium produces no effect whatever. Strong beef tea to be taken in small quantities. To eat as much ice as she pleases. Sept. 27th.—Vomiting, abdominal pain, and intestinal obstruction, con- tinue. Abdomen considerably swollen. Sore in the left groin looks very unhealthy. Thirst and dryness of the lips and fauces are much relieved by the pieces of solid ice. Has taken opium in three grain doses every second or third hour, which has caused apparently no effect whatever. Sept 29th.—Vomited matters to-day are distinctly fceculent. The abdomen above the umbilicus and in the left flank is greatly swollen, very tender, and tympanitic; over the right lower third it is collapsed. A dirty sanious discharge is poured from the wound in left groin. Pulse 110, very small and weak. Tongue brown and dry. Quite sensible, but much exhausted. Utters low moans, and complains principally of dryness of mouth and throat, which continues to be relieved by the ice. Bowels continue closed. To have a tablespoonful of wine and beef-tea every hour, and § viij. of beef-tea injeeted into the bowels slowly, flight and morning. Pulv. Opii, gr. iij. to be given only at night. Sept. 30th.— The discharge from the groin to-day is fceculent, as well as the vomited matters. Complains of no pain, but there is commencing delirium. Pulse 100, scarcely to be felt. Prostration extreme. Distension of abdomen, and other symptoms the same. Died October 1st. Sectio Cadaveris.—Thirty-six hours after death. Body pale and emaciated. Over Poupart's ligament was an oval ulcer, measuring an inch and a half in its longest diameter, whicii wras slightly oblique from above down- wards. Its base was superficial, of a brownish-black colour, and fceculent odour. Thorax.—Slight chronic adhesions between pleurae on right side. Lungs some- what emphysematous anteriorly. Thoracic organs otherwise healthy. Abdomen.—On opening the abdominal cavity, the liver, stomach, and intestines superiorly, were seen to be covered by a uniform membranous expansion of lymph. The remainder of the intestines and the uterus were matted together, and bound down to the left side of the pelvis, leaving a considerable cavity in the right side, which was occupied by about a pint of dirty reddish-brown fluid, possessing a strong fueculent odour. On separating the intestines, a knuckle of the ileum, in its upper third, was found to be strangulated in the left inguinal ring, presenting externally to it, and forming the base of the ulcer, two soft prominent projections. On the summits of these were two ragged ulcers perforating the gut. Into the superior of tliese a probe only passed a few lines; into the inferior it readily passed into the 490 DISEASES OF THE DIGESTIVE SYSTEM. dilated and upper portion of the intestine. The duodenum, jejun um, and three or four feet of the ileum, up to the point of strangulation, were greatly distended with flatus and fluid feces, resembling that found in the right side of the peritoneal cavity. The small and large intestines below the strangulation were collapsed and apparently contracted. About eight inches from the strangulation, in the upper part of the gut was an ulcer the size of a halfpenny, with two perforations in its centre, each about the size of a goose's quill, through which fluid fceces had escaped into the peritoneal cavity. For about eighteen inches, extending from the strangulation, the ileum was of a dark mahogany, and in the centre, as well as near the strangulation, of a claret colour, evidently gangrenous. The rest of the intestines and other abdominal organs were healthy in texture. The gall-bladder was distended with tenacious bile having the appearance of tar. Commentary.—In this case the intestine had been strangulated in the inguinal ring seven days previous to admission, and the symptoms on her coming into the house were not only those of intestinal obstruction, but of peritonitis also. Purgatives had been administered before she came in. Mr. Syme recognized an abscess which was opened without causing relief, external to, and covering the hernia. In the evening, peritonitis, with symptoms of perforation, was more unequivocally pro- nounced, and the case became hopeless. Large doses of opium failed to relieve the pain. Ileus was established on the 11th, and an artificial anus on the 13th day, without relief—gangrene and perforation of the intestine having caused escape of foeces into the peritoneum, and of course death. The two cases previously given exemplify two modes in which the intestinal canal may become permanently obstructed, viz., by morbid growths compressing it from without, and by the strangulation of a hernial protrusion. An instance of internal obstruction from a band of lymph acting as a ligature, and constricting the gut, will be found under the bead of Ovarian Dropsy. (Case of Jessie Fleming.) A variety of other causes may also occasion permanent obstruction, such as invagina- tion, accumulation of fceces or foreign bodies, and calculi impacted in the tube, inflammation, gangrene, paralysis, etc. In most of these cases dis- tension of the upper and corresponding collapse of the inferior portion of the intestine occur, followed at length by ulceration or rupture, occasion- ing fatal peritonitis. Vomiting is a common symptom of permanent obstruction, and when the disease is far advanced, the fceces are pro- pelled backwards, and rendered by the mouth, constituting ileus, as in Case LXXVIII. The pathology of this anti-peristaltic action of the tube has been much discussed, more especially as to whether it be owing primarily to spasmodic contraction, or to paralysis. In all such cases it has been found that one portion of the intestine has been over distended, and another collapsed, and thus, even though a mechanical obstruction does not exist, a portion of the tube may be inflamed, and even gan- grenous, giving rise to ileus, without the passage being actually closcl. In these cases the cause of the obstruction producing ileus is not easy * See Abercrombie on Diseases of the Stomach an Abdominal Viscera.—Cases xxx., xxxi. and xxxvi. DISEASES OF THE INTESTINES. 491 to determine; but the reasoning of Abercrombie on this point has always appeared to me so good, that I shall quote it in his own words. " If we suppose, then, that a considerable tract of the canal is in a col- lapsed state, and that a mass of alimentary matter is propelled into it by the contraction of the parts above, the series of actions which will take place will probably be the following :—When a portion, which we shall call No. 1, is propelling its contents into a portion Xo. 2, the force exerted must be such, as both to propel these contents, and also to overcome the tonic contraction of No. 2. The portion No. 2 then con- tracts in its turn, and propels the matter into No. 3 ; this into No. 4, and so on. Now, for this process going on in a healthy manner, it is necessary that each portion shall act in consecutive harmony with the other portions; but there appear to be several ways in which we may suppose this harmony to be interrupted; (1st) If the portion No. 1 has contracted and propelled its contents into No. 2, and No. 2 does not contract in its turn, the function of the whole will be to a certain extent interrupted, and the contents will lodge in No. 2 as in an inanimate sac. The parts above continuing to act downwards, one of two results will now take place : either the parts above will be excited to increased con- traction, and the matters will be forced through into No. 3, indepen- dently of the action of No. 2, and so the action be continued; or, new matter being propelled into No. 2, this will be more and more distended, until an interruption of a very formidable nature takes place in the function of the canal. (2d.) If, in the series of actions now referred to, No. 2 contracts in its turn, while some obstacle exists to the free dilata- tion of No. 3, it is probable the motion may be so inverted, that the contraction of No. 2 may dilate No. 1, and that the action may thus be communicated backwards. In the state of parts here referred to, vari- eties may occur, which appear to give rise to important differences in the phenomena. The obstruction to the dilatation of No. 3 may exist in various degrees; in a smaller degree, it may not prevent it from acting iu harmony with other parts, when the quantity of contents is small, and only a small degree of dilatation is required ; but, when there is an increased distension of the parts above, either from increase of solid contents, or from some accidental accumulation of flatus, then a greater degree of expansion may be required than No. 3 is capable of, and, in this manner, interruption may take place, to the harmonious action of the canal. It is probably in this manner that, in connection with slight organic affections of the canal, we find the patient liable to attacks of pain and other concomitant symptoms, which at first occur only at long aud uncertain intervals, but at length terminate in fatal ileus." The treatment of intestinal obstruction, however it originates, must always be a matter of anxious consideration. At first it is more or less difficult to determine whether there be only an obstinate constipation, which may be overcome by purgatives, or whether there be a mechani- cal obstruction, rendering them useless and perhaps dangerous. Under these circumstances, I think one full purgative at least should always be given as a rule, for the simple reason, that not only may its action overcome many forms of simple obstruction, but because without it no one can determine whether or not there is an obstruction at all. As 492 DISEASES OF THE DIGESTIVE SYSTEM. soon, however, as it becomes evident with what we have to do, all attempts to stimulate the action of the canal should cease, and we must have recourse to anodynes to diminish spasm, lessen irritability, and if possible, cause relaxation. Surgical means may be had recourse to, if the nature of the case admit of them, and operations performed with a view of relieving the strangulation or extracting any impacted mass" and the colon may be dilated with air or fluid, by means of long tubes. These important points, however, are so purely surgical, that I need not dwell upon them here. INTESTINAL WORMS. The observations of recent helminthologists, but more especially of Siebold, Van Benedin, Dujardin, Leuckart, Steenstrup, and Blanchard, have cleared away the mystery which so long hung over the origin of tape-worms and other entozoa. It seems now determined that tape- worms are only further stages of development of Cysticerci, as flukes are only further stages in growth of certain Cercarias. This important fact is a result of the researches now everywhere prosecuted with so much zeal by anatomists and physiologists in embryology, and from which it has resulted that many animals hitherto considered altogether distinct species, bear the same relation to each other as a caterpillar does to a butterfly. Professor Siebold first pointed out that the Cysficercus fasciokrit found in the liver of the mouse, reaches its ultimate stage of develop- ment in the intestines of the cat, and is there transformed into the Tonia crassicollis. This fact was confirmed by a careful series of ob- servations made by Dr. Henry Nelson, who, in his thesi,s presented to this University in 1S.">0, carefully traced and figured all the various stages which the tape-worm of the cat passes through. Each joint of this worm is estimated to contain 12-3,000 ova, which gives for the entire animal about 12,f)00,000. These minute bodies pass off by the foeces in incalculable numbers, and enter the body of the mouse mixed with its food or drink, or by licking its furry coat, to which they ad- here. From the alimentary canal of the mouse they may enter the liver of that animal in three ways: 1st, They may ascend the bile ducts. 2dly, They may pass through the coats of the intestine, and penetrate the adjoining portion of the liver. 3dly, They may bore their way into one of the mesenteric veins, aud be carried by the blood along the vena porta to the liver. Dr. Nelson considers the last to be the most correct view, for, as he shows, the ova are furnished with temporary teeth, which enable them to pierce the tissues. That they do not perforate the intestine, and so get into the liver, is shown by the fact that they are most developed on the surface of that organ, and least so in its interior. Neither are they found especially in the biliary ducts, like the Distomata. Hence the blood-vessels seem to be the channel of their introduction—an idea still further supported by facts, the number of which is rapidly augmenting, which demonstrate the presence of entozoa in various stages of development in the blood INTESTINAL WORMS. 493 itself. Arrived at the liver, these ova are transformed into Cysticerci fasciolnres, and would never proceed further in development in the mouse; but being eaten by the cat, they become tape-worms, and are developed into Toniee crassicolles. This series of observations renders it probable, that all the various kinds of Taenia are only different Cysticerci in advanced stages of development. Dr. Nelson points out that " the head of the Cysticercus cellulosus resembles in every respect that of the Tonia solium of man. The two figures given by Bremser are identical, if we allow for stretch- ing of the neck in the latter. Both have a double circle of hooks, and although the Tonia solium is sometimes found without any teeth, Bremser has fully proved that this is the result of age, and not the original condi- tion. He also observes that as the worm increased in age, one row of the double corona first fell off, and was after a time followed by the other, leaving the worm thus unarmed. The size of the head in both are similar, as also are the attenuated neck, and the gradually increasing body." Besides, man feeds on animals in which these Cysticerci are common, especially on the pig and sheep; and it has been observed that, in countries where meat is often eaten raw, as in Abyssinia, tape-worms are very common. The reason of the rare occurrence of Taenia in civilized countries, is probably owing to the cooking of food, which destroys the'vitality of the Cysticerci. Very thorough curing or salt- ing moat also appears to produce the same effect. However, it may easily be conceived, that owing to meat being very underdone, or to the tenacity of life in certain of these creatures (and many of them resist a high temperature without injury), they may occasionally escape the action of the teeth, arrive living in the human stomach, and be converted into young Taeniae. These ideas with regard to the origin of tape-worms have been con- verted into certainties by the experiments of Dr. Kuchenmeister, first recorded in the Prague Vierteljahrschrift (Band i. 1852, p. 12(3). He fed dogs and cats upon parts of animals which contained different kinds of Cysticerci, and subsequently found the tape-worms into which these had been transformed in various stages of development, according as the life of the animal who had eaten the Cysticerci had been more or less prolonged afterwards. Every precaution seems to have been used in these experiments, one of which may be cited:—An old dog, during a period of from six to eight weeks, was frequently purged with castor oil, so as to prevent the possibility of tape-worms being present. On the ISth of March, 1851, he ate food containing ten Cysticerci; on the 25th he ate as many more ; and on the 1st of April, several others which were not numbered. On the 10th of April the dog was killed, and thirty- five Tamiae were found in the intestines, of which five were from 124: to 390 millimetres (from about 5 to 15 inches) in length, and possessed from 130 to 160 joints. There were six others, from 25 to 96 millimetres (1 to 5 inches) iu length, having from 40 to 60 joints. There were 21 others, which measured from 8 to 16 millimetres (£ to \ an inch) in length, in which the joints were so indistinct that they could not be counted. Lastly there were three, measuring from 4 to 5 millimetres (£th of an inch) in length, in which the joints could scarcely be dis- tinguished. Considering the power of contraction and elongation pos- 494 DISEASES OF THE DIGESTIVE SYSTEM. sessed by these worms, their length was not so decided a character of their stage of development, as the size of the head and hooks, which corresponded to the three periods in which the Cysticerci had been swal- lowed. Similar results have since been obtained in cats; and even in a man, a condemned criminal, to whom Kuchenmeistcr gave Cysticerci in broth, and found tape-worms in his intestinal canal after death. On feeding dogs upon the liver of the mouse, containing the C. fasciolaris, Dr. Kuchenmeister never found Taeniae in the intestines. But when he fed cats on the same liver, the intestines contained the Tauia crassicollis. This observation indicates that not only are certain Cysticerci transformed into certain Taeniae, but that the former can only undergo this transformation in certain habitats, or in peculiar animals. Although the present amount of our knowledge does not enable us to state from what kinds of Cysticerci many species of Ttenia are formed, it seems probable, from the observations of Siebold, Nelson, and Kuchen- meister, that theCysticercus fasciolaris of tl\e mouse is transformed into the Tenia crassicollis of the cat; the C. pisiformis of hares and rabbits into the T. crassiceps of the fox; the C. tenuicollis of ruminantia and squirrels into the T. serrata, so common in the dog; and the C. cellulostu of the pig, sheep, and rabbit, into the Teenia solium of man. It is also tolerably certain, from the observations of Eschrieht, that the Bothriocephalus latus found in man in certain countries, especially in Russia, is the further development of a species of Ligula, which exists in large numbers in the flesh of the dorse, and other fish of the northern seas. Numerous instances have occurred, especially in India, where men encamped on the borders of a lake have subsequently been attacked by tape-worm, evidently in consequence of the water they consumed con- taining the ova of the worm. The parasite also has been known to infect Hindoos who have eaten no flesh. There can be little doubt, therefore, that the numerous ova of tape-worms voided by animals may enter the intestines of man with the food or drink, and there be trans- formed into Taeniae. This direct mode of entry must not be overlooked while investigating the undoubted origin of the worm from its cystic stage of transformation in the tissues of other animals. Dr. Fleming considers that the frequency of measly pork in Ireland is due to the pig being reared in the peasant's cabin, where it has commonly a dog for its companion, which auimal is almost always infected with tapd-worm, and must void a multitude of minute ova that find ready access to the ali- ment of the other. " Experiment shows," he says, " that the ' measle' is generated in the muscle of the pig by feeding it with ripe joints of the dog's tape-worm (the Teenia serrata now considered to be the same as the Tonia solium or human tape-worm), and that the same tape- worm is developed iu the intestines of a dog fed with fresh measly pork. The measle is not generated in the dog by feeding it with the tape-worm eggs."* Why in some animals these ova are fully developed into Taeniae in the intestines, whilst in others they enter the blood and are trans- formed only into Cystic worms in the liver, brain, or other organs, is probably owing to peculiarities of structure which have not yet been investigated. "' Dublin Quarterly Journal of Med. Science. Feb. 1857. INTESTINAL WORMS. 495 The importance of the head of tape-worms, so long recognised by practical physicians as the only certain proof of the complete expulsion of the worm, has also received an explanation from the researches of helminthologists into the anatomy and development of these animals. Notwithstanding the doubts expressed by Van Benedin as to the lateral canals being connected vvith the digestive system, and his notion of their being peculiar secreting organs, Dr. Nelson in his Thesis has distinctly traced them into the suckers of the Tania crassicollis. From each of the four suckers canals descend, which afterwards unite, two and two, to form the lateral canals. He also carefully describes the manner of feed- ing and propulsion of the contents of these canals from the cephalic to the caudal segment. Hence the head is important as the means by which the animal is nourished. But the head is further important, as pointed out by Van Benedin, as the part from which all the joints are thrown off by gemmiferous repro- duction—those formed first being pushed downwards, and afterwards undergoing further development. Hence why the joints are narrow near the head, and become larger and longer near the tail. These caudal joints after a time separate, and then, according to Van Benedin, may still go on developing, and become, he thinks, a species of fluke or distoma. In fact, he considers a tape-worm a; a compound fluke-worm, the whole consisting of three stages or periods:—-1, The cy>tic head (Scolex); 2, The compound tape-worm (Strobila); 3, The separated joint (Proglottis). This latter view, however, is opposed by the observa- tions of Steenstrup as to the development of the fluke, as well as by what we know of the arrangement of the nervous and digestive systems of this entozoon. The intestinal worms hitherto discovered in man are—the Ascaris hmbricoides ; Teenia solium ; Bothriocephalus latus ; Tricocephalus dispar; and Ascaris vcrmieularis. None of these are very common in Edinburgh, a circumstance which I attribute to the diet of the people, as well as to the excellent quality of the water distributed over the town. In unhealthy children, indeed, Ascarides are occasionally observed, but such children seldom enter the Infirmary. Lumbricoid worms in man are very rarely observed here, whereas in certain districts on the Continent, and especially in the Rhenish provinces, the great majority of bodies I have seen examined contained them in abundance. Tape-worm also is very rare, though sometimes met with, of which the following cases are examples :— Case LXXIX."—Tape-worm treated by the ^Ethereal Extract of the Male Shield Fern. History.—James Seth, sel 35, a weaver—admitted April 7th, 1852. When a boy he used to pass the lumbricoid worms; during the past six months he has also observed ascarides. It is now three years since he first noticed the fragments of the tape-worm in his stools. These fragments were then about a foot in length, and were noticed at intervals of months. About twelve months ago the fragments occurred almost every day for six weeks, varying from single joints to a piece six ■ Reported by Mr. William Broadbent, Clinical Clerk. 496 DISEASES OF THE DIGESTIVE SYSTEM. feet in length. No long piece has been passed for three months. No information can be obtained as to the kind of food on which he has lived; but his apnetite has remained natural. Before admission he was treated with turpentine by the mouth and also by injection. Progress of the Case.—April 8th.—To have 25 grains of the ethereal extract of the male shield fern; and in a few hours, a powder containing three grains of calomel, and one drachm of compound jalap powder. April 9th.—Several fragments of Taenia, in single or double joints, or in longer pieces, were passed, being 70 inches in all. They varied in breadth from one-eighth to one-fourth of an inch.—April 22d. —The dose was repeated on the 10th, but only two or three single joints were found. No further trace of the worm has been obtained by administration of castor oil, and the patient was discharged cured. Was re-admitted July 1st.—States that two months after he left the hospital he again detected joints of the entozoon in his stools. He was at once ordered twentv- four grains of the ethereal extract of the male shield fern, a,nd a subsequent dose of castor oil. • Numerous fragments, in all 8 feet in length, were discharged in the next stool. July 9th.—The remedy was repeated on the 5th without further effect. Castor oil has also been administered, but no fragments appear. Patient now states that he has been in the habit of drinking marsh water of impure quality, and of eating salt pork meat. July 13th.—Dismissed cured. Case LXXX.*—Tape worm expelled by the ^Ethereal Extract of the Male Shield Fern. History.—Catherine Watt, set. 25, married, with children—admitted November 20th, 1854. She had always enjoyed good health, until three years ago, when joints of tape-worm passed from her involuntarily when out working, and they have con- tinued to pass from her involuntarily, and sometimes in large quantities by stool ever since. On one occasion she passed blood at stool with portions of tape-worm. Has taken various kinds of medicine, but, with the exception of turpentine, does not know what they were. They have all been ineffectual. Symptoms ox Admission.—On admission she complained of tenderness in the left iliac region, and of tenesmus when at stool; but, with the further exception of the frequent passage of joints of tape-worm, the functions of the body were performed with regularity. She was ordered 3 ij of the cethereal extract of the male shield fern, to be followed in the morning by ; j 0I> castor oil. This caused the evacuation of seven joints of the worm, all of which were longer than they were broad. Another 3j dose of the extract was ordered at night, also to be followed by 3 j of castor oil in the morning. Progress of the Case.—November 22d.—Only three joints of the worm passed. To have this evening Z ss of the extract. Nov. 2?>l— This morning after taking the oz. dose of castor oil, she passed many separate joints, and several long portions of taenia. The whole together, when measured, was calculated to be about fifteen yards long. One portion was evidently formed of the joints of the worm near the head, as they were broader than they were long, and not above the tenth of an inch in length. Some joints were square and others longer than they were broad, measuring from half an inch to three-quarters of an inch iu length. No head could be discovered, though carefully searched after. She remained in the house till the 6th of December; but although she took 3 ss of the extract three times, and one dose of 3ij, no more joints of the worm came away. This woman was freed from the worm for many months, but it subsequently returned. * Reported by Mr. Almeric W. Seymour, Cliuical Clerk. INTESTINAL WORMS. 497 Case LXXXL*—Tape-Worm expelled by the same remcdi/. History.—William Perry, aet. 6, son of a soldier—admitted November 19th, 1855. Has been troubled with the tape-worm since he was two years old. Has passed separate joints often without medicine ; doses of rhubarb and jalap have brought away more ; the child has also taken turpentine. A year and a half ago he obtained a prescription at this Infirmary, for a medicine which expelled a very large portion of the tape-worm* In six months it was necessary to repeat the same medicine, again with success. But the symptoms have again returned; the child is always hungry and wants drink ; complains of pain in his belly, and passes joints of the entozoon per rectum. His food latterly has been plain, consisting of milk, bread, tea, potatoes, and some meat. The meat is boiled for broth, and is shared with him by father and mother, neither of them bein" aifected. He is fond of sugar, butter, and salt. Progress of the Case.—November 21st. Ordered 30 grains of the athereal extract of the male shield fern, with a subsequent dose of castor oil. Nov. 23d.—As the re- medy was ineffectual, it was increased yesterday evening to one drachm. This moraine, an unbroken mass consisting of six yards and six inches of the tape-worm joints, was evacuated; the smallest joints were one-fourth to one-sixth of an inch in breadth and length; the head was not found. Dec. 25th.—After two other administrations of the extract, and more frequent administrations of castor oil, no further fragments of the taenia have been procured ; was discharged.; Commentary.—Of all the vermifuge remedies proposed for the expul- sion of tape-worm, I have found the aethereal extract of the male shield fern the most effectual—a preparation first proposed by Peschier of Geneva, and since strongly recommended by Dr. Christison. That it readily dislodges large masses of the parasite, has been witnessed by all who have tried it, although it has not succeeded in every instance in permanently destroying or removing the animal. This, however, appears to me in grelt part, if not wholly, accounted for by the circumstance that patients, on being dismissed, return to the kiud of food from which they originally received the ova of these worms. This is very likely to be the case in certain English counties, where bacon and other prepara- tions of pork are common articles of diet among the people. Dr. Paterson of Tiverton has recorded some very obstinate cases, which resisted the action of the male shield fern, of the kousso, and of turpen- tme.t Now, in Devon, pork is a very common article of diet, whilst in Scotland certainly it is not ^much employed as food. I carefully interrogated the woman, Catherine Watt, as to whether she had eaten pork, and she admitted, that about the time the disease commenced, her husband being out of work, her diet had been very poor, and had con- sisted in some measure of salt pork, and occasionally of rabbits. Whether the Cysticercus cel/ulosus, commonly found in the flesh of pigs, could have retained its vitality in the salt pork eaten by this woman, cannot, of course, be stated with certainty. But it is worthy of remark, that the flesh of pork is frequently sold cheap to the lower orders, after it has been laid in brine for a very short period, or been imperfectly cured, so * Reported by Mr. John Glen, Clinical Clerk. f Monthly Journal of Medical Science. July, 1854. 32 498 DISEASES OF THE DIGESTIVE SYSTEM. that the tenacious vitality of these Cysticerci, or of the ova of Ta;nia> is by no means necessarily destroyed. Then, rabbits are known to be very commonly infested with Cysticerci; so that her indulgence in cither kind of animal food may have been the means of introducing Tmnia: into her economy. The general considerations previously given as to the origin and mode of development of tape-worms must render it evident, that, whilst by means of vermifuge remedies the practitioner endeavours to expel such as are already formed, his chief reliance, in preventing their return, must be placed on careful attention to the food and drink consumed by his patient. Case LXXXII.*—Tape- Worm expelled by Kamala. History.—Mary Park, aet. 9, a thin cachectic-looking girl, native of Edinburgh, where she has for the most part resided—admitted 11th January 1859. Her mother states that for four years she has never been free from worms, for which she has taken turpentine, castor-oil, and other remedies, without benefit. Progress of the Case.—On the 12th of January a table-spoonful of castor-oU brought away a few long joints of a tape-worm. On the afternoon of the 16th of January two drachms of kamala in powder were given. On the same evening she had three motions, followed early the next morning by a fourth. In the three first stools were several isolated joints of tape-worm, but in mthe fourth there was a mass, con- sisting of the body of the worm several yards long. A careful search was made for the head, but without success. The smallest joints were the tenth of an inch broad. Jan. 23d.—One drachm of kamala in powder was administered, followed by three copious motions, in whicii no portions of worm could he found. No more of the worm having passed, she was dismissed January 31st. Commentary.—Whether a permanent cure was accomplished in this case it is impossible to say, as the head and neck of the worm, not- withstanding the most careful search, could not be found. * Kamala has been recommended to us by medical men in India as a cheap and power- ful anthelmintic, and has recently been pretty extensively tried in this country. Dr. M'Kinnon, of the Horse Artillery, published a brief account of it in the Lndian Annals of Medical Science for October 1853; and it is referred to by Dr. Royle in his Materia Medica as an active vermifuge. It is a dark, brick-red coloured powder, brushed off from the capsules of the Rottlera tinctoria, a species of euphorbiaceae found in the hilly portions of India. Under the microscope it exhibits a mass of blood-red semi-transparent granules, more or less shrivelled, mingled with stellate hairs, to the irritating properties of which some have ascribed the vermicidal properties of the drug. The dose is from 3 U to 3 iij for an adult. Dr. T. Anderson says an alcoholic tincture in z ss doses is also very effectual (Indian Annals, October 1855). Unlike the root of the male shield fern, it is in itself a violent purgative. But whether it will ultimately be ascertained to destroy tape-worm more effectually than that drug, further observations alone can deter- mine. Dr. Christison has informed me that not long ago (1^9) an Indian officer, who had taken a dose of the Kamala for several con- * Reported by Mr. H. Graham Dignum, Clinical Clerk. PERITONITIS. 499 secutive months, with the effect only of expelling considerable quantities of the worm, was permanently cured by one dose of the Male Shield- Fern Extract. PERITONITIS. Case LXXXin.*—Acute Peritonitis from bursting of Graafian Vesicles into the Peritoneum—Pleurisy—Inter-lobular Pneumonia. History.—Margaret M'Guire, set. 21, a milliner, native of Edinburgh—admitted September 27th, 1855. Had enjoyed good health until the 21st of the month, when being sent out on a message, while walking she suddenly experienced a sensation as of a stone being dropped into the pelvis (so the patient describes her feeling), immediately followed by intense pain. She went immediately to bed, but was prevented from sleep- ing by the intensity of the pain, which increased in severity. At first felt only in the lower part of the abdomen, it gradually spread upwards towards the upper part of the cavity, but has again, within the last day or two, become concentrated in the lower and right part of the hypogastric region. Symptoms on Admission.—On admission her appetite is entirely lost. The tongue cannot be seen, owing to an old anchylosis of the lower jaw. Lips dry and cracked, with sores on them in places. Vomiting, which greatly aggravates her pain, has fol- lowed every attempt to take food since the beginning of the attack. Abdomen some- what swollen. The hypogastric region is dull on percussion. Diarrhoea has continued ever since she took a dose of castor oil four days ago. Pressure causes intense pain on every part of the abdomen. The breathing is hurried and irregular, entirely thoracic in character. Respiration 24 per minute. No cough. No dulness, on per- cussing the chest, as far as can be determined ; though examination is difficult, owing to the extreme pain which any movement causes the patient. Pulse 124, full and thrilling. Menstruation had been suspended for two months previously,' but has come on profusely within the last two days. Has frequent desire to pass water, which is voided in small quantity, attended with great heat and uneasiness. Face flushed ; ex- pression anxious ; severe headache. Applicentur hirudines xv. abdomini. To be fol- lowed by hot fomentations. R Pulv. Opii, gr. vi.; Conserv. Rosar. q.s., ut fant pil, vj.; Capiat unam tertid qudque hord. Progress of the Case.—Oct. 1st.—The patient has regularly taken the pills of opium; is in a very weak state; breathing laboured; pulse 154. Both purging and vomiting have in a great measure ceased. Conjunctivae slightly tinged yellow, lb take strong beef-tea, and Sherry f iij. Oct. 2d—Patient appears to be sinking; pulse 160, quick and fluttering; respiration laborious and painful; skin cold and moist; abdominal tenderness great; swelling in abdomen rather increased ; bowels open this morning; stool free and fceculent. Urine acid; sp. gr. 1020; deep orange coloured, contains a small amount of albumen, is tinged green by nitric acid. Crystals of triple phosphate seen under microscope. Oct. 3d.—Patient continued to sink during the night, and died this morning. Sectio Cadaveris.—Forty-eight hours after death. The tissues were well nourished ; more than one inch of fat in abdominal parietes. * Reported by Mr. Alexander Simpson, Clinical Clerk 500 DISEASES OF THE DIGESTIVE SYSTEM. Thorax.—Heart and pericardium healthy. The entire surface of each pleura was covered by an exudation of recent lymph. This lymph was in some places thin in others nearly a line in thickness; it was soft, and had an unhealthy appearance being of a dirty yellowish-green colour. There was no fluid effusion in either pleura. Left lung, when cut into, presented nothing remarkable. The lower third of the right lung presented a singular marbled appearance, in consequence of each pulmonary jobule being surrounded by a layer of coagulated exudation, generally about one-eighth of an inch in thickness. Careful examination demonstrated the fact that the inter- lobular vessels had poured forth an exudation, which had coagulated outside the lobules, which were cedematous, but not hepatized. Abdomen.—The whole surface of the peritoneum was coated with lymph, but there was no collection of serum. The lymph in some places was in flakes, in other situa- tions it was of the consistence of thick gruel, closely resembling pus. The coils of the intestines were glued together by lymph ; hut the exudation was most abundant near the pelvis. The whole of the intestinal canal was carefully removed and exam- ined ; there was no appearance of ulceration or of perforation. Appendix vermiformis normal. The liver was of a brick-red colour, and was decidedly softer than natural. The kidneys likewise were somewhat softened, but otherwise appeared healthy. The spleen was of pulpy consistence, and broke down under the slightest pressure. The uterus was healthy. The right ovary was about the size of a walnut; on being cut into, its stroma was found somewhat softened; it contained an unusual number of graafian vesicles. Externally there was adherent to the serous covering a layer of firm lymph, so adherent that it could only be removed with difficulty. It apparently originated from the rupture of one or more graafian vesicles, several of which were on the surface, large, and filled with sanguineous serum. The left ovary was the size ol a small orange, and contained a cyst about the size of a walnut, filled with blood, Such of its substance as remained was of exactly the same consistence as that on the right side. The peritoneum covering it, however, was healthy. The veins in the broad ligaments were examined, but presented nothing unusual. Commentary.—In the case of this young girl, the menstruation, after being suspended for two periods, comes back profusely ; and when walk- ing, she experiences a sudden pain deep in the pelvis. This is followed by excessive agony and all the symptoms of acute peritonitis. She is admitted into hospital on the sixth day. Leeches and fomentations are applied locally, but without any avail. A grain of opium is given every third hour, but without checking the disease. She dies on the eleventh day. On dissection, both ovaries are found enlarged and cystic; the right one is firmly encrusted with recent lymph, and several cysts immediately be- low the layer of exudation are enlarged, prominent, and filled with san- guineous serum. The inference obviously is, that one or more of those graafian vesicles had burst into the peritoneum, instead of into the fallo- pian tubes, and so excited the peritonitis. The cause of the disease spread- ing to the right pleura and interlobular spaces could not be discovered. In such a case where the peritonitis was clear and evident from the first, the treatment by quietude, warm fomentations and leeches locally, and opium internally, was indicated and put in practice. Purging rarely occurs, though it did in this instance; generally speaking, there is great constipation in peritonitis. Under such circumstances active purgatives should not be administered for two or three days after the onset of the PERITONITIS. 501 inflammation, and then only the mildest remedies of that class; or ene- mata may be given. Percussion, by indicating whether the ccecum or rectum are the parts distended with fceces, will occasionally enable us to decide whether an aperient or an injection will be most appropriate. Other cases occur where, from acute symptoms being absent and local tenderness obscure, active purgation is often practised, to the detriment of the patient. This is very apt to occur when acute peritonitis is com- bined with jaundice and liver disease. The treatment of such cases is most difficult, as the means requisite for overcoming obstruction in the gall ducts are those which we should avoid in peritonitis. In cases arising from perforation of the stomach and intestines, the utmost caution is required (which cannot be too often enforced) before stimuli and purgatives are given. (See Cases LVIII. and LIX.) Although, in the vast majority of cases, peritonitis arises from some lesion of the abdominal organs, which, as in the present case, affects the serous membrane secondarily, it sometimes happens that no lesion to account for the inflammation can be discovered after death, although the Bymptoms of perforation may have existed during life. In such cases the inspection should never be concluded without a careful examination of the appendix verniiformis, where I have seen minute perforations very apt to escape notice. This part, besides being exposed to all the ordinary diseases of texture, is especially liable to have impacted in it grains of wheat, barley, or other kind of seed, cherry-stones, pins, and a variety of foreign bodies, which pass readily through the other portions of the intestines, but which, in the appendix, may give rise to ulceration, perforation, and fatal peritonitis. Although our first efforts in cases of peritonitis should be directed to relieve pain, maintain quietude, and diminish peristaltic action by means of opium, we must not lose sight of the necessity of favouring such trans- formations in the exudation as will cause absorption or chronic adhesions. All exhaustive remedies, therefore, are to be avoided; and as soon as the circumstances of the case admit of it, nourishment, and if necessary, stimuli should be administered. Cask LXXXIV.*—Tubercular Peritonitis with great Deposit in Parietal Layer—Tu bercle and Hepatization of Lungs—Pleuritis—Adherent Pericardium—Commen- cing Fatty Degeneration of Heart—Biliary Congestion and Fatty Degeneration of Liver—Slight Leucocythemia. History.—Elizabeth Barker, set. 17—admitted October 6th, 1854; single; em- ployed in a factory; has been ill for about eight months. In the month of February- last she was attacked with a " fever," which she attributes to working in a cold and damp room. This confined her to her bed, and she was under medical treatment for two months, at the end of which time she was much better. A fortnight afterwards she was attacked with pain in the lumbar region and left side, and with a dry cough, and she did not pass so much water as usual Her abdomen and legs also became swollen. She took medicines, which partially removed the swelling. She came to Edinburgh three weeks ago, and since then the swelling in the abdomen and legs has been gradually increasing. * Reported by Mr. Almeric W. Seymour, Clinical Clerk. 502 DISEASES OF THE DIGESTIVE SYSTEM. Symptoms on Admission.—On admission, urine scanty and high-coloured; sp. gr. 1030; does not contain albumen. She has never menstruated. Complains of pain over the lumbar vertebrae, increased by pressure. Tongue moist and furred, appetiu impaired. Has a sour taste in mouth, and is troubled with flatulence. Bowels costive. Cardiac sounds normal. Pulse 128, small and thready. A friction sound is audible over the inferior part of both lungs, anteriorly, posteriorly, and laterally, with dulness on percussion, and diminution of vocal thrill. In the upper part of right lung, anteriorly and posteriorly, the respiratory murmur is audible, with slight in- crease of vocal resonance. Over upper part of left lung anteriorly, the natural respiratory murmur is audible, but posteriorly there is a marked increase of vocal reso- nance, with tubular breathing. Posteriorly cegophony at the angle of right scapula. Skin moist, of natural temperature. $. Hydrarg. Protoiod. gr. vj ; Ext. Hyotcyami Z ss ; Conserv. Rosar. q.s. ut fiant pil. xij. Sumat unam bis die. IJ Sp. .Klh. Nitric! § iss ; Tr. Scillm ; Tr. Digitalis aa Z ij ; M. Sumat. 3 j ex aqua indies. Progress of the Case.— October 11th.—Dyspneea continues. Pain in abdomen increased. Has been suffering from purging for the last 24 hours. To take chalk mixture with Sol. Mul. Morphia;. Oct. 14th.—Six leeches were ordered to the sternum yesterday. To day the friction sound has disappeared. To have § ij of port-wins. Nov. 1st.—The distended abdomen measures 32£ inches. Fluctuation distinctly felt. Vertical hepatic dulness 2J inches. Dull pain in hepatic and right lumbar region, hut no tenderness, as it can he handled and pressed freely without causing inconvenience. Feet cedematous. Sweats considerably. I£ Potass. Acetat. Z ij; Sp. uEth. Nitrici § ss; Mist. Scillos § viss; M. Sumat ^ ss ter indies. Omittantur alia. Nov. 12th.—Quantity of urine much increased. Abdomen measures 31 inches. Nov. 22d.—Abdomen measures 30J inches. Nov. 25th.—Fluid in abdo- men much diminished. Swelling and tension of its walls greatly decreased. Circular measurement 29 inches. On palpation a distinct hardness may be felt in the right hypochondriac region, extending into the epigastrium. Tongue dry and brown. Has been suffering from diarrhoea for some days past. The stools have of late been clay-coloured, and slightly jaundiced tint of skin has made its appearance. Urine contains bile, and is slightly coagulable by heat and nitric acid. Blood presents a slight increase in number of white corpuscles. To have a starch enema with Tinct. Opii. Nov. 26th.—Much worse. Skin cold. Face sunken and pale. She lies on left side ; any other position causes great dyspneea. Respiration 36 to 40 per minute. Coarse crepitation may be heard over the whole right side. Pulse 120, very weak. Diarrhoea continues, but stools this morning were fceculent. Urine dark brick red; sp. gr. 1012, with some traces of bile. Not a trace of chlorides present. To have the enema repeated immediately, and 3 oz. of brandy. Nov. 27th.—She gradually sank, and died to-day at 10 p.m. Sectio Cadaveris.—Twenty-seven hours after death. External Appearances.—Body emaciated. Abdomen somewhat distended. Thorax.—The pericardium was universally adherent. The adhesions were firmi and were broken down with difficulty. The valves of the heart were healthy, but the muscular substance was of a brownish-red colour, and rather softer than natural. The size of the heart was normal. There were firm old adhesions over the upper lobe of the right lung. Over the lower lobe there was a thin layer of recent lymph. Between the diaphragm and the base of the lung was a pouch containing about six ounces of turbid fluid, in which floated some flakes of lymph. The whole lung felt PERITONITIS. 503 firm and dense. When cut into, it presented a somewhat granular surface of a red colour, was scarcely crepitant, broke down readily, and some portions of it sank in water. Scattered through it were a number of yellow masses, from the size of a millet seed to that of a small pea. They were of cheesy consistence, and were pretty readily broken down. They were scattered equally through the pulmonary substance, and were not more abundant at the apex than elsewhere. None were softened. The left lung was universally adherent, but there was no recent lymph. The lung felt firm, and when cut into presented altogether the same appearance as the rio-ht lunc. The same yellowish masses were scattered through it. The b.onchial glands were enlarged, and when cut into were found to contain yellow, cheesy, tubercular matter. Abdomkx.—The cavity of the abdomen contained about a gallon of yellowish tolerably clear fluid. The parietal peritoneum was very much thickened by a deposit, varying from about one line to half an inch in thickness. It was of a yellowish colour, but, on looking closely into it, numerous opaque points, of the size of pins' heads or so, were seen separated from one another by a clear substance. On cutting into the de- posit this appearance was still more distinct. ' Numerous blood-vessels were seen on its surface, and in its substance; and on the former were numerous particles of extra- vasated blood of a bright red colour. The deposit was of firm consistence. The coils of the intestines were firmly adherent by tolerably firm lymph. Their coats were softened, so that, in endeavouring to separate the adhesions, they tore readily. On looking closely at the surface of the intestines, numerous small, semi-transparent, yellowish-white deposits were seen on the serous surface, and there presented all the usual characters of tubercle. The mucous coat of the intestines was healthy. The capsule of the liver was thickened, and the upper and anterior part of it was adherent to the diaphragm. The liver was externally of a yellow orange colour. On cutting into it, numerous opaque yellowish-white masses varying from the size of a pin's point to that of a millet seed, were seen surrounded by deep orange-coloured matter. The surface of the section was quite smooth; the tissue of the liver was rather softer than natural; and there did not appear to be any increase in the amount of fibrous tissue. The liver was small and weighed 2 lb. 7 oz.; sp. gr. 1051. The gall bladder was small, its coats were thickened, and it was bound down to the liver by fibrous tissue. It contained about two drachms of orange-coloured bile. The spleen was natural.— Mesenteric and lumbar glands enlarged, of white appearance, of a smooth surface on section, yielding a copious opaque juice on pressure. The kidneys presented nothing unusual. Microscopic Examination.—The muscular fibres of the heart had lost, to a cer- tain degree, their striated appearance, whicii was replaced in some by granular fatty matter. The masses of deposit in the lungs presented all the usual characters of tu- bercle. On examining the thickened peritoneum, large groups of tubercle corpuscles and granular matter were seen to be surrounded and isolated by fibrous tissue. The pale, opaque-looking points in the liver consisted of accumulations of fat, partly free, partly in hepatic cells. The surrounding parts were loaded with yellow biliary matter. There was no increased quantity of fibrous tissue. The tubes and cells of the kidneys appeared quite natural. Commentary.—This is a characteristic case of so-called tubercular peritonitis, associated with pulmonary tubercle and various other lesions. In a practical point of view it is to be remarked, that the symptoms were wholly different from those in the previous case. There was no abdominal tenderness, no inflammatory fever—and, notwithstanding the 504 DISEASES OF THE DIGESTIVE SYSTEM. large amount of lymph exuded, some of it recent, all the symptoms were those of ascites dependent on atrophy of the liver. In some cases of this disorder, the peculiar doughy feeling communicated to the hand, and the roughened friction perceptible on moving the two perito- neal surfaces over the other, gave an indication of the nature of the disease—the latter symptom was absent in the present case in conse- quence of the accumulation of fluid. Occasionally the amount of tu- bercular exudation is very great; I have seen it matting together all the intestines and abdominal viscera in a layer varying from a half to an entire inch in thickness. In such cases also it frequently happens that whilst the abdomen is loaded with tubercle, the lungs are compara- tively free from it. The mesenteric nnd lumbar glands in these cases are very apt to become hypertrophied, and the blood to contain an unusual number of colourless corpuscles. In a man, James M'Arthur, who died in Paton's Ward during the summer 1857, these glands were enlarged. There was also an enormous collection of tubercular exudation in the abdo- men, which on examination was found to form a layer from one-half to an inch in thickness, glueing the intestines and abdominal viscera to- gether. On examining a drop of his blood under the microscope in the usual way, during life, from twenty-five to forty colourless corpuscles could always be counted in the field of the instrument. (Sec Leuco- cythemia.) Case LXXXV.*—Cancer of various Abdominal Organs and of the Lungs, producing Symptoms of Peritonitis. History'.—Christina Galbraith, aet. 52, a fish-cleaner, at Newcastle, single—ad- mitted November 29, 1854. The patient states that, until nine months ago, sheen- joyed good health, since which time her strength has been diminishing. She has been decidedly ill for the last three months. Her first symptoms were pain in the epigastrium, a feeling of cold, great thirst, anorexia, sickness, and severe night sweats. The pain in the epigastrium has gradually increased up to the present time. About ten weeks before admission, she noticed that her abdomen began to swell, and the swelling has since gradually increased. Her feet have, for the last five years, evinced a tendency to oedema towards evening, in consequence, as she thinks, of her work requiring her to he much in the erect position, and lately they have become more swollen. Four weeks ago she had an attack of jaundice accompanied by severe pain in the lumbar and right hypochondriac regions. The colour of the stools is not known, but she thinks her bowels were regular at the time, although she is habitually subject to constipation. A week after its appearance, her bowels became very loose; the stools were fceculent and abundant. On one occasion she passed a considerable quantity of blood, accompanied by what she describes as " great lumps and strings, but of the colour of which she has no idea. At this time she had no vomiting, but felt great pain over the whole of the abdomen, which became very swollen and tense. She improved under medical treatment; the bowel complaint disappeared, and the pain in the abdomen abated. But she does not know how long the attack lasted. During its continuance she also suffered from vomiting; the matters ejected were sometimes of a green, at others of a coffee-ground colour. The bowel complaint and * Reported by Mr. 0. Beaujeard, Clinical Clerk. PERITONITIS. 505 the pain returned with great severity on her voyage from Newcastle to Edinburgh. She alao vomited considerably, and was brought to the Infirmary in a state of great exhaustion, on the evening of the 29th of November. Symptoms on Admission.—On admission, she complained of great pain over the epigastrium and right hypochondrium, and generally all over the abdomen ; face very anxious; pulse small and quick. Ordered Wine and Brandy, Tannin and Opium Pills, and four leeches to right hypochondrium. Next day was carefully examined. Face and conjunctiva? have a yellowish tinge; countenance anxious, but speech is clear and comprehension quick. She complains both of a continuous and a shooting pain, worse over the epigastrium and over the left side of the abdomen, in the course ofthe descending colon. The pain felt last night in the right hypochondrium has been diminished by the leeches, which bled well. She lies with greatest ease on the right side, and feels great pain when she assumes the supine position. The abdomen is exceedingly tender on pressure; it is swollen, tense, and tympanitic, permitting nothing deep-seated to be felt. Pungent heat, and dryness of skin over its surface. Tongue white, with prominent papillae, pale, smooth, and glossy at tip and edges. Complains of constant bad taste in month; has a burning pain at epigastrium, and most intense thirst, but cannot take cold water, as it causes immediate vomiting, though she does not otherwise feel sick. Appetite entirely gone ; bowels have not been moved since her admission. Urine diminished in quantity, high-coloured, with a deposit of lithates; the chlorides are present; sp. gr. 1014 ; she has a sense of heat in passing it. Catamenia last appeared about a month ago. Pulse 108, small and weak. Apex of heart beats between fifth and six ribs; transverse dulness normal. Sounds normal. Breathing mostly thoracic ; respirations, 32 per minute ; cannot take ■ a full breath without pain; has a short hacking cough. Chest expands equally, but imperfectly. Percussion good, both anteriorly and posteriorly; respiratory murmurs natural. Has headache, tinnitus aurium, and muscae volitantes. Feels sick and giddy on sitting up. There is oedema of the feet, ankles, and legs. To have wine 4 oz., and in the evening a Turpentine and Asafeetida enema. Progress of the Case.— December 1st.— The enema was followed by two fcecu- lent and hard stools. Pain in the abdomen considerable—most felt below the margin ofthe right false ribs. Complex anorexia. Great thirst; pulse 104, small and hard. Dec. 2d.—State much the same; bowels not again opened. Pain in the abdomen being increased, she was ordered six more leeches to the right hypochondrium, and the following diuretic mixture— R Potasscc Acetatis 3 ij ; Sp. uEth. Nitrici ?ss; Mist. Sulla?, I vss. M. 3 ss. to be taken three times a day. Dec. 5th.—Breathing natural; abdomen not so tense and hot; pain greatly diminished; appetite not improved; stools dark but healthy; pulse 96, small and weak. Dense deposits of lithates in urine. Dec. 10th.—Pulse 92, very small and weak. No thirst; appetite not im- proved, abdomen less tense—fluctuation may be distinctly felt. Pain less—most severe on left side. Dec. 18th.—Passes very little urine; it is high coloured, and deposits lithates abundantly. Abdomen less tense—measures 33 inches in circumfer- ence. It is tympanitic, and fluctuation may be felt. Feet cedematous; bowels regular; no appetite, great thirst; slight catching ofthe breath. R Pulv. Digitalis, gr. iij, Pulv. Scilla, gr. vj, Ext. Taraxaci, q. s. ut fiant pil. vj. Sumat unam bis indies. Omittantur alia. Dec. 19th.—Urine much increased in quantity ; is very highly coloured; deposits lithates. Dec. 20th.—Great pain complained of in lumbar region. Yellowish tinge of complexiou increasing. To apply to the abdomen the ^"•ngio-Piline soaked in Inf. Digitalis of four times the usual strength. Dec. 21st.— 506 DISEASES OF THE DIGESTIVE SYSTEM. The Spongio-Piline has relieved the pain in the abdomen. Breathes easier. Thinks her urine diminished in quantity. It is of a deep copper colour. Has vomited her break- fast for the last two days, hut is not sick otherwise. Bowels regular, appetite not improved; pulse 108, weak. Dec. 23d. —Vomiting more frequent; is much troubled with flatulence; tongue pale, smooth, and glossy; bowels regular. Dee. 25th.—Tr. Iodinii to be painted over the abdomen. Dec. 27th.—The iodine caused her grca pain, which was, however, relieved by warm fomentations. The swelling of the abdomen and tympanitis, the cough and the expectoration, have increased; breathing slightly laborious. R Sp. jEth. Sulph. 3 iij ; Sol. Mur. Morph. 3j; Mist. Snll9 | iiss. To be taken in half ounce d>s?.s when the cough is troublesome. Dec. 30th.— Abdomen measures 34 inches in circumference. Bowels regular; percussion normal over chest; mucous and sibilant rales heard on auscultation. Coughs much; expecto- ration abundant, purulent, and tenacious; pulse small and weak; legs and feet very cedematous; urine as before. Jan. 2d.—Jaundiced tint of skin is growing deeper; distension of abdomen from tympanitis increased; pulse rapid and thready; vomits all her food immediately after taking it, together with a quantity of black matter; thirst great; stools pale-coloured but consistent. To omit the Squill and Digitalis Pill, and to take Potass. Bitart. 3j ter indies. Jan. 4th.—Jaundice increases; urine very small in quantity, and contains bile. Swelling of abdomen augmented; great pro- trusion oflower ribs, but breathing is not much affected. Vomiting continues. There is oedema of feet, legs, and hands; she is getting decidedly weaker. Pulse 96, steady and weak. Jan. 5th.—Died this morning at 2 a.m. Sectio Cadaveris.—Fifty-eight hours after death. The body emaciated ; the surface of a moderately yellow tinge ; abdomen much distended and fluctuating. Thorax.—The pericardium and heart were healthy; there were a few slight old adhesions on the left side of the chest; the left lung, when removed, had an irregular feeling from the presence of a number of masses, some immediately under the pleura, others embedded in the pulmonary tissue ; the masses visible externally had a circum- ference equal to about that of a fourpenny piece; their margins were slightly promi- nent, while they were depressed or flattened in the centre; they appeared of a grey- ish-white colour, and felt firm and hard; on cutting into the lung, pretty numerous masses similar in size could be seen scattered through it; they were generally of a white or greyish-white colour, while some were yellowish, as if stained by biliary matter ; most of these masses felt tolerably firm, but yielded on pressure a small quantity of a glairy juice; others, however (which were more opaque-looking than the rest), crumbled down easily under the fingers. The right lung was very densely adherent throughout externally ; it presented masses similar to those found in the left lung, and others could be felt in its substance ; it was not cut into, but was sent entire to the university museum; the pulmonary tissue intervening between the ma-ses was quite healthy. A few of the bronchial glands at the root of each lung were a httle enlarged, and when bisected were found to contain a substance like that met with id the tumours of the lungs. The bronchi were unaffected. One gland in the anterior mediastinum immediately under the upper part of the sternum was of the size of a walnut, and on being divided, was found converted into a mass of almost cheesy con- sistence, of a yellow colour, mottled by the presence of a good deal of black pig- mentary matter. Abdomen.—The cavity of the abdomen contained about a gallon and a half of a PERITONITIS. 507 clear yellowish fluid. Peritoneal membrane everywhere healthy. The liver which was much enlarged, presented a very irregular appearance, in consequence of the projection from its surface of numerous masses of a whitish-yellow colour, varying from the size of a pea to that of the fist; some were rounded, others of "a very irre- gular form. Only a very few of those masses presented any central depression- When cut into, the substance of the liver was found, to a great extent, occupied by a similar matter; at so.i.e places it occurred in small isolated masses but in general it was found infiltrated in large patches. It was of a yellowish colour • some parts of it, however, were opaque, while intervening portions were clear and semi- transparent ; other parts, again, were intermediate between these conditions; the matter was generally tolerably firm, but the more opaque parts had a tendency to crumble down. The hepatic tissue itself was of a yellowish colour, and moderately firm. The weight of the entire liver was 7 lbs.; behind the liver a mass of enlarged glands surrounded and compressed the vena cava, the gall-bladder and common duct; the vena cava was somewhat diminished in size; the gall-bladder was much contracted, being little larger than an almond, and contained scarcely any bile; on passing a probe from the gall-bladder along the cystic duct, the latter was found quite occluded, a little before its point of junction with the common duct ■ a probe was passed from the duodenum along the common duct, but both it and the hepatic duct were compressed and contracted; the enlarged glands, when cut into, were found converted into firm yellowish masses, quite similar to those met with elsewhere. The pancreas was healthy; the stomach felt indurated towards its pyloric end, and on being cut into, a large ulcer was found near the pylori orifice; it was of an oval form, about 3| by 2\ inches, its longest diameter bein<* from above downwards; its right margin was about an inch from the pylorus. The ulcer had a hard thickened base, and a very irregular surface from the presence of numerous fungating excrescences of a greyish-white colour. The margins of the ulcer were elevated above the surrounding mucous membrane, but were irregular looking, as if they had been gnawed by some animal. There was no perforation. The rest of the stomach and the duodenum were healthy. Some of the gastric lymphatic glands, particularly some of those connected with the lesser curvature, were enlarged and cancerous. The spleen was natural. The kidneys, when cut into, were of a yellowish colour; their surface was a little irregular, appa- rently resulting from old cysts; a few cysts were seen in the surface, and also in the cortical portion; several of the lumbar glands, lower down than the mass found behind the liver, were enlarged and similarly affected. The uterus and ovaries were healthy. Microscopic Examination.—On examining a little of the juice squeezed out of any of the masses above described, tolerably large nucleated cells were found. Many of them presented the usual appearance of cancer cells; others, however, were small, and many nuclei were seen free. In the opaque portions, the cells were less distinct, and there was a large quantity of fatty matter. The cells of the liver con- tained a good deal of biliary matter, but they were otherwise quite healthy. The kidneys, when examined microscopically, also appeared healthy. Commentary.—This subject of cancer of the lungs, liver, stomach, and other organs, when she entered the clinical ward, presented all the symptoms of acute peritonitis, including great tenderness, with disten- sion of the abdomen, fever, and increase of urates in the urine. There was, however, no evidence, on palpation, of the nodular swellings found alter death; these were masked by the accumulation of fluid and tym- 508 DISEASES OF THE DIGESTIVE SYSTEM. panitis. Neither did physical signs indicate the cancerous deposition in the lung, it being so diffused as not to occasion any marked abnormal respiratory symptoms; such as did exist were explicable by the abdo- minal disease. The facts presented in these three cases indicate the uncertainty of our diagnosis in abdominal diseases. In the first, it is true, the symp- toms correspond with the acute peritonitis of authors; but in the second there were no such symptoms, though there was abundance of exudation ; while the third case presented all of them in a marked and characteristic degree, in connection with cancer of the abdominal organs, and effusion of serum. I never saw a case which better satisfied me of the insufficiency of mere symptoms, for the purpose of arriving at an exact knowledge of a patient's real disease. The history of this case, it is true, indicated the existence of some chronic disease, but all the positive symptoms, after her admission, including extreme tenderness of the abdomen, its distension, tympanitis, constipation, high fever, vomit- ing, etc., pointed out that the chronic disease of the stomach and other organs had terminated in acute peritonitis. Yet, on examination, peri- tonitis there was none, but only serous effusion, or ascites evidently resulting from the organic disease of the liver obstructing the abdominal circulation. When contrasted with the last case, in which the perito- neal membrane was covered with lymph, the present one, where it was healthy, exhibits a remarkable discordance with systematic descriptions of disease. The true exudation had not one of the so-called symptoms of that lesion, whereas, in the last case, there was every symptom, with a perfectly sound peritoneum. I have recorded therefore this case at great length, because the acute symptoms will speak for themselves, and because, when compared with some remarkable cases afterwards to be given of pleuritis without the usual symptoms, it serves, in my opinion, to convince us that many of our existing notions as to the pathology of acute diseases require to be modified. For other examples of perito- nitis, see Cases LVIII. and LXXVIII. Case LXXXVI.*—Cancerous Peritonitis—Ascites and Hydrothorax—Paracentesis Abdominis—Arrested Phthisis Pulmonalis. History.—Margaret Purdon, set. 63, a widow, has had two children—admitted December 15th, 1856. Three years ago she had profuse hematemesis, accompanied by loss of blood per anion, which caused faintness. In a few days, however, she quite recovered, and remained perfectly well until three months ago, when she first observed that the lower part of the abdomen was swollen, but not painful. About a fortnight afterwards she experienced severe pain in the left lumbar region, together with a sensation of cold water trickling down her left thigh as far as the knee. Two months after the first symptoms had shown themselves, the abdomen had become gradually much distended, and she experienced a "dead pain in the epigastric region, which, she says, was constant, but not aggravated by pres- sure, and caused great shortness of breath. Simultaneously with this epigastric pain a scantiness and turbidity of the urine appeared, and a day or two subsequently * Reported by Mr. Alex'r M'Leod Pemberton, Clinical Clerk. PEK1T0NITIS. 509 both feet and legs became very much swollen, the right one especially so. During the last fortnight she has taken several doses of rhubarb and magnesia, the purga- tive action of which has been followed by considerable alleviation of her symptoms, and diminution in the size of the abdomen, and of the dropsical swelling of the inferior extremities. Symptoms on Admission.—The abdomen is so distended as to measure at the epigastrium 29{, and at the umbilicus 35 inches round. It fluctuates on palpation, but there is no pain on pressure. In every position the lower portion of the abdo- men is dull, and the upper tympanitic on percussion. No tumour can be detected, nor can the amount of the hepatic dulness be accurately determined. The tongue is covered with a white fur on the right side, and is perfectly clean on the left. She has a good appetite, but cannot eat much on account of the uneasiness it occasions in the epigastrium—a symptom from which she is now seldom free. The bowels are opened naturally every other day. No flatulence. There is considerable dyspneea; a slight cough, but no sputum. Percussion is resonant over the whole chest. At the apex of the left lung expiration is prolonged and hard, and the vocal resonance increased. Pulse 8.">, of good strength. Heart's size and sounds normal. The face is much emaciated and pale. Both feet and legs somewhat cedematous; the right one most so. Does not sleep well on account of the dyspnoea. Urine sp. gr. 1012; contains phosphates in solution, but no albumen. Progress of the Cask.—January 5th.—Since coming into the house she has had an occasional dose of castor oil, and her symptoms have on the whole been much alleviated. There is, however, great orthopncea at night, and she says it is easier to lie on tho left side. A careful examination to-day has determined that there is great dulness on percussion over the lower half of right lung, and that the respiratory mur- murs there are inaudible. The abdomen now measures at the epigastrium 31£, and at the umbilicus 37 inches. Pulse 92, feeble. Passes urine, loaded with phosphates, freely. To have extra nutrients, and four ounces of wine daily. January 12th.—In consequence of the great dyspneea, which is daily increasing, paracentesis of the abdomen was performed, and 190 ounces of a pale, greenish yellow fluid were drawn off. This fluid was of the sp. gr. 1012, and formed a solid, gelatinous mass on the addition of heat. On standing it became slightly turbid, but exhibited nothing but a few scattered blood corpuscles under the microscope. The operation was followed by a tendency to syncope, which was removed by the free use of port wine and brandy. Jan. lith.—Feels greatly relieved by the operation. Several nodulated swellings can now be felt under the flaccid abdominal integuments, especially on the left side. Jan. 11th.—Though greatly relieved, complains of great weakness.* Jan. 15th.— Though liberally supplied with stimulants, died this morning at half-past two, appa- rently from exhaustion. Sectio Cadaveris.—Thirty-five hours after death. External Appearand es.—Great emaciation. Abdomen flaccid, she having been tapped a short time before her death, and 190 ounces of serum removed. Thorax.—The external surface of the pericardium contained a number of can- cerous .nodules, varying in size from a pepper-corn to that of a small bean, of a white and pinkish-white' colour. The internal layer of the pericardium and the heart were healthy. The right pleura contained about four pints of serum. The lung was com- pressed and pushed up against the spine. Its upper fourth was spongy, but most of the three inferior fourths were carnified, and contained little air. Scattered over 510 DISEASES OF THE DIGESTIVE SYSTEM. the pulmonary pleura were numerous cancerous masses, of a rounded or oval form varying from the size of a pin's head to that of a split pea. They were of a clear white colour, rose abruptly from the pleura, aud were generally half a line or a line deep. Some of them had a slight central depression, and in many, blood- vessels could he seen. The costal pleura had similar nodules, and flat patche? covering it; some of the latter being the diameter of a shilling. The apex of right lung was strongly puckered, and contained several concretions surrounded by dense pigment; the rest of its tissue was healthy. The left lung was more voluminous than the right. The pleurae at the apex were adherent and thickened. On section this was found to correspond to an old tubercular cavity of the size of a small filbert, also surrounded by dense tissue loaded with pigment. The substance of the bin* was otherwise healthy, and the pleurae generally presented only a few small cancerous mases scattered over them, similar to those on the opposite side. The bronchial and mediastinal glands were healthy. Abdomen.—There were two or three pints of clear fluid in the abdominal cavity. The whole of the peritoneum (parietal and visceral) was studded over with cancerous masses. The great omentum was shrivelled, drawn up, and converted into a thick mass of opaque, moderately firm, cancerous matter, the substance of which con- tained numerous yellow opaque points. The transverse colon was dragged up towards the stomach, and much compressed by this mass. All the adjoining veins were greatly congested. The" peritoneum covering the lower surface of the dia- phragm was lined by a thick layer of cancerous matter, which appeared to have been deposited in nodules, which were so thickly placed as to have run into one another, forming a layer about two lines thick. At other parts of the peritoneum, nodules and small patches of cancerous matter were scattered about. The whole of the mesentery was studded with little masses from the size of a grain of sand to that of a pepper-corn. Similar masses were found in the serous coat of the small intestines. The meso-colon and meso-rectum were thickened and covered with cancerous masses. The uterus, urinary bladder, and ovaries were matted together by cancerous exudation. None of the abdominal viscera or glands were involved in the cancerous disease, which was ex- clusively confined to the serous membrane. Microscopic Examination.—The different nodules of cancer presented all stages of development and disintegration of the cancer cells; in some places numerous naked nuclei; in others, large compound cells; in others, debris and fatty degeneration, form- ing yellow masses of the reticulum. Commentary.—The insidious approach and development of so large an amount of cancerous exudation on the peritoneum is worthy of ob- servation. It is very possible that the disease existed three years pre- vious to her admission into the house, when the hemorrhage occurred from the mucous membrane of the stomach and bowels. But she rapidly recovered, and remained well uutil dropsical symptoms supervened in consequence of the pressure of the indurated cancerous masses on the abdominal veins, inducing effusion. At no time was there any general fever, pain, nor tenderness on pressure. In this respect the case strongly contrasts with the last. Here, with extensive disease of the peritoneum, there were no symptoms of peritonitis; there, with the peritoneum per- fectly healthy, violent symptoms of peritonitis were manifested. Indeed, the only symptoms occasioned were those resulting from pressure on the lungs, by the accumulation of serum in the peritoneal and right pleural PERITONITIS. 5H cavities The orthopnoea thus occasioned was so distressing as to induce me to have the abdomen tapped ; and it is worthy of remark that, al- though thereby the greatest relief was experienced, she rapidly sank. Indeed, it seldom happens when, in ascites, resulting from organic dis- ease, this operation is had recourse to, that death is long delayed—a re- markable proof of the fallacy of that system which is ba~ed on the treat- ment of symptoms. Hence, as with the large bleedings formerly prac- tised for the cure of inflammations, it is true we give relief, but we also increase the mortality. In a case very similar to the above, occurring in a young man, aet. 20, admitted under my care during the winter 1858, there was the same universal cancerous peritonitis, and the same distension of the abdomen from fluid without local tenderness. Instead of " nutmeg liver "—that is, incipient cirrhosis—however, the organ presented the disease in a more advanced condition. Difficulty of breathing, notwithstanding, was never bo urgent, the pleurae being healthy, and three weeks before death, the abdominal tension spontaneously disappeared, so as to enable me to feel the nodulated omentum through the abdominal walls, and thus determine the nature of the case. He was a groom, and the first symptom of the disease appeared in the form of varicose veins in the lower extremities. These on admission were enormously swollen and tortuous, especially in the popliteal and inguinal regions, where they formed tumours the size of pigeons' eggs. After death the swellings were found to consist of dis- tended veins filled with firmly clotted blood of a red brick colour. The cause of the varicosities in the extremities was the pressure occasioned by the tight and thickened omentum over the external iliac veins, just before they passed under Poupart's ligament. It results that the cancer must have existed in the abdomen, when he was actively pursuing his employment, for the varicosities appeared a year before his admission. In both cases the ascites may have been mainly owing to the hepatic disease. (See also Case LXXVII.) SECTION YI DISEASES OF THE CIRCULATORY SYSTEM. Before proceeding to narrate and comment on lesions of the heart and large vessels, allow me to remind you of some of the rules which the laborious researches of many able men have established for your guidance in the diagnosis of cardiac diseases. They are as follows :— 1. In health, the cardiac dulness, on percussion, measures, immediately below the nipple, two inches across, and the extent of dulness beyond this measurement commonly indicates either the increasd size of the organ or undue distension of the pericardium. 2. In health, the apex of the heart may be felt and seen to strike the chest between the fifth and sixth ribs, immediately below and a little to the inside of the left nipple. Any variations that may exist in the posi- tion of the apex are indications of disease either oi^the heart itself or of the parts around it. 3. A friction murmur, synchronous with the heart's movements, indi- cates pericardial or exo-pericardial exudation. 4. A bellows murmur with the first sound, heard loudest over the apex3 indicates mitral insufficiency. 5. A bellows murmur with the second sound, heard loudest at the base, indicates aortic insufficiency. 6. A murmur with the second sound, loudest at the apex, is very rare, but when present it indicates—1st, Aortic disease, the murmur being propagated downwards to the apex ; or, 2d, Roughened auricular surface of the mitral valves ; or, 3d, Mitral obstruction, which is almost always associated with insufficiency, when the murmur is double, or occupies the period of both cardiac sounds 7. A murmur with the first sound, loudest at the base, and propagated in the direction of the large arteries, is more common. It may depend, —1st, On an altered condition of the blood, as in aucemia; or, 2d, On dilatation or disease of the aorta itself; or, 3dly, On stricture of the aortic orifice, or disease of the aortic valves,—in which case there is almost always insufficiency also, and then the murmur is double, or occupies the period of both sounds. I have also seen cases which satisfy DISEASES OF THE CIRCULATORY SYSTEM. 513 mc that it may occasionally depend on roughness of the ventricular sur- face of the mitral valves, and on coagulated exudation attached to the internal surface of the heart. S. Hypertrophy of the heart may exist independently of valvular disease, but this is very rare. In the vast majority of cases it is the left ventricle which is affected, and in connexion with mitral or aortic disease. In the former case the hypertrophy is uniform with rounding ofthe apex; in the latter, there is dilated hypertrophy, with elongation of the apex. Attention to these rules alone will, in the great majority of cases, enable you to arrive with precision at the nature of the lesion present. In cases in which there may be any doubt, you will derive further assistance from an observation of the concomitant symptoms, such as,— 1st, The nature of the pulse at the wrist; 2d, The nature of the pul- monary or cerebral derangements. Thus, as a general rule, but one on which you must not place too much confidence, the pulse is soft or irregular in mitral disease, but hard, jerking, or regular in aortic dis- ease. Again it has been observed that carebral symptoms are more common and urgent in aortic disease,- and pulmonary symptoms more common aud urgent iu mitral disease. I have purposely said nothing now of diseases of the right side of the heart, and of a few other rare disordered conditions of the organ, because I am convinced that an appreciation of the rules above given is the best method of enabling you to comprehend and easily detect any exceptional cases which may arise. In truth, however, I have remarked in our examinations at the bedside that your difficulty is, not how to arrive at correct conclusions from such and such data, but how to arrive at the data themselves. You have to determine,—1st, By percussion, whether the heart be of its normal size or not; 2d, Whether an abnormal murmur docs or does not exist; 3d, If it be present, whether it accompanies the first or second sound of the heart; aud 4thly, At what place and in what direction the murmur is heard loudest. These points ascertained, the conclusion flows from the rules previously given. But no instruction on my part, no reading or reflection on yours, will enable you to ascertain these facts for yourselves. In short, nothing but percussing the cardiac region with your own hands, and carefully listening to the sounds with your own ears, can be of the slightest service, and the sooner you feel convinced of this truth the sooner are you likely to overcome these pre- liminary difficulties. This is the reason why a series of cases assembled m the ward of an hospital is so valuable. By careful examination of them, you can at once convince yourselves of the accuracy of the facts affirmed by others to exist,—reflect on the probable correctness of the diagnosis formed at the bedside, watch the various complications and the effects of treatment, and finally, observe how, in the fatal cases, by fol- lowing the rules given, the accuracy of the diagnosis has or has not been confirmed by post-mortem examination. Attn- you have made yourselves familiar with the ordinary forms of heart disease, you will find that occasionally very puzzling instances occur where the above rules do not apply. These exceptional cases should always be carefully studied. Indeed, this is what is now being done by the cultivators of physical diagnosis throughout Europe, with a view, if 33 514 DISEASES OF THE CIRCULATORY SYSTEM. possible, of determining the characters which distinguish disease of the right from disease of the left side of the heart; those indicative of lesions of the pulmonary artery, of chronic forms of pericarditis, of open foramen ovale, of clots in the ventricles or auricles, etc. etc. Well observed cases of these rarer diseases, however, are still too few to enable us to generalize confidently regarding them. I have frequently examined exceptional combinations of signs with the utmost care, and then been denied a post- mortem examination, or again have stumbled on rare forms of lesions after death in cases where, during life, sufficiently careful and repeated examination of the physical signs had not been made to secure accuracy. I would strongly advise you to attach little importance to the record of such exceptional cases, and never to record such yourselves, unless equal care have been shown in the examination of physical signs and functional symptoms during life on the one hand, and in anatomical investigation after death on the other. PERICARDITIS. Cask LXXXYIL*—Acute Pericarditis—Recovery. History.— Jane Stambroke, aet. 25, servant—admitted January 7th, 1857. Six months ago she entered another ward in the Infirmary, on account of rheumatic pains in the ankle joints. These pains were unaccompanied by general fever, and there id no evidence that the heart was then affected. During the last six weeks, however, she has experienced considerable dyspnoea, palpitation, and uneasiness over the central part of the sternum, increased by active exertion, or on ascending stairs. Five days ago, after exposure to sudden changes of temperature, she experienced towards evening a distinct rigor and increased pain in the praecordia, which compelled her to desist from working, and retire to bed at an earlier hour than usual. The next day she felt somewhat easier, but on the following one the symptoms increased in intensity, and have continued up to the present time. Yesterday evening six leeches were ap- plied, and caused relief, which, however, was not permanent. Symptoms on Admission.—Cardiac impulse is faintly felt between the fourth and fifth ribs. Dulness on percussion, at the level of nipple, extends transversely four inches from the right edge ofthe sternum, which is its internal boundary. On auscul- tation a loud double friction murmur is audible, over and limited to the cardiac orgin, loudest over the sternum and base. The systolic and diastolic sounds are inaudib.e in consequence of the loud friction murmurs. Pulse 108, regular and of moderate strength. She cannot lie on either side, and prefers the sitting to the recumbent posture. Says she has a slight cough but no expectoration. Percussion elicits com- parative dulness over the two lower thirds of left back, and there is audible ovcrtho same space increased vocal resonance and cegophony, without rales. Inspiratory mur- mur on right side is somewhat harsh, but otherwise normal; is sleepless inconsequence of cardiac uneasiness and dyspnoea, which is considerable. Has not menstruated lor the last two months, but the other functions are well performed. Warm fomentation* to be constajitly applied to the precordial region. Progress of the Case.—January 9lh.—The pains and dyspnoea have been * Reported by Mr. M'Leod Pemberton, Clinical Clerk. PERICARDITIS. 515 greatly relieved by the fomentations. No friction murmur audible. The urine densely loaded with urates. Pulse 80, soft. Nutrients with wine 3 ij. Jan. 10th.__ S'o pain or dyspnoea. Friction sound slight, and only audible over right side of cardi.ic organ towards the base. Transverse dulness there is diminished by a quarter of an inch. Physical signs of left lung the same. No crepitation. Chlorides in the urine abundant. Jan. 11th.—Xo friction audible over heart, but cardiac sounds nre distant. From this time she rapidly became well. On the 13th, marked dulness, increased vocal resonance, and cegophony much diminished over left back. On the 18th, the transverse cardiac dulness measured two and a half inches, and there remained only increased sense of resistance on percussion over left back, with slight crgophony. On the 23d, complained of loss of appetite and slight dyspeptic symptoms, which disappeared the following day. On the 27th she walked out and did not experience so much palpitation or dyspneea as before the present attack. Was dismissed Jan. 31st. Commentary.—This was a pure case of pericarditis in a rheumatic girl, in which all the symptoms and physical signs were very carefully examined. The disease went through its natural stages with great rapidity. On the fifth day, when she was admitted, there was great distension of the pericardium from exudation, with friction sounds. Then for a day these were absent, probably from the two surfaces being separated by scrum. On the seventh day, distension of the peri- cardium began to diminish, and there was slight return of the friction. From this time there was rapid decline in the area of dulness, which on the fifteenth day was nearly normal. The local pain she experienced was before admission treated by the application of six leeches, but was still present on her admission. Warm fomentations to the part removed it at once, and constituted the only medical treatment she was subjected to iu the house. .Nutrients of course were given, and a little wine. The pulmonary physical signs were probably dependent on pressure of the lung backwards by the distended pericardial sac. Case LXXXVIIL*—Pericarditis and Endocarditis—Ilydropericardium. History.—Barney Kilpatrick, oet. 25, a miner—admitted July 8th, 1850. Nine weeks ago he was suddenly seized with dyspnoea and a feeling of weight or dull pain in the cardiac region. A fortnight since, th's became much more acute, and has continued up to the time of admission. For five years he has been much exposed to wet aud changes of temperature, but never had rheumatism. Symptoms on Admission.—Cardiac duluess measures three and a quarter iiches transversely, and is limited above by the margin of the third rib. Apex beats between the fifth and sixth ribs, two inches below, and considerably to the right of the nipple. All over the dull region a double friction sound is heard, resembling a roughened bellows murmur, but superficial. Beyond the region of the dulness these murmurs suddenly cease. Action of the heart regular. Pulse 96, regular, small, »nd feeble, stronger on the right than on the left side. The slightest movement induces pain, extending from the cardiac region down the left arm to the fingers; great dyspnoea; no cough or other pulmonary symptoms; no fever ; no cerebral symptoms or tendency to syncope. * Reported by Mr. David Christison, Clinical Clerk. 516 DISEASES OF THE CIRCULATORY SYSTEM. Treatment and Progress of the Case.—Twelve leeches were ordered to be applied to the cardiac region, and a calomel and opium pill to be taken every six hours. On the 11th, the friction murmurs were much louder at the base than at the apex. The pulse 108 ; feeble at left wrist; at the right wrist it had a double impulse —a pretty strong beat being followed by a weaker one. ? vj. of blood to be drawn from the cardiac region by cupping, and a pill to be taken every four hours. On the 13th the breath had a mercurial fcetor. Pulse stronger; less dyspnoea; friction murmurs more faint; pain in arm diminished. On the 14th pulse full; slight fever ; six leeches to be applied to the cardiac region ; morphia draught at night. On the 15th, friction murmurs only heard at the base; anorexia; can take no food; omit calomel and opium pills. 16th.—Friction murmurs have disappeared, but there is a soft bellows murmur with the second sound, heard at the base. 18//t.—Had an attack of severe dyspnoea and syncope ; pulse 100, regular, but feeble : 3 iv of wine; cardiac dulness increased. 19th.—Orthopnoea; pulse weak and fluttering; a quiver- ing pulsation felt in the cardiac region ; faintness ; cedema of feet and legs. Stimu- lants to be freely administered. Died early in the morning of the 20th. Examination of the body was not allowed. Commentary.—This was a well-characterized case of pericarditis. At first the endocardial murmur was masked by the friction sounds, but as these disappeared, its existence became apparent. It was observed that, as the mercury affected the system, the friction murmur diminished ; but there is every reason to believe that this was not so much owing to absorption of the exudatiou, as to increase iu the amount of serous effu- sion. To the combined effects of pressure on the heart from liquid with- out, and incapability of performing its function from incompetency of the aortic valve, the fatal event must be attributed. Since this case occurred, upwards of seven years ago, I have satisfied myself that the treatment pursued was not judicious, and that the local abstraction of blood, with administration of. mercury under such circum- stances, is not only useless but injurious. It is true no fair comparison can be drawn between this and the preceding case, inasmuch as here we had undoubted valvular lesion complicating the pericarditis. But this ought to be an additional reason against depletion. I have given it, however, as a fair example of cases that used formerly be pretty common, but which now, owing to our improved pathological views applied to practice, are somewhat rare. The following case was treated differently. Case LXXXIX.*—Acute Pericarditis followed by Acute Double Pneumonia—Recovery —Aortic Incompetence—Subsequent Articular Rheumatism—Sudden Death— Adherent Pericardium—Fatty Enlarged Heart—Thickening of Aortic Valve*. History.—Jessie Douglas, set. 22, employed in a paper warehouse—admitted November 19th, 1855. Has never been very healthy; has had several attacks of rheumatic fever, the last being about seven years ago. On the 9th, current, after exposure to cold and damp, she was seized with rigors and pain in the back. These disappearing, were succeeded by pain and slight swelling of the knees, lasting ouly for a few days. During all this time, though ill, she had no headache, vomiting, Reported by Messrs. Geo. Rabertson and R. P. Ritchie, Clinical Clerks. PERICARDITIS. 517 nor pain in the chest, but the shortness of breath and palpitation to which she is subject became aggravated. She was under medical treatment, and got purgative medicine? but was neither bled nor leeched. Symptoms on Admission.—Apex beats distinctly between the fourth and fifth ribs, immediately under and a little to the inside of the nipple; heart's impulse is heaving, and sensibly moves the whole mamma ; it can be felt but very indistinctlv in the normal position; there is no thrill. Transverse dulness at the level of the nipple 4§ inches. Heart sounds are exceedingly indistinct, and muffled at the apex, but no murmur is heard there. At the base the first sound is almost inaudible, but with the second there is heard a soft blowing murmur. Pulse 80, full, regular, incompressible. Breathing is rather laboured; respirations are 34 per minute, but regular; there is slight cough and no sputum. Percussion is everywhere good; vocal resonance is greater under the left than under the right clavicle; no rale is audible, but respiration is exaggerated under the right clavicle, and inspiration is blowing under the left. She speaks languidly, does not sleep, and on sitting up feels faint. She is thirsty, and has no appetite ; the bowels are open ; catamenia are regular. Urine is neutral, sp. gr. 1018, not albuminous ; deposits copious urates and phosphates; contains no chlorides. Patient lies on her back ; cheeks rather flushed; the skin warm and perspiring; no pnin nor swelling of any joints. Ordered half an ounce every fourth hour of the follow!ug :—R Liquor. Ammon. Acetat. et Aqum aa. ?, ij. Pno(ii!Kss of the Case.—November 20th.—At the apex, the cardiac sounds con- tinue exceedingly indistinct and muffled. At the base, immediately above the nipple, there is heard with each cardiac sound an exceedingly soft blowing noise equal in intensity and duration; it extends over a considerable space, being heard hut very feebly under the right nipple. Immediately under the centre of both clavicles, there is a prolonged blowing noise, occupying the period of both sounds. Pulse 72, full and somewhat jerking; palpitations are occasionally urgent; respi- rations 36, laboured. Ordered twelve leeches to be applied over the preecordia, and subsequently warm fomentations. 21st.—The leech bites bled well. There is great heaving and expansive motion of the whole praacordia; at the apex murmurs are indistinct—at the base a double blowing murmur, most clear over the head of the sternum. There is no friction audible—no pain, and the palpitations are not increased. Pulse 80, slightly jerking, but weak. She cannot sit up from tendency to faint; is depressed and exhausted in her aspect. Urine scanty ; still contains no chlorides. Ordered three ounces of wine with beef-tea; to be kept perfectly quiet. 22d.— The skin is covered with moisture ; respiration 46 ; pulse 84 ; still jerking and weak. The apex beats exactly under the fifth rib, a little to the inside of the nipple. At the base there is now a loud creaking which is double, and very loud nt the margin of the sternum. Transverse dulness 3£ inches. Ordered to discon- tinue the saline mixture. In the evening loud friction was audible at the apex as well as at the base, and the apex beat had fallen about two lines below and to the inner side. 23d.—Pulse 72, of same character; respirations 35. At the base of the cardiac organ, instead of the double friction heard yesterday, there is now a single continuous creaking. The same sound is audible at the apex. '24th.—Pulse. 80, still slightly jerking, but soft ; respirations 38 ; apex as yesterday. There is continuous churning friction at base ; at the apex it is heard, but less loud and continuous. R Spir. JEther. Nitrici 3 iij; Tinct. Colchici 3 j ; Aquce 3 vss; II. One ounce thrice a-day. Also R ; Pulv. Opii gr. iij ; Extract. Catechu gr. xv ; Confect. Rosar. g. s. ut fiat massa in pilulas sex dividenda ; one to be taken every sixth hour. 25th.— The same friction murmur ; pulse 80 ; respirations 36 ; urine is hyperlithic, and still contains no chlorides. 26th.—Pulse 82 ; slightly 518 DISEASES OF THE CIRCULATORY SYSTEM. jerking, more compressible ; respirations 32 ; skin dry and hot ; tongue moist; Ins no appetite ; urine the same in character ; the friction is less churning and coutinuoui and occurs more with the first sound. 28th.—At the visit to-day, dulness is detected in the left scapular region near the inferior angle, over a space the size of the hand, with crepitation, and pealing vocal resonance. Friction in cardiac region is now diminishing both in intensity and duration. Ordered three additional ounces of trine. (From this day commenced an intercurrent attack of pneumonia, affecting the left lung, terminating in seven days. Besides dulness, crepitation, and increased vocal resonance, there were on the fourth and fifth days a friction murmur at the base of the left lung. The chlorides began to reappear in the urine on the fourth day. A blister was applied (3 by 4) to the right side anteriorly on the 29th, and of the same size to the left lateral region on Dec. 2di) Dec. 2d.—On percussion, the transverse cardiac dulness is 3\ inches ; the apex beats feebly between the fifth and sixth ribs. At the base, one long rough prolonged sound is heard, and at the level of the nipple this is plainly connected with a second of a friction character. Over the centre of the sternum, on a level with the nipple, this hoarse blowing (or friction ) is loudest, and is still audible at the right of the sternum within 1-$- inch of the right nipple. Pulse 96, still jerking and soft. Dec. 6th.—Considerable dulness detected to day on the right side from the inferior angle of scapula to the base. Respiration is almost inaudible, and is faintly bronchial. Over area of dulness a little fine crepitation may also be detected on inspiration, and vocal resonance is increased. Pulse 126, soft, jerking ; respirations 52 ; great dyspneea. (From this attack of pneumonia on the right side, the patient began to recover on the seventh day. Throughout the whole course of it, the chlorides in the urine were abundant; there was little cough or sputum.) Dec. 12ih.—The cardiac friction murmur has totally disappeared from the apex. At the base a blowing murmur is now heard with the second sound, the first being free from murmur. 26th.—This morning, about 9.30, the patient having assumed the recumbent position for a few minutes, violent palpitations came on, and forced her to sit up ; she felt as if about to faint, and was so agitated as to be almo>t unconscious. At 11 a.m., the palpitation had somewhat subsided, but the cardial action was still very viobnt, shaking the whole person, and causing severe pain in the chest. Pulse almost continuous, beating about 180 times in a minute, jerking and incompressible ; no difficulty of breathing ; no affection of the head ; face pale and anxious ; patient restless, and occasionally moaning. The urine passed soon after this paroxysm is scanty, of brick colour, turbid, clears up on application of hi at, but on further heating and being fully acidified, a slight coagulum is obtained. From this paroxysm she recovered towards the evening, under the use of Ammoniated Tincture of Valerian and Sol. Mur. Morphiae. 31st.—Patient now sits up for about two hours every day, and begins to be very hungry. January 1st.—Cardiac sign" are the same as at last report ; at the apex nothing but a dull impulse is heard ; at the base there is still the blowing with the second sound. From this date she gra- dually increased in strength, moving about in the ward and occasionally taking walks in the town. The pulse 90 to 100 per minute ; was easily raised to 100 or 120 by excitement. Palpitations also were readily caused by any surprise, lasting for about fifteen minutes, and accompanied by a marked soreness along the sternum. On the 15th of February it is reported no change in the cardiac sounds had occurred. The transverse dulness 2| inches ; the pulse 96, full and regular, retains its jerking char- acter. Is discharged much relieved on the 17th February. She v\as re admitted (under the carte of Dr. Christison) on the 29th of February, labouring under an attack of articular rheumatism ; she gradually became conva- lescent, but continued weak, easily agitated, with painful palpitations and threaten- ing of syncope. The blowing murmur with the second sound at the base continued, PERICARDITIS. 519 but the most careful examination, by inspection, percussion, or auscultation, failed to elicit any other physical sign, the dulness being still 3i inches across. In this condition she continued in the ward, moving about, and in tolerable health, when on the evening of May 14th she suddenly started up with a cry, and immediately fell back, pale gasping, and almost pulseless, and expired within three minutes, notwithstanding the sedulous administration of restoratives and stimulants. Sectio Cadaver is.—Thirty-nine hours after death. Thorax.—The pericardium was found universally adherent. The heart was uniformly enlarged, wei-hing twenty eight ounces. On passing a stream of water down ihe aorta, it escaped very freely into the ventricle. On examination the aortic semilunar valves were found thickened and shortened. There were no vegetations on the valves. The auriculo-ventricular orifices, especially on the right side, were a little dilated. The left ventricle was very much dilated, and its walls were fully of the nor- mal thickness. The right ventricle was of normal dimensions. The lungs were congested posteriorly and inferiorly, but were otherwise everywhere natural. The muscular substance of the heart was everywhere of a pale fawn colour, soft, and easily breaking down under the finger. Ab»omi:\.—The abdominal organs were natural. Munosroric Examination.—The pericardial adhesions were composed of well formed areolar texture, in firm bands aggregated closely together. The substance of the heart presented all stages of the muscular fatty transformation; thn fasciculi in most places being brittle and the transverse striae obscure, while here and there fatty granules were numerous, displacing more or less of the sarcous substance. Commentary.—This case was carefully observed for nearly a period of six mouths. On admission it was evident that a pericarditis existed with such distension of the pericardium, that the two diseased surfaces did not rub upon one another, so as to occasion friction murmurs. The pulse was full and jerking, but the exact character of the valvular lesion could not then be determined. There was also dyspneea, and with a view of diminishing this and other symptoms, twelve leeches were applied, with the effect, however, of rendering her weak and faint. AVine, nutri- ents, and quietude were immediately ordered, and subsequently consti- tuted the treatment. The following day the pericardial distension began to diminish, and a returning friction murmur to appear. As the pericardiac signs decreased, the evidence of aortic incompetency became more evi- dent, and latterly a prolonged blowing with the second sound at the base was the permanent sign of aortic valvular lesion. She also suffered from two distinct attacks of pneumonia, one on the left, and then subsequently on the right side, during the whole of which time wine with nutrients were assiduously administered, with the effect of conducting her favour- ably through these formidable complications. All who witnessed the case were satisfied that this woman, during these two pneumonic attacks, in both of which were present all the characteristic symptoms and phy- sical signs of the disease, owed her life to good nourishment and stimu- lants, and that the slightest approach towards an antiphlogistic treatment would have been fatal. It was further observable, that at this time the pulse was full and jerking—many would have called it hard—so that *lie presented what has frequently been described as the symptoms of an 520 DISEASES OF THE CIRCULATORY SYSTEM. exquisite case of pneumonia; in short, that very group of symptoms in whicii writers have advised us to bleed largely. I have myself no doubt that such cases with aortic disease and dyspnoea were, previous to the days of physical diagnosis, regarded as typical examples of pneumonia, were bled largely, and served to swell the great mortality which, as wc have previously shown, characterised a former practice. Under an opposite treatment, however, she gradually recovered, aud became so well (though still labouring under the aortic incompetency with tendency to palpitation), that she insisted on going out. She was so imprudent, however, as again to catch articular rheumatism, and re-entered the Infirmary; the cardiac physical signs and symptoms, however, remaining unchanged. She again recovered, but died suddenly from a fatal syncope. On examination of the body, the correctness of all the facts observed was confirmed, and the nature of the case rendered perfectly clear. The two layers of the pericardium were everywhere adherent; the aortic valves were thickened and incompetent, explaining the persistence of the valvular murmur and jerking pulse; the left, ventricle was hypertro- phied, as shown by percussion ; and the muscular substance ofthe heart was fatty, accounting for the sudden death. Case XC*—Acute Pericarditis supervening on Phthisis. History.—Edward Campbell, set. 30, a porter—admitted September 5th, 18.">6. For twelve years has been of very intemperate habits, unsettled in his occupation, and often insufficiently nourished. About one month ago he first noticed a short dry cough, attended with little expectoration till a few days ago, when it became rather copious and yellow. Four days ago, the sputum for the first time was tinged with blood; about the same time the stools became frequent and loose, and severe night sweats appeared. He has been subject for some time to shiverings, but cannot remember any special rigors ushering in the present attack. Symptoms on Admission.—There is marked dulness on percussion at the apex of left lung, and latterly in the axillary region. There is also cracked-pot resonance over the left front, from the first to the fourth intercostal space. On auscultation, there aro coarse moist rales, during inspiration and expiration, over the whole left lung, ante- riorly, laterally, and posteriorly, with increase of vocal resonance, amounting to bron- chophony superiorly. Over the lower third of the left lateral region, there is friction with inspiration. The right lung gives the normal results on auscultation and percus- sion. The sputum is copious, frothy, and streaked with blood; considerable dyspneea; the cardiac organ is healthy; the pulse is 112, rather incompressible; the appetito bad; the bowels are regular ; the skin hot; the face of a purplish hue; the patient is emaciated, weak, and lies on his back ; does not sleep well; there is great tremulous- ness of the limbs; the urine is not coagulable, and it contains abundant chlorides; sp. gr. 1020. Progress of the Case.—September 5th-21st.—Has been treated with small doses of antimony, and a blister two inches square over left mammary region. The strength has been supported by nutritious diet and wine, or occasionally gin. On the 11th, the sputum was carefully examined, and yellow elastic tissue was cu- * Reported by Dr. Thorburn, Resident Physician, and H. N. M'Laurin, Clinical Clerk. PERICARDITIS. 521 covered under the microscope. The physical signs on the left side are very slightly altered; the rales are less numerous; there is more bronchial breathing. At the right apex there is now dulness, harsh respiration, and occasional crepitation at close of the inspiratory murmur. The fever, though still great, has considerably abated. Pulss generally 120, soft. From Sept. 21st to 30th, the pulmonary phenomena were little altered, although they were subject to remissions, but the diarrhoea, which the patient had before only slightly experienced, became veiy troublesome. Oct. Itt,__To-day a distinct double friction murmur is audible all over the cardiac region, soft at the base, more coarse and loud towards the apex. The cardiac dul- ness on percussion is extended—externally it cannot be limited, hut internally it reaches to the ccntie of sternum. No fremitus; pulse 128, feeble, intermittent, and compressible; respirations 36 per minute; voice hoarse ; cough painful; sputum purulent; patient weak, but feels no pain anywhere, and expresses himself as being so well, that he is even anxious to go out and see a friend. Has no appetite; the diarrhoea continues. Oct. 2d to 9th.—The pericardial friction continues distinct. There is also pleural friction murmur on the left lateral region more distinct and ex- tensive than on admission ; the right side is dull at the apex, with moist rales during inspiration; to-day there are friction sounds during expiration at the right base. Oct. 9thto\'th.—The auscultatory phenomena are unaltered. The moist rales in lung are more coarse and bubbling ; dyspnoea is intense ; respirations 60 per minute ; the face is livid ; the pulse more and more weak, becoming imperceptible. Oct. 17th.— Died this morning. Sectio Cadavcris —Fifty-one hours after death. The body was emaciated. Thorax.—The left lung was infiltrated throughout with grey tubercle ; at the opcx there was great condensation around three or four cavities containing pus, the largest being the size of a hen's egg. Numerous smaller cavities existed throughout the upper lobe, which, with the cut bronchi, poured out abundant pus on the texture being squeezed. The right lung was also infiltrated with grey tubercle throughout the upper lobe ; at the apex there were two cavities the size of hazel nuts. Its inferior lobe was thinly scattered with the same tubercle, and was greatly engorged with blood and serum. Universal adhesions on both sides. Both layers of the pericardium were covered with villous lymph, generally about one-eighth of an inch in thickness. Between them were about two ounces of serum. The valves and substance of the heart were healthy. Abdomen.—The abdominal organs were healthy* Microscopic Examination.—The structure of the villous lymph in this case was very carefully examined, and Fig. 380 p. 267, is a representation of the struc- ture. The villi varied greatly in length and size, and could be perceived by the naked eye. Individually they were of pulpy consistence, consisted of a delicate membrane, covered in many places by layers of pavement epithelium (Fig. 3S0, b). Their substance consisted of an aggregation of fibre cells in all stages of develop- ment, several of them were floating loose in the field of the microscope (Fig. 3S0, c). On the addition of acetic acid the whole became very transparent, showing the mere outline ofthe villi, with fusiform nuclei imbedded in them. Here and there they con- tained transparert spaces or vacuoles, having in some transverse markings or folds externally (Fig. 380, a, a). The heart was subsequently carefully injected by Profes- sor Goodsir, and portions of it may now be seen in the University Museum, with the layer of lymph nearest the muscle containing a rich plexus of vessels filled with coloured size. 522 DISEASES OF THE CIRCULATORY SYSTEM. Commentary.—On the admission of this man (September 5), 11C was labouring under intense fever. He had cough and expectoration tinged with blood; dyspnoea; livid face; hot pungent skin; pulse 112, firm; dulness with cracked-pot sound on percussiou over left clicst anteriorly ; and coarse moist rales during inspiration and expiration. These were the symptoms of acute pneumonia in its suppurative stao-e. On the other hand, the disease was described to have come on a month before with dry cough; there was no distinct rigor ushering in the attack; and the chlorides in the urine were abundant. Hence it might be a case of acute tuberculosis. His general aspect tvi(), of good strength, jerkins; no venous pulse. April l\th.—Has continued the same, but insists on leaving the Infirmary, and is in consequence dismissed. Commentary.—This was an exceedingly interesting case of pericarditis and endocarditis, the former of which apparently terminated in adhesions, while the latter underwent a variety of organic changes, which were in- dicated by physical signs, and were carefully recorded in successive examinations. From these it seems probable that there was gradually developed considerable hypertrophy of the left ventricle, the apex of which descended downwards and outwards, whilst the pulse became more and more jerking. The aortic orifice was apparently constricted; and it is curious to observe, that whilst the murmur at the base at first was propagated upwards in the course of the large vessels, it subse- quently was propagated downwards towards the apex, and ceased abruptly above the margin of a certain area. The kind of organic lesion which gradually forming ultimately produced this result, it is useless speculating about, although it must be evideut that the aorta itself above the valves could not have been implicated. At one time it appeared to me probable that the pulmonary valves were affected, but a careful consideration of all the circumstances obliges me to negative this supposition. Again, the pressure of the pericardial exudation might have produced the murmur at the base. The constant blowing murmur at the apex indicated mitral insufficiency, a lesion which could not have been so intense as the aortic disease, as the murmur was always more soft, aud could easily be distinguished from the one at the base. Indeed it seemed as if this remained almost stationary, whilst the aortic lesion at length became the predominant one. I heard some few weeks after her dismissal that this girl was dead, but under what circumstances could not be ascertained. No doubt after the long observation and suc- cessive careful examinations this case underwent, much might have been learnt from a post-mortem examination. The disappointment which medical men too frequently experience iu this particular, doubtless con- stitutes an argument with some in favour of supineuess, and must at all times tend to check that habit of accurate observation, which is so essential for working out the difficult problems still unsolved in the dia- gnosis of cardiac diseases. Pericarditis consists of an exudation into the pericardial sac: the fibrin of which coagulates and attaches itself to the membrane, while ie serum is accumulated in the centre. Changes now occur m con- sequence of which the solid portion, or layer of lymph as it is called, assumes a villous structure and becomes vascular, whereby, in the majority of cases, the fluid is absorbed, and the two false membranes unite to form an adherent pericardium. These changes are described and figured, pp. 2i)ii, i!(57. (Fi»s. 379, 380.) This result, however, may be prevented by two circumstances:—1st, The exudation may be small in quantity and limited in extent, when it is transformed into fibrous tissue, becomes covered with a true serous membrane, and there is to adhesion with the opposite surface. This constitutes the white 528 DISEASES OF THE CIRCULATORY SYSTEM. patches so frequently observed on the heart in examining bodies after death, and they are equally frequent on other serous membranes. 2d The amount of exudation may be very great, the distension of the pericardial sae extreme, and the transformation into vascular absorbing villi thereby prevented. Under such circumstances, the nias-s of fluid remains stationary, passes into pus, or even increases, in consequence of dropsical effusion from pressure oti the vcius, and a so-called chronic pericarditis, or pericarditis with effusion (hydro-pericardium), is esta- blished. Auscultation and percussion are our guides to a knowledge of peri- carditis in the living subject. "With their aid the physician, if called in at the commencement, can trace the progress of the disease through the stages of commencing exudation with friction, gradual pyriform enlarge- ment with or without friction, absorption and disappearance.of the scrum with returning friction, and final adhesion of the two surfaces. Tin-, was accurately done in Cases LXXXIX. and XCl. An adherent peri- cardium, or a limited exudation confined to the posterior surface of the heart, is detectable by means of physical signs with extreme rarity. It is admitted that occasionally a pericardial may closely resemble a valvular murmur, but then the former is superficial, often intensified by pressure of the stethoscope, is not permanent, and is liable to be affected by pos- ture, and by the greater or less energy of the cardiac contractions. As regards percussion, it is necessary to remember that when the amount of fluid is small, say from two to four ounces, the pericardial sac is not distended, but remains flaccid. The fluid gravitates towards the lower end, and produces the appearance represented in Fig. 41'J. In cases of acute general pericarditis, such as Cases LXXXVTI. and LXXXIX., the amount of fluid may reach from ten to twenty ounces, when the pericardium is distended, becomes pyriform with the base down- wards, as represented Fig. 413. In such cases it may be determined by percussion, to extend upwards to the top ofthe sternum, aud downwards to below the xiphoid cartilage. It may pass to the right of the sternum on one side, and left of the nipple on the other, more or less displacing the lungs, especially pressing backwards on the left one. In chronic pericarditis or hydro-pericardium, more than three pints of fluid have been found iu the sac, in which case the pyramidal form of acuta peri- carditis is lost, and it becomes globular, as in Fig. 414. In such cases it encroaches so far on the left lung as to push it entirely backwards. The liver aud stomach are at the same time displaced downwards to a great extent, by the descent of the central tendon of the diaphragm. Hence the epigastric prominence, and the pain on pressure in the epigas- trium, sometimes observed in cases of pericarditis. While the increasing effusion into the pericardium displaces the lungs, liver, and stomach, it also causes, especially in the young, prominence of the lower sternum and adjoining left costal cartilages, and widening of the left intercostal spaces. If very extensive, it presses backwards and upwards on the bifurcation of the trachea, causing extreme dyspneea. Iu such cases relief is experienced by sitting up and leaning lorward iu bed, when ihe pressure on the trachea is removed by the gravitation of the fluid down- wards and forwards.—(Sibson.) Pressure on the oesophagus may aho occasion more or less dysphagia. PERICARDITIS. 529 Functional symptoms, however they may induce us to suspect, can never alone positively enable us to affirm the existence of pericarditis. They are very variable in different cases, and appear to me to be dependent more on the general susceptibility of the nervous system, Fig. 412. Fig. 413. than on anything else. Moreover, we have seen that the symptoms of local pain, dyspnoea, and so on, are often absent. In the case of Cainp- oe» (Use XC.) while the friction murmur told its tale with the greatest clearness, he denied that anything was wrong with his heart wnatever, and yet after death the two pericardial surfaces were found Fi" til' r?-aCCid Pericardium with small amount of fluid.—(Sibson.) -ASibion 1 ended Pe«cardium, of a pyriform shape, as an ordinary pericarditis. 34 530 DISEASES OF THE CIRCULATORY SYSTEM. covered with soft shaggy lymph. In Case XCL, where after death there was adherent pericardium leading to general anasarca, the man could not remember that he was ever affected in any way with cardiac disorder (See also Case LXXXVIII.) This important fact has been noticed by many physicians—thus " acute peri- carditis is often so latent as to be discoverable only by physical signs."— (Stokes.) "The disease may be absolutely latent from first to last. I have known patients with several ounces of fluid and exu- dation matter in the pericardium, grow irritated, when inquiries were made about symptoms connected with the heart."—(Walsh.) But the cases of Douglas and Young, which have been recorded, must satisfy us that pericarditis is a most serious complaint. The adhesions which form often more or less em- barrass the action of the heart, and above all, impede its normal nutri- tion; in one case they caused gen- eral dropsy, and in the other fatty degeneration of the texture of the heart. Much has been written as to the F'"'4U complications of pericarditis. The association with acute rheumatism is so common, that some have classi- fied cases into rheumatic and non-rheumatic (Ormerod, Jfarhham.) The causes of this association are as yet unknown. Dr. Taylor further sought to establish a relation between pericarditis and Bright's disease. Thus, out of 38 of his cases, 20 occurred in the progress of acute rheumatism, and ten were complicated with renal disease. It so hap- pens, that in none of my cases of pericarditis has there been a compli- cation with Bright's disease, and yet this last lesion is so common in Edinburgh, that it i3 scarcely conceivable, if it were really a cause of the former, that it should have escaped my notice. Dr. Christison also says, in his work on " Granular Degeneration of the Kidneys " (p. 94), that " pericarditis is seldom seen among the sequelae." We cannot, therefore, be too cautious in reasoning as to the causes and treatment of pericarditis from the supposed conditions of the blood with which it ia thought to be associated. Complications with pleurisy, pneumonia, and pulmonary emphysema are much to be dreaded, especially as regards the ultimate effects on the heart itself, although they may not prove imme- diately fatal. (See also Cases CVIL, CVIIL, and CX.)__________ Fig. 414. Excessive distension of pericardium, as in chronic pericarditis or hydro- pericardium.—(Sibson.) PERICARDITIS. 531 The treatment, like that of all other forms of acute inflammation up to a recent period, was at first antiphlogistic, but, for ths reasons previ- ously given (p. 263), this is no longer the rule. Case LXXXVII. demonstrates how, in a tolerably healthy person, the disease passes rapidly through its natural progress. But should there be depression of the vital powers, stimulants and nutrients are demanded, as in Case LXXXIX. If there be local pain, the application of a few leeches, or, what is often better, of warm fomentations or a hot poultice, tends to relieve it. Quietude of body and mind is essential to the treatment. In young persons especially, unnecessary physical examinations should be carefully avoided. If the principle of practice formerly put forth be correct (p. 264), viz., that a true inflammation cannot be cut short, and that the only end of judicious medical practice is to conduct it to a favourable termination, we should expect its truth to be manifested in such a disease as pericarditis. Xow this, I think, we do see. Contract the treatment of Hope with that of Stokes, and what a difference is observable. The former energetic in lowering remedies, the latter cau- tious, and constantly warning us not to proceed too far. Though he recommends blood-letting, it can only be practised with his consent at a time, to an extent, and under circumstances when obviously it is likely to do no harm. On the other hand, he points out how, in some circum- stances, "even a vigorous action of the heart, a jerking pulse, and an increased action ofthe carotids, do not necessarily contra-indicate wine ;"* and remarks, " that the omission of that active antiphlogistic treatment, still so often employed in the first stages of inflammation, might be of no great detriment to the patient."! For my own part, I am satisfied that there are no circumstance■; in which an antiphlogistic practice can di- minish the progress of the disease, whilst in the vast majority of cases it does positive harm, by checking the vital force, so necessary for enabling the patient to struggle through his malady. It has been supposed that the action of mercury has an especial ten- dency to favour absorption in cases of pericarditis, not only of the serum, but of the organised lymph itself. I have now given it in many cases, two of which are recorded at length (Cases LXXXVII I. and XCIL), but could never satisfy myself that it had the slightest influence in forward- ing or modifying the natural changes which occur. The best evidence on this subject, however, is to be derived from a careful analysis of forty cases of acute rheumatic pericarditis, by the late Dr. John Taylor, in which mercurial ptyalism was produced with the following results :— 1st. Ptyalism was not followed by any abatement of the pericarditis in twelve cases. 2d, In one case ptyalism was followed by speedy relief. 3d, In two cases ptyalism was followed by a diminution, and then gradual cessation of pericardial murmur. 4th, In one case pericardial murmur had been diminishing for some days before, and it ceased soon after ptyalism was produced. 5th, In one caso pericarditis and pneumonia both incrca>ed in extent and intensity after ptyalism. Gtb, In four cases pneumonia supervened after the establishment of, and therefore was not prevented by, ptyalism. Was it caused by it ? 7th, In three cases endo- carditis supervened after ptyalism. 8th, In six cases ptyalism was followed * Stokes on Diseases of the Heart, etc., 1st. edit. p. 89. t Ibid. p. l.V 532 DISEASES OF THE CIRCULATORY SYSTEM. by pericarditis. 9th, In one case ptyalism could not be produced and yet the pericarditis went on favourably. 10th, In two cases ptyalism was followed by extensive pleuritis. 11th, In one case ptyalism was fol- lowed by erysipelas and inflammation ofthe larynx. 12th, In two cases rheumatism continued long after ptyalism was produced.* Thus out of the forty cases only four can be said to have become better after the mercurial action on the system was established, and in these there can be little doubt that it was purely a matter of coincidence. Indeed I have often observed in hospital cases, that when mercury has been said to be most successful, its physiological action has been established just about the time when, during the natural progress of the disease, the fric- tion or blowing murmur may be expected to cease. It seems to me impossible to reconcile these positive facts with the strong opinions of some eminent physicians as to the good effects of mercury in pericarditis. " If a person," says Graves, " is seized with very acute pericarditis, how unavailing, will be our best-directed efforts unless they be succeeded by a speedy mercurialization of the system!" The case of Stambroke (Case LXXXVII.) is alone a sufficient answer to such a remark, not to mention the researches of Louis, who demon- strated that only one out of six cases was fatal when they were left entirely to nature. Acute pericarditis, therefore, should be treated according to the gene- ral principles previously referred to. During the acute febrile symptoms, salines and quietude. If there be much local pain, a few leeches and local warmth. If there be excited action and dyspneea, aether and mor- phia, and as early as possible nutrients and wine to support the vital changes which it is necessary for the exudation to go through, so as to favour absorption. Active purgatives should be avoided, and I am by no means sure that blisters are of any avail. My experience induces me to concur with a remark by Dr. Markham, viz., " that rheumatic pericar- ditis is an inflammation attacking rather those of weak than of strong constitution; that it is much more common in the delicate and young than in vigorous persons at the prime or middle periods of life ; that the degree of inflammation, that is, the general febrile reaction and the local exudation, is also greater in them than in the strong; and moreover that the disease is more fatal.! VALVULAR DISEASES OF THE HEART. Although morbid anatomists have described a variety of lesions which may cause imperfect action of the valves of the heart, I prefer grouping them together under one head. However they originate, whether from mechanical rupture, from endocarditis, deposits of fibrin, morbid growths, or other cause, they practically amount to the same thing. The disease is imperfect valvular action, and the duty of the physician is to prevent as much as possible the consequences which this is likely to occasion. * Brit, and For. Med. Review. Vol. 24. ! Markham on Diseases of the Heart, etc. P. 103. VALVULAR DISEASES OF THE HEART. 533 It is also his duty—while taking every advantage of the laborious efforts which have been made to place the physical diagnosis of those valvular injuries on an exact basis—to remember that perfection is far from having been reached. Careful observations are still required to clear up many doubtful points, and to unravel the difficulties which arise from compli- cation of injuries in the mechanism and vital properties of so important an organ. Hence, notwithstanding the admirable monographs which have been published on this subject, constant research is necessary, not only to confirm what is already known, but to determine with precision points that are doubtful, and conditions as yet scarcely recognizable. " A time may come," says Stokes, " when the science of diagnosis will be carried to such perfection, that we shall unfailingly determine not only the con- dition of each portion of the heart, but discover the rise and watch the progress of every interstitial change in its structure, and every mutation of its vitality."* If so, it can only be done by the careful study and analysis of individual cases. Case XCTH.f—Incompetency of Aortic Valves—Dilated Hypertrophy of Left Ven- tricle—Dilatation of Ascending Portion of Aortic Arch—Chronic Arteritis with Aneurismal Pouches. History.—William M'Ritchie, set. 38, fireman on board a Newcastle steamer, entered the clinical ward, complaining of palpitation, dyspneea, and cough, on the 4th of Janu- ary, 1850, At that time it was ascertained that the cardiac dulness was of unusual extent, and that a blowing murmur existed with the second sound at the base of the heart. He remained in the house under treatment until February 2d, when all the urgent symptoms having left him, he was dismissed. He was re-admitted on the 14th March, the palpitation, cough, and dyspneea having returned, together with anasar- cous swelling of the abdomen and inferior extremities. Symptoms on Admission.—On percussion, the cardiac dulness measures four inches transversely. The apex beats between the sixth and seventh ribs external to the nipple. The carotid and subclavian arteries beat strongly. A loud and prolonged bellows mur- mur is heard with the second sound, loudest at the base of the heart, and propagated in the course of the large arteries. First sound is normal in character. Pulse 70, regular, hard, and jerking. Respiration hurried ; cough and dyspneea urgent; inspi- ration harsh ; expiration prolonged; face livid; pain and dizziness in the head; occa- sionally loss of vision; disturbed sleep; nausea and anorexia ; abdomen considerably swollen from ascites; inferior extremities cedematous ; legs cold. Progress ok the Case.—During April the symptoms continued with more or less intermission. In May he became liable to attacks of syncope, accompanied with angina and palpitations. In the beginning of June it was observed that the bellows murmur with the second sound assumed a rougher character over the arch of the aorta. He also complained of dysphagia and a pulsation in his throat, which obliged him to keep his head in a particular position. On the 14th he was seized with an unusually severe attack of angina and syncope, which in ten minutes was fatal. The treatraeut consisted principally in the exhibition of a variety of expectorants and anti- spasmodics, of which a draught containing ten minims of chloroform, and a teaspoonful * Markham on Diseases of the Heart, etc., p. 342. t Reported by Mr. Hugh M. Balfour, Clinical Clerk. 534 DISEASES OF THE CIRCULATORY SYSTEM. of Tr. Cardam. Co. afforded him most relief. A few leeches were also applied occa- sionally to the cardiac region. Sectio Cadaveris.—Forty hours after death. Thorax.—The pericardium contained three ounces of serous fluid. There was hyper- trophy with dilatation of the left ventricle of the heart, in consequence of which the organ weighed 1 lb. 4 oz., and its transverse diameter measured five inches. The mitral valve was healthy. The aortic valves were considerably thickened and curled inwards. Immediately above them the aorta was unusually dilated, the diameter of its calibre being two and a quarter inches. Water poured upon the aortic valves from above passed through the orifice without apparently receiving any impediment. One inch below the origin of the left subclavian there was an aneurismal pouch, the size of a walnut, projecting half an inch from the general outline of the vessel. The arteria innominata, and the origin of the right carotid artery, were also somewhat dilated and there was an aneurismal dilatation of the aorta opposite the superior mesenteric artery. The aorta, the coronary, and several of the larger arteries, were roughened internally by atheromatous deposits. The lungs were emphysematous anteriorly, and cedematous at their apices. Head.—Brain pale; slight subarachnoid effusion ; cerebral arteries slightly athe- romatous. Abdomen.— Abdominal organs healthy. Case XC1V.*—Incompetency of Aortic Valves—Hypertrophy of Left Ventricle and Auricle—Obstruction and Incompetency of Mitral Valve—Pneumonia. History.—Samuel Crawford, set. 42, employed at Chemical Works—admitted June 10th, 1850. He has been subject to palpitation and dyspnoea, after any considerable exertion, for four or five years. Last February he had to leave off work on account of these symptoms, which subsided in a fortnight under medical treatment. Three days ago they once more returned. He has noticed, during the last four or five months, swelling of the feet, legs and abdomen. He never had rheumatism or any other serious complaint. Symptoms on Admission.—The cardiac dulness measures three inches and a quarter transversely. The apex beats between the sixth aud seventh ribs, two inches below and to the left of the nipple. The carotid and subclavian arteries heat strongly. Over the apex a bellows murmur is heard, with both sounds of the heart. Over the base there is a loud prolonged blowing murmur with the second sound, which is propagated in the course of the large vessels. The first sound heard at the base is unusually short and muffled. The pulse is regular, strong, and jerking. He has cough, and consider- able dyspneea. Percussion over the lungs is resonant, but posteriorly and inferiorly there are fine moist rales. He is liable to giddiness and a feeling of faintness on sud- den exertion: Can only sleep in a half sitting posture, resting somewhat on his left side. Considerable oedema of the lower extremities. Other functions normal. Progress of the Case.—The cough and dyspneea continued. On the 13th ot June the urine became scanty and high coloured. On the 17th there was diarrhoea. Moist and dry rales were heard over a considerable portion of chest, and there was much cough and expectoration. On the 26th the urine was again abundant, but there was general fever, cough suppressed, dyspneea, and expectoration tinged with * Reported by Mr. David Christison, Clinical Clerk. VALVULAR DISEASES OF THE HEART. 535 blood. Pulse 108, full and hard. Crepitant and mucous rales were heard over the lower portion of the right side. On the 28th, all oedema of the extremities had disappeared, but there was decided pneumonia on right side. Low delirium during the night. Died on the morning of the 29th. On the first day § x of blood were drawn from the arm with immediate relief, but it was followed by sleeplessness and agitation at night. He was then ordered § vj of wine daily, and a mixture con- taining expectorants and diuretics, with tincture of digitalis. Local blood-letting, by means of leeches, was also practised from time to time. The scantiness of the urine and oedema gave way under the use of cream of tartar in 3 j doses three times a day. When the pneumonia came on, local blood-letting, by cupping to § xij, and tartrate of antimony internally were employed, but without success, although the former relieved the dyspneea. Sectio Cadaveris.—Forty-eight hours after death. Thorax.—The pericardium contained four ounces of straw-coloured serum. The heart weighed twenty-three and a half ounces. This increase in size was owing to hypertrophy of the walls of the left ventricle and auricle, and to dilatation of the right ventricle. The aortic valves were fringed with numerous warty vegetations. One of the valves was ruptured, and the raptured edges were. studded over with granules of recent exudation. In consequence of these lesions the valves allowed water to rush rapidly through, when poured on them from above. The septal leaf of the mitral valve was perforated in two places by orifices of sufficient size to admit a crow quill. These orifices were surrounded by vegetations, presenting a funnel- shaped prolongation on the internal surface of the valve, through which the orifice passes. There were several other vegetations on the opposite leaf of the valve and fringing its margin. One of the choreas tendineae was broken across at its valvular attachment, the ruptured or floating end being thickly covered with fibrinous vegeta- tions. Aorta healthy. The lower, middle, and a portion of upper lobe of right lung dense, hepatised, presenting a reddish-gray colour, and yielding sanguineous pus on squeezing the cut surface. Abdomen.—Abdominal organs healthy. Commentary.—Both the cases now detailed exhibit very strongly how the rules formerly mentioned, correctly applied, enable us to deter- mine the nature of the cardiac lesion present,—for you will remember that, in both, the lesions named at the head of each case were confidently stated to exist, before the body was examined. In Case XCIII. " a bel- lows murmur was heard with the second sound, loudest at the base of the heart, and propagated in the course of the large arteries." Rule 5 tells us that this indicates aortic insufficiency, and on examination such was found to exist. As the case progressed, however, he complained of a pulsation in his throat and of dysphagia; aud it is worthy of remark, that not only had an incipient aneurism formed in the arch of the aorta, which explained these symptoms, but that a tendency to the formation i>f aneurisms existed in other parts of the arterial system. In Case XOIY. the diagnosis, though more complicated, and therefore more difficult, was also determined on by paying attention to the same rules. " Over the apex a bellows murmur was heard with both sounds of the heart." Xow rule 6 tells us that this indicates mitral obstruction with insufficiency, and a description of the lesion found affecting this valve after death, must convince us that whilst the vegetations prevented proper 536 DISEASES OF THE CIRCULATORY SYSTEM. closure of the orifice, some of thein must also have obstructed the flow of blood in its passage from the auricle to the ventricle. But there was also a bellows murmur with the second sound, heard loudest at the base ■ and this, as in Case XCIIL, is a sign of aortic insufficiency. A careful determination of the cardiac signs, therefore, and an exact appreciation of the facts in the first instance, led us, in accordance with the laws previously generalized, to a correct conclusion as to the nature of this complicated case. No two cases could better convince you of the dia- gnostic value of physical signs. The treatment in the last case is what I should now consider as far too depletory. On looking back to it after seven years' additional experience, it will be observed that it confirms all that I have prev ously stated as to the inutility of such practice. The hard pulse of the pneumonia which ushered in death, was evidently caused by the aortic disease, in the same manner that a similar compli- cation in the course of pericarditis was attended with the same symptom. (See Case LXXXIX.) Case XCV.*—Incompetency of Mitral Valve. History.—Agnes Murray, set. 41—admitted June 16th, 1850. About eighteen months ago she first experienced, without any obvious cause, palpitations and pains in the cardiac region, which have continued ever since. They became more violent after exertion, and were accompanied by dyspneea. Latterly there has been an cedematous swelling of the legs, abdomen, and face. She has had four attacks of haemoptysis, the first occurring eighteen months, and the last three months ago. Symptoms on Admission.—The cardiac dulness measures two and a quarter inches across. The apex of the heart beats under the sixth rib, below and a little outside the nipple. Over the apex there is heard a harsh bellows murmur, which diminishes in intensity towards the base and large vessels. Pulse 80, weak. Great dyspneea and palpitation on exertion, and occasional severe pain in the cardiac region. Resonance of lungs natural. Posteriorly, over right lung, loud sibilant murmurs are heard, both with inspiration and expiration. Expectoration abundant. No anasarca at present, or cerebral symptoms. Progress of the Case.—This woman, under the action of small doses of digitalis and cream of tartar, and the occasional application of a few leeches to the cardiac region, became gradually much better. The palpitations, dyspneea, and bronchitis disappeared. She was dismissed greatly relieved, July 16th. Case XCVI.f—Incompetency of Mitral Valve—Pulmonary Hemorrhage—Hydro- thorax. History.—Robert Ross, set. 30, a lath splitter—admitted June 28th, 1850. ror some time past he has occasionally experienced palpitation, and observed now and then slight swelling of the legs. He first became severely ill only seven weeks ago, when he was seized with repeated vomitings, which continued two days. He sub- sequently caught cold, to which he is very liable, and since then has been labouring under cough, dyspneea, a feeling of tightness across the upper part of the abdomen' and general weakness. * Reported by Mr. Edmund S. Wason, Clinical Clerk. f Reported by Mr. David Christison, Clinical Clerk. VALVULAR DISEASES OF THE HEART. 537 Symptoms on Admission.—Cardiac dulness cannot be distinctly defined. The apex beats feebly between the fifth and sixth ribs, two inches below the nipple. A bellows murmur is heard with the first sound over the apex, but much more distinctly three inches to the right of it, near the sternum. It is almost inaudible over the base. The second sound is normal. Pulse 100, small and soft. Considerable dyspnoea and cough; sputa viscid and tinged with blood. No dulness on percussion over the lungs. Sibilanl, mucous, and crepitating rales are heard very generally over the inferior parts of the chest, both anteriorly and posteriorly. No increase of vocal resonance. The general surface is slightly jnundiced. On careful percussion of the liver, its inferior border presents a prominence, anteriorly the size of an egg, over the pylorus. Progress of the Case.—Up to the 3d of July there was occasional vomiting. The inferior extremities became cedematous, and fluid accumulated in the abdomen. On percussion, the resonance over the right lung is diminished as high as the scapula; there is a slight increase of the vocal resonance. On the 8th of July, the surface generally was anasarcous. From the 10th to the 15th, the dyspneea greatly increased. He expectorated on various occasions mouthfuls of florid blood. Latterly, he could only lie on the left side. The left side of the chest became completely dull on percus- sion, with absence of respiration. He was now removed from the Infirmary by his friends. Leeches to the epigastrium, with naphtha and anodynes internally, checked the vomiting. The principal object of the treatment, however, was, by means of diu- retics, to increase the amount of urine, and thereby diminish the anasarca. Pills of lead and opium were also administered to check the haemoptysis. Commentary.—The two last cases contrast very strongly with the two first. In both, the bellows murmur was heard only with the first sound, loud over the apex, diminishing towards the base; and rule 4 telis us that this indicates mitral incompetency. The concomitant symptoms fully bear out this diagnosis. The pulse was weak,—the pulmonary organs were those disturbed, while the cerebral functions were unaffected. In Case XCV. there was bronchits, which diminished under appropriate treatment. In Case XCVI. bronchitis also existed, but it was much more general, and mingled with a certain degree of collapse of the lung on the right side. Extravasation of blood into the pulmonary tissue of both lungs had most probably also taken place, as indicated by the haemoptysis; and, latterly, the general dropsy which prevailed affected the thoracic cavities, causing hydrothorax on the left side. The man was evidently in a dying condition when his friends insisted on his removal; and I was rather surprised to hear that he lingered a fortnight before death took place. No examination could be obtained. Cask XCVII.*— Mitral Incompetency—Hypertrophy of left Ventricle—Attack of Acute Rheumatism, followed by Aortic Incompetency. History.—John Conolly, cet. 49, a joiner—admitted June 22d, 1850. He has for some years past been subject to pain in, and swelling of, the joints. Eighteen months ago he was suddenly seized with pain iu the cardiac region, unaccompanied Reported by Mr. Charles Murchison, Clinical Clerk. 538 DISEASES OF THE CIRCULATORY SYSTEM. by dyspneea, but followed by severe cough. He has been copiously bled, and under- gone a lengthened treatment. Symptoms on Admission.—The cardiac dulness measures 2J inches across. The apex beats in a hollow between the xiphoid cartilage and the cartilage of the seventh left rib. Heart's impulse strong. A bellows murmur can be heard with the first sound, synchronous with the cardiac impulse. It is loudest at the apex, and diminishes in intensity towards the base. Pulse 74, full and strong. No cough, but considerable dyspneea on making the slightest exertion. Percussion and auscultation indicate slight pulmonary emphysema anteriorly, but no bronchitis. Slight tinnitus aurium, and dimness of vision occasionally. There is a patch of psoriasis figurata, an inch and a half in diameter, on the right cheek and side of the nose. Progress of the Case.—July 1st, he was attacked with severe articular rheu- matism in the hip, knee, and wrist joints, whicii had entirely disappeared under appro- priate treatment on the 9th. On the 14th he had diarrhoea, accompanied by consider- able discharge of blood per anum. This continued in smaller quantities from time to time. On the 22d, a careful examination exhibited a change in the cardiac signs. The impulse over the apex was more prolonged, with a deep murmur and jog. The bellows murmur synchronous with the impulse, was no longer audible, but one can be heard alternating with it at the base,—that is, with the second sound. Great pulsation of the carotid, subclavian, and humeral arteries was seen and felt, and a loud puffing murmur, synchronous with their dilatation, could be heard over them. His general health, however, was greatly improved, the local and other symptoms having disap- peared ; and he left the house, at his own desire, July 24th.—At first he took digitalis for six days, with a view of diminishing the cardiac impulse and pain. It was then suspended on account, of the nausea and weakness it apparently occasioned. The rheu- matic fever and arteritis were combated by salines, diaphoretics, and venesection to the extent of § xij. Afterwards the local pains rapidly yielded to small blisters placed over each affected joint. The diarrhoea and discharge of blood were checked by pills of lead and opium. Commentary.—This man, after frequent attacks of Rheumatism, entered the Infirmary, labouring under hypertrophy, with incompetency of the mitral valve. At the time there was no bronchitis, but he had previously suffered from severe cough and pulmonary derangement. Whilst in the house, one of his acute rheumatic attacks came on. Many of his joints were swollen and exceedingly painful; but this affection yielded to one small general bleeding, tartar emetic internally, and blisters locally, in eight days. The effect of this attack was to give rise to acute endocarditis, which, instead of affecting the auriculo-ven« tricular orifice formerly diseased, fixed itself upon the aortic valves. The lesion, however, must have been slight—probably limited to a few. small vegetations upon the margins of the valve—because the murmur was soft in character, and the incompetency not of such amount as to occasion either cerebral or other functional symptoms. The pulsation in the large vessels, however, was greatly augmented, and there is every reason to fear, that should the incompetency continue (as is most probable), the aorta and cavity of the left ventricle will both become dilated. VALVULAR DISEASES OF THE HEART. 539 Case XCVHI.*—Mitral Incompetency—Hypertrophy of Left Ventricle—Aortic In- competency and Obstruction—Angina. History.—Edward Monro, set. 41, a painter—admitted June 24, 1850. Two years ago, without any assignable cause, he was suddenly seized with angina, consisting of severe pain in the middle of the sternum, often running down the left arm, accom- panied by violent palpitations. Since then the paroxysms have been increasing both in frequency and intensity. Symptoms on Admission.—The cardiac dulness below the nipple measures three and a quarter inches transversely. The apex of the heart cannot be felt to beat at any par- ticular spot. Heart's action is regular. A distinct bellows murmur can be heard ac- companying both the first and second cardiac sounds, which are equally loud at the apex and at the base. Both are heard loudest to the right of sternum, opposite the second, third, and fourth costal cartilages. A loud blowing murmur is heard over the carotid arteries. Pulse 74, regular. Has a slight cough, with expectoration. Lungs resonant on percussion, and on auscultation the inspiratory murmurs are louder and rougher than natural, and the expiration is slightly prolonged. He has frequently expectorated small quantities of dark-coloured blood. There is great dyspneea on making the slightest exertion, and he has occasional severe attacks of angina. There is considerable dyspepsia. Slight dimness of vision, and muscae volitantes, but other- wise no cerebral symptoms. Progress of the Case.—The attacks of angina returned four and five times a day. They occasioned great agony, profuse perspiration, and increased action of the heart, during which the murmurs were heard louder. There was also occasional nausea and tendency to vomit. On the 8th of July he fainted, being unconscious for five minutes. At this time the murmur with the first sound assumed a whining character, heard the loudest at the apex. There was a double bellows murmur heard distinct from this, at the base. July 11th.—There was cough and expectoration. A fine moist rale could be heard over the lower half of left chest, both anteriorly and posteriorly. No dul- ness on percussion, or increased vocal resonance. July 15th.—He has now only one attack of angina in the day, which is also much less severe. The cough and expec- toration are diminished. A mucous rale still perceptible in left lung inferiorly. A whin- ing murmur with the first sound is still heard at the apex, and a double bellows murmur at the base, propagated in the course of the great vessels. He left the house at his own desire. The attacks of angina were at first treated with anodyne and antispasmodic draughts, containing M. v. of chloroform for a dose. Afterwards they were greatly re- lieved by taking carminatives, such as three drops of each of the oils of aniseed and cajeput dropped on sugar. Latterly they greatly diminished after 3 vj °f blood were drawn from the cardiac region by cupping. The bronchitis was treated with anodynes and expectorants. Commentary.—When this man entered ihe Infirmary it was very diffi- cult to determine at what point the two bellows murmurs were heard loudest. Repeated and careful examination failed to discover whether one or both were referable to the apex or to the base ; and in consequence we could not, according to the rules given, determine whether the disease was aortic, mitral, or both. This was probably owing to the circum- stance of the abnormal murmurs originating in two places, and being at the same time so similar in tone, that the diffusion of sound was pretty * Reported by Mr. Charles Murchison, Clinical Clerk. 540 DISEASES OF THE CIRCULATORY SYSTEM. equal over the whole cardiac region. But as the case progressed the murmurs underwent such modifications as left us in no doubt. The murmur with the first sound over the apex assumed a whining tone, so that it was easily separated from the double bellows murmur which still re- mained loud at the base. The former, according to the rules given, must have depended on mitral incompetency; whilst the latter, for the same reason, must have been owing both to incompetency and obstruc- tion of the aortic orifice. The man laboured under slight pulmonary, as well as cerebral symptoms. His chief complaint, however, was the angina, the attacks of which were in him very severe, causing the most excruciating agony, and bathing the whole surface with sweat. This, in its turn, seemed to be connected with a state of dyspepsia which existed. Whenever gas accumulated in the stomach, so as to distend that organ and press the heart upwards, the attacks were most severe. The car- minatives gave relief by causing discharge of this gas. After local bleeding, and an improvement in his general health, but more especially in the dyspeptic symptoms, the angina diminished in intensity. The two last cases recorded exhibit how important it is carefully to examine the cardiac signs from time to time as the case progresses, and to watch the modifications they undergo. W'here doubt and difficulty prevail, it is only in this way they can be removed. Under such circum- stances, never state an opinion at all, but continue to watch until the signs become permanent and unequivocal. This advice you will find to be even more useful in private than in hospital practice, for reasons which I shall allude to hereafter. But not only are frequent examina- tions useful in clearing up different points in diagnosis, they also reveal to the pathologist the changes which take place in the affected parts. Of this the following case affords us an instructive example. Case XCIX.*—Incompetency of the Aortic Valves with Musical Murmur—Hyper- trophy with Dilitation of Left Ventricle—Pneumonia—Pulmonary Hemorrhage. History.—William Caird, set. 29, labourer—admitted May 30,1850. Five months ago he first noticed that he became unusually breathless, and had palpitations after exertion. He continued to work until two months ago, when, being engaged in lifting heavy stones, lie was suddenly seized with pain in the cardiac region, violent cough and haemoptysis. He entered the Glasgow Infirmary, from which he was discharged, much relieved, in a fortnight. Since then he has been subject to giddiness, dyspneea, and palpitation, with occasional haemoptysis. Symptoms on Admission.—Cardiac dulness extends three and three quarter inches transversely. The apex beats between the sixth and seventh ribs, three inches below, and a little to the left of the nipple. A bellows murmur is heard with the second sound, loudest at the base, and propagated in the course ofthe large vessels. The first sound is normal. Pulse 92, strong and regular. He feels a shooting pain in the cardiac region, extending to the epigastrium. There is great dyspneea, and palpita- tion on exertion. Slight cough, and fine moist rale in both lungs, heard inferiorly and posteriorly. Occasional giddiness. Progress of the Case.—The pain in the cardiac region and epigastrium was * Reported by Mr. David Christison, Clinical Clerk. VALVULAR DISEASES OF THE HEART. 541 the chief source of complaint during the progress of the case. The dyspneea and pal- pitations were from time to time distressing. There was occasional vomiting. On the 12th of July, it was observed that the bellows murmur assumed a whining character, and on the 15th it was distinctly musical, like the chirping of a small bird. On the 17th the heart's action was tumultuous, and vomiting was very distressing. On the 23d there was considerable haemoptysis, mouthfuls of blood being evacuated. On the 24th, there was dulness on percussion, over the inferior portion of chest, and distinct crepitation could be heard with increased vocal resonance. The cardiac dulness was determined, on careful percussion, to measure five inches transversely. The vomiting and haemop- tysis defied all remedies. The pulse was 100, soft. He gradually became weaker. The urine was scanty, and oedema of the legs appeared. Latterly there was muttering delirium at night. Died on the 29th. At first he experienced relief from the cardiac and epigastric pains, after small local bleedings by means of leeches and cupping. Blisters were also applied. All kinds of remedies were tried to check the vomiting but with little effect. Antispasmodics were employed to relieve the dyspneea; and latterly, as the pulse became weak, wine and stimulants were freely administered. Sectio Cadaveris.—Thirty hours after death. Thorax.—Haert much enlarged, weighing 25 ounces, owing almost entirely to hypertrophy with dilatation of the left ventricle. When water was poured upon the aortic valves from above, it passed rapidly through the orifice. The aortic valves were thickened throughout and shortened; their curled-in and dense margins were one-tenth of an inch thick. Two of the valves were uuited at their neighbouring sur- faces, so as to form one, the only vestige of a septum between them being a hardened nodule at the base of the enlarged valve. On the edge of the smaller valve was a warty excrescence, the size of a coffee-bean, soft in consistence, composed of recent exudation, and infiltrated with blood, so as to present a purple colour. There was red hepatisation of the posterior and inferior portion of both lungs, and there was consid- erable apoplectic extravasation in the substance and the neighbourhood of the diseased portions of the lung. The bronchi were filled with frothy mucus. Abdomen.—The liver presented the nutmeg appearance, being in the first stage of cirrhosis. Other organs healthy. Commentary.—Vie had very little difficulty in determining, from the cardiac signs in this case, that, according to the rules laid down, there was incompetency of the aortic valves, with dilated hypertrophy of the left ventricle. The bellows murmur, which was at first sore, gradually changed its character as the case progressed, without altering its posi- tion. It became whining, and then chirping, constituting what is called a musical murmur. It is generally found in such cases that a solid body projects into the current of the blood as it flows through the valve, so as to be thrown into vibrations; and it was interesting to discover, on the examination of the body, that the vegetation described exactly fulfilled these conditions. From its softness also there is every reason to suppose it was of recent formation, originating probably about the time the musi- cal murmur was first observed. From the great induration of the aortic valves, there can be very little doubt that they bad been affected for a long time, at least many months; but it becomes a question, whether the adhesion and formation of one valve out of two might not have been 542 DISEASES OF THE CIRCULATORY SYSTEM. caused by a rupture of one or both valves, two months previously, at the time he was lifting heavy stones, and was suddenly seized with cardiac pain and other symptoms. It is worthy of observation, also, that, although he had cerebral symptoms, the lungs were greatly affected, the bronchitis latterly passing into pneumonia with pulmonary hemorrhage. Case C*—Mitral Incompetency—Hypertrophy of Left Ventricle—Dilatation and Disease of Arch of Aorta—Aortic Incompetency. History.—Hugh Devine, set. 40, labourer—admitted July 17, 1850. Dates his illness from a severe strain of the back, eighteen months ago, but is not sure when he first noticed dyspneea and palpitation, which have prevented him from working for the last eight months. Never had rheumatism or haemoptysis. Symptoms on Admission.—Cardiac dulness measures two and three quarter inches transversely. The apex beats between the fifth and six ribs, two inches below, and a little to the right of the nipple. A bellows murmur with the first sound is heard at the apex, decreasing towards the base. A bellows murmur of a rougher character is also heard with the first sound at the base, which is prolonged in the course of the large vessels. The second sound is normal. There is distinct pulsation under the clavicles, but none above the sternum. Pulse 104, regular, full, and jerking. No cough or pulmonary symptoms, with the exception of dyspneea on exertion. Has frequent pain in the upper part of the head and across the temples, and occasional dimness of vision. The thyroid gland is somewhat enlarged. Progress of the Case.—Since his residence in the Infirmary the symptoms have been greatly ameliorated. The dyspnce.i, palpitation, and cephalalgia, have nearly disappeared. The cardiac signs, however, have undergone considerable change. On the 16th of August it was reported that there is still a bellows murmur with the first sound, heard loud at the apex. An inch above, and to the inside of the nipple, a loud, harsh, grating murmur is heard with the first sound, and followed by a soft bellows murmur with the second. In the course of the aorta there is unusual impulse, and coinciding with it there is a bellows murmur, which is propagated along the carotids. He was dismissed, September 12th. Commentary.—This man was examined with great care, and cardiac signs ascertained to exist which are not often associated together. Fer instance, there was a distinct bellows murmur, loud over the apex and diminishing towards the base, which, according to the rules given, we ascribed to mitral incompetency. Over the aortic valves, however, and extending along the arch of the aorta, there was a bellows murmur of a rougher character, and also occurring with the first sound. Now rule 7 tells us that this may depend on three circumstances,—" 1st, On an altered condition of the blood, as in anaemia; 2d, On dilatation or dis- ease of the aorta itself; or, 3d, On stricture of the aortic orifice, in which case it is almost always associated with insufficiency, and then the mur- mur is double." It is clear that the first and third propositions would not apply, and I therefore came to the conclusion that in addition to mitral regurgitation, the aorta was dilated and diseased, the former indi- cated by the increased impulse, and the latter by the roughened murmur. Latterly, when dismissed, the roughened murmur over the aorta assumed * Reported by Mr. David Christison, Clinical Clerk. VALVULAR DISEASES OF THE HEART. 543 a rasping character, and a soft bellows murmur was also heard with the second sound,—so that the dilated and diseased aorta had at that time probably become associated with aortic incompetency. Cask CI.*—Constriction of Mitral and Tricuspid Orifices—Aortic Incompetence —Anasarca—Hydrothorax—Collapse of Left Lung—Brighfs Disease of Kidney. History.—Elizabeth King, aged 26—admitted July 20th, 1855. Two years ago she entered this Hospital, labouring under an attack of acute rheumatism; was dis- missed reheved at the end of six weeks, but soon afterwards she was again laid off work by general anasarca ; and in the November of the same year (1853) she ao-ain returned to this Infirmary. She was a patient in the Clinical Wards; was treated for double pneumonia ; was recognised at that time to labour under mitral insufficiency ; was much relieved during her stay, and discharged in the middle of February, 1854. But she has never recovered her strength. Three months ago she became affected with swelling of the legs and abdomen, with occasional slight lumbar pain, and with severe pain in the hypogastric region attendant upon the abdominal swelling. The pain and the swelling have gradually become worse. She has been confined to bed for the last ten days. Symptoms on Admission.—Impulse weak; apex beat not definable; transverse dulness three and a half inches ; at the normal site of apex beat there is a double blow- ing murmur; the same is audible all the way up to the clavicle, but it diminishes in intensity from below upwards. Pulse 86, small and weak ; palpitation, vertigo, slight cough ; muco-purulent expectoration ; dyspneea on exertion, with occasionally ortho- pnoea at night; face slightly livid, with a faint tinge of yellow ; is naturally freckle i Has great thirst and little appetite ; the bowels are costive. The urine is scanty, of an orange-yellow colour; sp. gr. 1015 ; is not albuminous. The lower extremities and the skin over the hypogastric region are cedematous, tense, and painful on pressure. Yesterday had severe pain in the right iliac, passing to the lumbar region. Does not sleep well at night. Progress of the Case.—The pain in the right iliac region disappeared under treatment during the first week. Vomiting occurred at every meal during the same period. After the 24th July, the urine contained a large quantity of bile, and the whole body became slightly jaundiced. No increase in urine could be effected. On the 9th August it is reported very scanty and albuminous. The anasarca steadily increased, with painful tension of limbs and abdomen. Ultimately the whole trunk, upper extremities, and face became cedematous. Respiration became more embar- rassed, and over the upper parts puerile. On the 8th August there were signs of hydrothorax on the left side. The dyspneea, cough, sleeplessness, and want of nou- rishment wore out her remaining strength ; and she died Sept. 5th. At first, leeches followed by warm fomentations, were applied to the hypogastric and right iliac regions to relieve the local pain. Subsequently, diuretics and cathartics were employed to relievo the anasarca, combined with nutrients and latterly stimulants. Sectio Cadaveris.—Eiyhteen hours after death. Body extremely anasarcous. Thorax.—Heart weighed 10£ ounces, lay unusually transverse, with apex pointing to left side. The right auricle was dilated, especially the auricula; the foramen ovale within the annulus was not patent, but the membrane was pushed back into * Reported by Mr. D. M'Gregor, Clinical Clerk. 544 DISEASES OF THE CIRCULATORY SYSTEM. a pouch; its lining membrane was much thickened. The tricuspid valves were thick- ened at their margin, and so constricted that the first joint ofthe little finger up to the root of the nail could alone pass. The pulmonary valves were quite healthy. The left auricle was not dilated; the mitral valves were thickened and constricted so as only to admit the first joint of the little finger up to about the middle of the nail • the tendinous cords were so shortened that the valves appeared to be fixed directly to the summit of the columnas carneas. The aortic valves were also thickened (more at the margin than the base) so as to be inelastic and incompetent. Both ventricles hyper- trophied and dilated. The left lung was collapsed ; about one pint and a half of fluid in the pleural cavity. The right lung was adherent throughout, especially at the base, to the diaphragm ; the diaphragm itself was adherent to the costal pleura from the sixth rib downwards. On section, the lung appeared very cedematous in some portions, and in others coUapsed. Abdomen.—The liver was fatty; weighed 2 lb. 10} oz The spleen seemed healthy, The kidneys were atrophied, especially the right, which weighed 2\ ounces; and on section presented a good specimen of the hard, contracted, and granulated kidney of Bright. In the left kidney only one cone was disorganized. The uterus and ovaries were normal, and the intestines healthy. Case CIL*—Constriction of Mitral and Tricuspid Orifices—Oedema—Hemorrhage into the Lungs. History.—William Page, aet. 20, ploughman—admitted August 30th, 1852. States that nine months ago, while carrying a heavy sack of grain on his back up a flight of stairs, his foot slipped, and he fell with the load upon him. Asserts that he was insen- sible for a fortnight afterwards, and on recovering was affected with cough and bloody expectoration for a month. He has also been constantly liable to palpitation, dyspneea, and starting from sleep, and been unable to ascend stairs in consequence of the violent palpitations and feeling of faintness thereby produced. Says he was in perfect health at the moment of the accident, and never had rheumatism. He has been subjected to various kinds of treatment, and been salivated with mercury without any benefit. Symptoms on Admission.—Apex of the heart beats distinctly in the intercostal space between the sixth and seventh ribs. The impulse is strongest in a line drawn verticaUy from the nipple—is full and rather diffused. The pulsations at the heart are more numerous than those at the wrist. On percussion the cardiac dulness measures three and a half inches across. On auscultation a prolonged blowing mur- mur is audible with the first sound at the apex, which decreases in intensity towards the base of the organ, and is entirely lost at the commencement of the great vessels. Second sound normal. Pulse 72, full, not hard; and there is an occasional small, sharp beat occurring after every five or six of the ordinary pulsations. Breathing slightly accelerated, amounting to dyspneea on the slightest exertion; occasional cough, followed by tough mucous expectoration, interspersed with a few points of a dirty rusty colour. Percussion normal, and auscultation over lungs only elicits a few scattered sibilant sonorous rales, posteriorly on left side. The appetite has been diminished, with occasional vomiting for the last three months. Is apt to start hur- riedly from sleep after lying down, and is disturbed by dreams. Slight cedema of the feet and ankles. Urine healthy. Other functions normal. Progress of the Case.—During the months of September and October the symp- * Reported by Mr. William Calder and Mr. David Milroy, Clinical Clerks. VALVULAR DISEASES OF THE HEART. 545 toms gradually increased. The dyspneea became more urgent, and the paroxysms more frequent. The cough with bloody expectoration, the oedema, general weakness, and palpitations were all augmented. There has also been occasional vomiting, and the skin has assumed a yellow jaundiced hue. He had again been put under a mer- curial course, and a variety of remedies were employed to relieve cough and spasm, all of which produced only temporary relief. On taking charge of the case on the 1st of November, I found a loud blowing murmur occupying the period of both sounds at the apex, the impulse of which was felt between the fifth and sixth ribs two inches in a straight line below the nipple. Over the xiphoid cartilage the second sound was determined to be healthy, immediately following the blowing with the first. At the base also the second sound was heard distinctly normal, and the blowing with first sound, though still loud, more distant. Sputum was gelatinous, deeply tinged with fluid blood. Anteriorly the chest was resonant, but inferiorly and posteriorly percussion was slightly impaired, with occasional crepitating rale and double friction. Pulse 120, feeble and irregular; great weakness. Nutrients with wine. November 12th.—Is worse. Great lividity of face and orthopnoea. Heart's action so tumultuous that no individual sounds can be distinguished. Extremities oedematous and cold. Pulse imperceptible. In this condition he continued until the 15th, when he died. Sectio Cadaveris.—Forty-four hours after death. Body not emaciated ; surface considerably jaundiced. Thorax.—Pericardium contained several ounces of serum. Heart much enlarged, especially on right side. Right auricle the size of a large orange. Left auricle also considerably distended. Both ventricles dilated, the walls not much hypertrophied. Endocardium of left auricle thickened and opaque. Mitral valve constricted, its edges rigid, and partly calcareous, so that it could only admit one finger. The tri- cuspid valve was also constricted, so as scarcely to admit two fingers. This was owing to thickening and shortening of the valvular segments, which were also abnor- mally adherent to each other at their extremities. At the edge of one valve were a, few rough granulations of lymph. Aortic and pulmonary valves healthy. Both. lungs were emphysematous anteriorly, but the dilatation of individual air-cells was not extreme. In the posterior and inferior portions were irregular condensed masses of hemorrhagic extravasation, varying in size from a walnut to a hen's egg. Inter- spersed through the lungs generally were several miliary tubercles. The pleura? were adherent, in several placed, and also contained a few tubercles. The tracheae and bronchi were loaded with viscid muco-purulent matter. Abdomen.—Liver congested, presenting to a certain extent the nutmeg appear- ance. Kidneys and other abdominal organs healthy. Commentary.—In both these cases careful examination of the heart did not enable me to form a conjecture that the tricuspid valve was diseased. Iu the first case the continued blowing at the apex completely masked the second sound, even at the base of the organ. In the other case, while the blowing occupied the period of both sounds at the apex, the second sound was audible towards the right, over the xiphoid carti- lage. In the case of King, there was also incompetency of the aortic valves, but in both the auriculo-ventricular valves were the chief seat of dinase. The symptoms were not unlike, and were characterized by excessive palpitation; great dyspneea, with oedema of the lungs in one, aud hemorrhage into the lungs in the other case; vomiting, dropsy, and 35 546 DISEASES OF THE CIRCULATORY SYSTEM. jaundice. None of which symptoms, however, either individually or collectively, can be said to indicate tricuspid as distinguished from mitral lesion. The origin of the two cases was widely different. The one dependent apparently on rheumatic endocarditis, the other caused by a fall and contusion, although how this should have affected both auriculo- ventricular valves is by no means clear. The utility of mercury was fairly tested iu Page's case, and as usual found to be of no benefit what- ever. Theoretically it is impossible to understand how this drug is to diminish thickenings of valves or contractions of the chordae tendineae, and practical experience has utterly failed in demonstrating its advantage in endocarditis any more than in pericarditis. Case CIIL*—Soft adherent Polypus, causing incompetency of the Mitral Orifice— Anasarca. History.—William Taylor, aet. 50, a compositor,—admitted Dec. 20th, 1852. The patient enjoyed good health till a year ago, when he became subject to attncks of vertigo. The first of these came on after a long race; they returned frequently, especially after meals. Three months ago, cough and dyspneea came on, which have gradually become worse. Two weeks ago his legs began to swell, and five days ago the lower part of both legs became of a purple colour, not disappearing on pressure, the rest of the skin of the body assuming a yellowish hue ; tliese discolorations have since increased. Has suffered much mental distress during the last six months. Symptoms on Admission.—Cardiac apex in normal condition; impulse somewhat increased. With the first sound there is a blowing murmur, heard loudest at the apex; second sound normal; transverse dulness normal. Pulse very small and weak, 120 per minute. Percussion of the lungs normal ; breathing hurried; respira- tions being 40 per minute ; no abnormal sounds audible on auscultation. Sleeps badly and is very weak. Tongue slightly furred; appetite bad; bowels consti- pated ; stools dark coloured. Urine in goodly quantity, high coloured, loaded with lithates; contains a slight amount of albumen. Legs swollen. Ordered to have 3 iv of wine and diuretic mixture. Progress of the Cask.—December 23d.—Crepitation over lower half of both lungs posteriorly; no dulness or increased vocal resonance. Expectoration streaked with blood. Weakness great; pulse hardly perceptible. Ordered expectorants and \ vj of wine. 24th.—Urine passed in very small quantity. Ordered diuretics with nitric ather and half the wine to be replaced by an equal quantity of gin. 25th.—Was delirious last night, and suffered from dyspneea. Died this morning at half-past eleven. Sect to Cadaveris.—Forty-eight hours after death. Thorax.—The pericardium contained about an ounce of turbid yellowish serum. The heart was slightly enlarged on the right side. All the cavities were full of blood, partially coagulated, the coagula being soft and coloured throughout. In the left auricle was a soft, gelatinous, semi-transparent mass the size of a pigeon's egg, which hung over the mitral orifice, and appeared to choke it up. It was firmly attached to the membrane of the auricle by a surface about half an inch square, in substance resembling colloid, aud externally was not unlike a soft polypus, or a mass of uterine hydatids ; on section, it was homogeneous, and consisted of a fibrous stroma, which could easily be torn, enclosing between its meshes a clear viscous * Reported by Mr. R. Brown, Clinical Clerk. VALVULAR DISEASES OF THE HEART. 547 fluid. The flnps of the mitral valve were somewhat thickened, without deformity or "thickening of the chords tendineae, which, with the columnas carneas, were quite healthy. The other valves were normal. The lungs were cedematous, with small hemorrhagic patches at various points. Abdomen.—The peritoneal cavity contained about half a gallon of clear serum. There was slight hepatic congestion of the liver, but the other abdominal viscera were unfortunately not examined by the pathologist. Microscopic Examination.—The attached polypus in the left auricle consisted of bands of fibrous tissue, crossing one another and forming oval and circular areolae con- taining a viscous serum. Embedded in these bands were nucleated cells, round, oval, and fusiform in shape. Some of the latter were lengthened out into fibres. They were fibre-cells exhibiting every stage of transformation, from the rounded cell up to that of perfect areolar tissue. Commentary.—The structure and firm attachment of the polypus in this case, can leave us in no doubt that it must have existed some time before death, and caused the symptoms of which this man complained. From its position it appeared calculated materially to interfere with the passage of the blood from the left auricle to the left ventricle, but the sound, during life, indicated an incompetency rather than a narrowing or stricture of the auriculo-ventricular orifice. To it, however, the excessive dyspneea, which was the chief character of the case during life, was most probably owing. The mass itself closely resembled, to the eye as well as under the microscope, some kinds of simple colloid I have seen; whether it originated in an exudation, in a deposition of fibrin from the blood, or in a combination of the two, it is difficult to determine; the last suppo- sition is the most probable. That coagula are formed from the blood in the cavities of the heart . during life, there can be little doubt, although we are ignorant of any means of detecting them. They have been supposed to be the result of endocar- ditis. If so, we must suppose that an exudation thrown out on the endo- cardial lining membrane causes roughness, which, as the blood flows over it, tends to produce fibrinous deposition from that fluid. However formed, two subsecpient changes may occur—1st. Fibre cells may be formed in it, and the whole gradually developed into a fibrous structure, as in Case CIII. This is very rare. More commonly it softens in the centre, and is gradually reduced to a fluid, which to the naked eye closely resembles pus. Such collections have been called "purulent cysts." I have fre- quently examined the contents of these cysts, and have no doubt that in many cases the so-called " purulent cysts " are simply formed by a mecha- nical disintegration of the clot, in the manner first described by 31 r. Gul- liver, and are not purulent cysts at all. I once found a pyriform clot in the right ventricle of the heart, firmly attached to the endocardium by its smaller extremity. It was the size of a ben's egg, and on cutting into it there flowed out two ounces of a fluid exactly like good laudable pus. Vet it did not contain one pus corpuscle, but was wholly made up of mole- cular matter, associated with the broken down debris of a fibrous clot, and a few collapsed colourless cells of the blood. In this way a micro- scope demonstrates, not unfrequently, that what was regarded as pus, and considered a proof of inflammation, is in truth quite unconnected with the latter process, and is owing to altogether different causes. 548 DISEASES OF THE CIRCULATORY SYSTEM. Case CIV.*—Enlarged Foramen Ovale—Phthisis. History.—James M'Queenie, aet. 27, a tailor—admitted June 23d, 1853. Has never been a strong man, having been very liable to suffer from colds and indigestion, Since boyhood he has been liable to palpitation and dyspneea on the slightest exer- tion. His health, however, continued pretty good till eighteen months ago, when he was admitted into this Infirmary. He then laboured under inflammatory fuver with coughs and pains in the chest; there was evidence of condensation of the apex of the right lung; and obscure shifting murmurs were heard with the cardiac sounds which led to the belief that the patient was suffering from subacute pericarditis in the course of tubercular disease. He was treated with aconite, and afterwards with mer- cury. He became much better, but did not entirely regain his health; the physical phenomena remained as before; cough and expectoration also continued. Of late these symptoms have become more troublesome, so as to induce him to re-enter the Hospital. Symptoms on Admission.—Apex of the heart beats slightly to the right of the usual position ; transverse dulness three inches ; sounds feeble and indistinct; with the first and running into the second, there is a peculiar whizzing, neither a blowing nor a fric- tion murmur; it is heard most distinctly at the base, is not constantly present, and is not propagated along the large vessels. Heart's impulse feeble, and producing a wavy motion under three intercostal spaces. Palpitation on exertion or mental excitement. Pulse 90, small and slightly intermittent. Under the right clavicle, dulness on percus- sion, with increased sense of resistance, and imperfect cracked-pot sound; on auscul- tation there are loud moist rales almost gurgling in character; much prolonged expi- ration ; loud bronchophony. Towards the lower margin of the right lung there is karsh respiration with sibilus. Below the left clavicle for a hands-breadth there are fine moist rales with prolonged expiration and loud vocal resonance; sibilus also, as on the right side. Posteriorly the signs correspond to those in front. Sputum abundant and muco-purulent; cough frequent, but not harsh; breathing easy. Appetite scarcely impaired. Occasional diarrhoea, now checked by astringents. Hepatic and splenic dulness normal. Great sweating at night. Urine of normal character. Ordered to take cod-liver oil, and to have nourishing diet. Progress of the Case.—June 23d to July 13th.—Treatment as above ; strength much increased. Yesterday had a rigor, followed by a stitch in the side; it was reheved after the application of leeches. July 13th-23d.—Has gradually become much worse. Suffers now from great dyspnoea, frequent cough, copious expectoration, night sweats, loss of appetite, diarrhoea, and great weakness. No great change in the physical signs; the heart sounds are much masked by the pulmonary rales. Has taken cod- liver oil, with occasional antispasmodics and astringents, and latterly ? iv of wine and 3 ij of brandy in the course of the day. July 24th.—Gradually sunk, and died at twelve noon. Sectio Cadaveris.—Twenty-five hours after death. Body much emaciated; rigor mortis moderate. Thorax.—No adhesions between the layers of the pericardium, or between the pleura and that membrane. The pericardium contains about two ounces of turbid yellowish fluid with small flocculi of lymph. Surface of the heart presents a milky patch the size of a shilling towards its base posteriorly, and there are some smaller ones over left auricle. Heart soft, flaccid, and fatty; it weighs twelve ounces. The * Reported by Mr. W. M. Calder, Clinical Clerk. VALVULAR DISEASES OF THE HEART. 549 right ventricle is much dilated and the walls are thin; the tricuspid orifice admits four fingers with ease; mitral valves very slightly thickened at the margins, but otherwise healthy ; aortic valves healthy. In the septum aurieularum there is a large opening which can admit three fingers ; evidently the foramen ovale much enlarged ; it is oval in shape, and the edges are smooth and rounded. Pulmonary artery dilated; calibre of the aorta diminished, and only half the size of the pulmonary artery. Right lung adherent all over. Adhesion firmest near the apex. The lung is non-crepitant throughout, and everywhere infiltrated with tubercle, which is most chronic at the apex, where there are several puckerings and dense cicatrizations. The left lung also infiltrated with tubercle, but not to so great an extent, and more recent. Abdomen.—The liver was much congested, with a linear cicatrix two inches long, situated half an inch anterior to its diaphragmatic attachment. The lower third of the ileum, with the ccecum and ascending colon, the seat of numerous tubercular ulcerations. A few tubercular deposits in the mesenteric glands. Other organs normal. ' Commentary.—The peculiarity of the cardiac sounds in this case, consisted in the existence of a kind of whizzing murmur, synchronous with the systole, and loudest at the base, combined with palpitations, feeble impulse, and a weak intermittent pulse. This combination of signs and symptoms forbade the supposition that the lesion was aortic, while the sex, and absence of murmur in the larger vessels, were opposed to the notion of its being anaemic. After death a large opening was found between the auricles, with smooth edges, which must have admitted the ready flow of blood through it. Whether the peculiar whizzing sound—which was neither loud nor constant—was caused by this open- ing, it is difficult to say, but judging from its situation and character, this is not improbable. The slight thickening of the flaps of the mitral valve did not seem to interfere with its competency, and certainly caused no murmur. Few well-observed cases of patent foramen ovale in the living subject have been recorded. In one recorded by Dr. Markham,* the open foramen ovale allowed the blood to pass readily from the right to the left auricle, but not in the opposite direction, excepting through two narrow slits. There was audible during life a loud, rough, and prolonged systolic murmur over the whole pericardial region, over the upper part and along the right border of the sternum, and in the whole of the upper half of the interscapular space. From an inquiry by Dr. John Oglet into this subject, when he was Curator of the Pathological 3Iuseum at St. George's Hospital, he found that of thirteen cases of patent foramen ovale, it was stated in seven that no murmur synchronous with the sys- tole existed. The size of the openings is not given. In one other case, a diastolic murmur was present, owing to undoubted disease of the aortic valves. Hence, of the whole thirteen, there was no evidence that this lesion produced a murmur at all. Dr. Mavkham's case being uncompli- cated and well observed, affords pretty strong evidence that a murmur may, under certain conditions, be occasioned by open foramen ovale, as does the one now recorded. But what those conditions are, as well as a * British Medical Journal, April 4th, 1857. f H)id. June 13th, 1857. 550 DISEASES OF THE CIRCULATORY SYSTEM. crowd of interesting points in connection with them, can only be deter- mined by future observations. Pathology of Valvular and Organic Diseases of the Heart. The lesions producing valvular diseases of the heart are various, and may be referred to mechanical violence, to the effects of exudation, acute or chronic, to depositions of fibrin, and to the different forms of defene- ration of texture. But, however occasioned, they all tend to produce subsequent changes in the texture and vital actions of the heart itself; above all, hypertrophy and fatty degeneration of its muscular walls, with increased, diminished, or irregular contractions of its cavities. Although it is with these latter that the physician has principally to do, a know- ledge of the former is essential to the correct appreciation and proper treatment of every individual case. llechanical injuries not unfrequently occasion sudden disease or rupture ofthe valves (Cases XCIX. and CII.), separating their attach- ments, and causing subsequent adhesions and fibrinous depositions. Great muscular exertion has also occasioned similar results. Four cases of this are recorded by Dr. Ii. Quain,* in one of which a smith, when working vigorously, experienced •' an uneasy shaking of the heart," shortness of breath, and heard a peculiar noise " up his chest, neck, and in his ears." On examination, a loud ringing musical murmur was heard over the aortic valves with the second sound, and there was a softer blowing with the first sound. After suffering two years, during which the sounds underwent different modifications, followed by cardiac hypertrophy, he died, and on dissection, the .conjoined attachments of two of the valves to the aorta were found to be separated from the wall of that vessel, so that they dropped below the level of the third, which retained its connections (Fig. 415). Cases of this kind would perhaps Fig. 415. be more frequently observed, if the origin of valvular diseases were more carefully looked for. * Monthly Journal of Medical Science. December, 1846. Fig. 415. Conjoined attachment of two of the aortic valves at a, separated from the aorta at b. Here the wall of the vessel was raised into a superficial elevation. At c, the margin of one valve was slightly everted, and studded with small granula- tions.—(R. Quain.) VALVULAR DISEASES OF THE HEART. 5,~1 Kmdation into or on the surface of the valves, constituting the endo- carditis of systematic writers, is a common cause of valvular disease. If acute, it may appear in the form of minute granulations, or forming a layer, varying in thickness and shape, on the surfaces or on the edo-es of the valves. If _ chronic, they are firm, and not unfrequently associated with an exudation whicii has also occurred in the texture of the valve itself, causing more or less thickening or induration of its various parts. In the same manner the chordae tendineae may become thickened and shortened from interstitial exudation. As a result, the edges of the valves do not come into accurate contact, and become incompetent to fulfil their functions. After a time, in consequence of excess of exuda- tion and subsequent contraction, the orifices are narrowed, and me- chanical obstructions offered to the free passage of the blood through them. In the aortic valves, in addition to thickenings and contractions, adhesions may occur, with or without the lacerations of septae formerly noticed. In this manner there may be two, rarely only one valve Fig. 416. Fig. 417. from laceration of the attachment to the aorta and subsequent adhesion Figv'41S. of the broken edges. In Fig. 416 the union of all the valves fo Fig. 416. A, Aortic orifice with one valve of a funnel-shape, seen from the front. d, The same valve seen from above, showing the original septas of the valve united together.—(Peacock.) rig. 417. Two vaives at the aortic orifice, with a rudimentary one interposed.— (Peacock.) fig. 418. Congenital malformation of the aortic valves. A, The aorta slit up lengthways. B, Transverse section ofthe aorta just above the valves.—(Brinton.) 552 DISEASES OF THE CIRCULATORY SYSTEM. resulted in the formation of one valve of a funnel-shape. In Fig. 415, two valves have, as it appears, been broken into one another and united together, so as to form one. In Fig. 418, one of the valves seems to have been abortive, or not developed. Again, the number of valves may be multiplied in consequence of adhesions being formed, and extra pouches thereby established. Thus four valves are occasionally met with, as in Fig. 419. Sometimes these are of unequal size, and are then most com- monly the result of disease. But I have seen four valves, all exactly like one another, in which case the malforma- tion appears to be congenital. I only know of one instance Fig- 419. in which five valves existed at the aortic orifice, and that is 'given by Dr. Peacock, in his recent valu- able work on " Malformations of the Human Heart, 1858," and which is copied (Fig- 420). The ex- cess is owing to the division of two valves, the Fig. 420. supernumerary segment being imperfect. The mitral valves, in addition to roughness and thickenings of the valves themselves, and various alterations of their edges in consequence of shortening of the chordae tendineae, present in chronic cases a great tendency to contraction of the orifice. On looking down into the auricle, these constrictions of the auriculo-ventricular orifice are seen to assume two shapes, the one being only, however, a greater degree of contraction than the other. In the first it exhibits a slit, or button-hole appearance, in the other a rounded or oval aperture—both openings being at the base of a funnel-shaped depression, caused by the adhesion, thickening, and contraction of the edges of the two valves. Deposition of fibrin from the blood may occur on the valves in conse- quence of laceration, or of exudations; but sometimes, so far as can be ascertained, without organic lesion. It has been experimentally proved, that the introduction of a thread across the aortic aperture, will cause the precipitation upon it of the fibrin of the blood—(Simon). Any Fig. 419. Four valves at the aortic orifice, from adhesion of one to the wall ofthe vessel, so as to form two pouches. Fig. 420. Five valves, formed from adhesions and production of septse in two valves. Peacock.) VALVULAR DISEASES OF THE HEART. 553 rough surface will produce the same effect. Indeed there is every reason Fig. 421. Fig. 422. to suppose, that when the blood abounds in fibrin, as especially occurs in acute rheumatism, such deposits may take place on the valves themselves, without any previous lesion of them, an occurrence which would serve to explain the relation between rheumatic and car- diac disorders. Be this as it may, there can be little doubt that such rheumatic constitution of the blood once established, fibrinous deposits are apt to be thrown down, which constitute the vegetations bo frequently found at the edges of the valves, resembling soft warty tumours, obstructing the orifices, and occasionally hanging down by peduncles into the ven- tricle (Fig. 423). Degeneration of the valves may occur in various ways, and in its nature be albuminous, fatty, or mineral. Thus the thickening and indurations owing to chronic exudation, may assume a density equal to ligament or fibro-cartilage. Or, ou the other hand, they may soften, un- dergo the fatty degeneration, and at length ulcerate, forming one or more perforations through the membranous portion of the valve (Fig. 423). _ Fig. 421. Mitral orifice, constricted so as to form an elongated and rigid slit resem- bling a button hole. Seen from the auricle. Fig. 422. Mitral orifice, greatly constricted, so as to form an oval aperture, at the bottom of a funnel-shaped depression. Seen from the auricle. fig. 423. Fibrinous vegetations, and atheromatous degeneration of an aortic valve with rupture. Fig. 423. 554 DISEASES OF THE CIRCULATORY SYSTEM. Lastly, it is by no means uncommon to find the thickened valves to have undergone the mineral degeneration, presenting nodules and masses of earthy matter, varying in size, more or less rough, resembling concre- tions, and obstructing the orifice in proportion to their size. The immediate result of all these different lesions is. that the valves being incompetent, and not closing perfectly, the blood regurgitates back into the ventricles or auricles at each systole or diastole, according to the valve affected; or if there be contraction and obstruction at the orifice it is propelled forwards with difficulty. In either case, increased mus- cular effort is required to carry on the circulation, and the result is the greater or less enlargement of the heart or hypertrophy. Hypertrophy of the heart may arNe from several causes; but by far the most common is disease in one or more of its valves. In this case it follows the law of increased growth formerly referred to (p. 148) whereby parts subjected to unusual exertion or increase of function augment in bulk. Hence either disease of the aortic or mitral valves induces hypertrophy, with dilatation of the left ventricle, from the neces- sity of increased action. The same causes operate on the other parts of the organ. Chronic bronchitis and emphysema, by impeding the cir- culation in the lungs, produce similar enlargements in the right ventricle, and so on. In chronic heart diseases, it is rare that the lesion is confined to one cavity, because, as it advances, it produces increasing embarrass- ment in the others. Thus hypertrophy of the left ventricle, in conse- quence of aortic disease, after a time induces enlargement of the left auricle; this embarrasses the return of blood from the lungs, causing con- gestions and derangement of those organs. These iu turn induce enlargement of the right cavities of the heart, and then the return of blood from the systemic circulation is impeded, causing congestions in the liver and other viscera. In consequence of the over-distension of the venous capillaries so occasioned, effusion of serum occurs, producing oedema, and more or less anasarca. As the dropsical fluid so occasioned augments, the pressure it produces interferes still more with the action of the kidneys, skin, lungs, etc., until at length life can no longer be maintained. These effects will follow more rapidly if, iu addition to the aortic, the mitral valves are disordered, or if further complications add to the gravity of the case. Thus the tricuspid orifice may also be affected (Cases CI. and CII.); or there may be adherent pericardium, or aneurism of the large vessels. Again, the course of these change- may be modified or inverted. The disease, for instance, may comnience in the lungs or liver, and, by the obstructions to the circulation thereby occasioned, may affect the heart secondarily. Or, conjoined with val- vular disease and cardiac hypertrophy, there may be primary lesions of the lungs, kidney, or liver. It is by pathological knowledge alone that the influence and mutual dependence of these various derangements can be understood, and a treatment judiciously directed to their relief. Fatty Degeneration of the Lleart.—The heart may be loaded and even more or less infiltrated with adipose tissue, producing one form of fatty- degeneration. By far the more important form, however, is the lesion, for a knowledge of which we are indebted to the recent researches of histologists, and more especially in this country of Paget. Ormerod, and Quain. Of its nature I have already spokeu (p. 218). It may occur as VALVULAR DISEASES OF THE HEART. 555 a sequela of every form of cardiac disease, but especially when the aortic valves are affected, as well as from a modification in the general condition of the system leading to fatty degeneration of a number of other organs. It may be observed, for instance, that in cases where the liver and kidneys are fatty, the muscular substance of the heart is commonly fatty also. Indeed there is no degeneration of texture more common than that of fatty heart, which, existing in various degrees, is dangerous in proportion to its intensity, extent, and complication with other diseases. In elderly persons more especially this degeneration may proceed to a great extent without even being suspected, and then some unaccustomed exertion, by demanding from the organ more forcible muscular contractions than it is capable of exerting, suddenly arrests its action, and fatal syncope is the result. Many cases of sudden death formerly ascribed to "apoplexy," or "spasm of the heart," may now be confidently affirmed to have been owing to this lesion. Its detection in the living body cannot be made with confidence. Slowness aod feebleness of the pulse have been by some thought diagnostic. But many extreme cases of this degeneration have died under my observation without any such symptom. It may cause rupture of the heart and fatal hemorrhage. Myocarditis, or true inflammation of the substance of the heart, is one of the rarest organic diseases known. Whether, in cases of pericarditis, the muscular substance below the serous membrane is the seat of an exudation, is yet to be determined by histological research. The intro- duction of the term " Parenchymatous inflammation," employed by Virchow, can only cause confusion, without in any way advancing our knowledge, as, in truth, it is no inflammation at all, but the fatty degene- ration of the muscular fasciculi just referred to. Treatment of Valvular and Organic Diseases of the Heart. That the various lesions of the valves are susceptible of being removed hy drugs, is one of those notions which the advance of diagnosis and pathology has happily expelled, and which seems now almost universally rejected. All that the practitioner can hope to accomplish, is to modify, and, if possible, check those resulting phenomena from which real danger is to be apprehended. But here much misconception has prevailed as to the real object to be kept in view, or rather the phenomena themselves have been wrongly interpreted by medical men. We have seen that valvular disease leads to dilated hypertrophy; this is accompanied by excessive action, and, especially if the aortic valves are diseased, by a strong, jerking, and hard pulse. The notion is very general that, simply because the pulse is strong, it is the mission of the practitioner to make it weak; that, because the heart acts violently, it ought to be made to beat quietly by lowering remedies. But the strong pulse and enlarged ventricle in the one case, is a wise provision of nature, set up to counter- balance the otherwise fatal consequences of the valvular obstruction ; and the violent action of the heart in the other is a proof of weakness rather than of strength, aud, instead of being lessened by bleeding and anti- phlogistics, requires for its removal tonics, nutrients, and calmatives. To 556 DISEASES OF THE CIRCULATORY SYSTEM. no one is medicine more indebted for making this proposition intelligible than to Dr. Corrigan,* and his views and practice have been acted upon to a great extent by those who have sedulously cultivated the physical diagnosis of disease of the heart. It is the attempt to treat mere symp- toms without a knowledge of the organic diseases on which they depend that leads to mistakes among medical men. But with that knowledge their judicious treatment of the effects of valvular disease of the heart forms one of the best examples of a modern scientific as distinguished from a» former empirical practice. What then we have principally to attend to in valvular diseases of the heart is, to do all in our power to support the normal strength of the economy, and avoid agitating the patient, instead of lowering the pulse, or giving mercury under the idea that thereby we are putting down an inflammation or causing absorption of the exudation. In this way per- sons affected with cardiac disease have continued to live quite uncon- scious of it for many years in comfort. If, however, it occasion dyspnoea, care must be taken to avoid sudden or great exertion, and violent emo- tions ; while by means of diet properly regulated, and by gentle exer- cise, a due supply of blood is maintained, and its unequal distribution between the lungs and liver prevented. Pain, angina, and paroxysmal attacks may be relieved by the cautious use of morphia, digitalis, aconite, and otlier sedatives, used as palliatives, and occasionally by car- minatives. (Case XCVIII.) When dropsy appears, we may delay its advance, and often get rid of it for a time, by means of diuretics, sudorifics, and even, if the strength admit of it, by drastic purgatives. According to Stokes, the action of these remedies may occasionally be assisted by mercurials. For any other purpose they are useless. When hypertrophy exists to any great extent, and there is obvious difficulty in propelling the blood through the lungs, as evidenced by excessive dyspnoea, lividity of the face, and irregular heart's action, the application of a few leeches, or cupping to the extent of four or five ounces of blood, frequently gives great relief for a time. Even dry cupping is often beneficial. If there be a tendency to faintness, or reason to suspect fatty disease of the heart, in addition to the other kinds of treatment referred to, a stimulant should always be at hand to be administered at the first approach of syncope. FUNCTIONAL DISORDERS OF THE HEART. What are called functional disorders of the heart, are in fact only symptoms of obscure organic diseases, of indigestion, or of weakness of the general system from alteration of the blood. They assume three principal forms :—1st, Angina pectoris, or spasm of the muscular walls of the heart, causing excruciating pain and a feeling of sinking difficult to describe. It is generally induced by exertion. We have seen it accompany organic disease of the organ (Case XCVIII.), and it has been frequently observed in connection with fatty heart and calcareous * Edin. Medical and Surgical Journal, vol. xxxvii. 1852. ANEURISM. 557 degeneration of the coronary valve. _ 2d, In chlorosis, and the anjemia of young women, there are palpitations with a tendency to syncope, accompanied by a blowing murmur at the base, with the first sound, of soft character and not permanent. It is propagated in the course of the large vessels, on placing the stethoscope over which, a continuous buzzing or humming-top murmur is audible (Bruit de diable of the French). The cause of this is very obscure, and is by some said to be arterial, and by others venous. (See Diseases of the Blood.) 3d, Similar palpitations, often with a small heart, in young men who fol- low sedentary pursuits, especially students of the learned professions. Their appetite is generally defective, the body weak and indisposed to exertion, the mind and nervous system irritable, and the sleep pre- vented by the excessive action of and uneasy sensations attributed to the heart. The treatment in all these cases is, when it is dependent on weak- ness, to increase the vigour of the constitution by nutrients, proper exercise, and the administration of chalybeates. In chlorosis, more especially, the different preparations of iron are beneficial. In young men, regulated exercise, suspension from study, attention to diet, and especially removing the attention from the heart at night by cheerful conversation, or interesting light reading, are the most useful means of removing the disorder. In all cases the concomitant derangements must he studied, and, if possible, removed, such as amenorrhcea, haemorrhoids, spermatorrhoea, dyspepsia, etc., etc. ANEURISM. Case CY.*—Aneurism of the Ascending Arch of the Aorta—Incompetency of Aortic Valves—Hypertrophy of Left Ventricle. History.—Charles Watt, set. 31, groom—admitted June 19, 1850. During the last eight months has frequently had occasion to lift heavy weights, and has occasional- ly felt slight pain in the epigastrium. This suddenly became very violent on the 8th of June ; and the next day, on walking, he experienced violent dyspneea. On the 11th he was cupped, with considerable relief. Has been aware of a pulsation in the neck for two years, but never suffered any inconvenience from it. No dysphagia. Symptoms on Admission.—The cardiac dulness extends three inches trans- versely. The apex beats with great force between the fifth and sixth ribs, two inches below, and a little to the left of the nipple. A bellows murmur is heard with the second sound, loudest at the base. The first sound is normal. In the right side of the neck, immediately above the sternum and clavicle, there is a pulsating tumour the size of a hen's egg, extending laterally two inches. It communicates a strong impulse and a peculiar thrill to the hand placed on it, and over it there may be heard a loud hoarse bellows murmur, synchronous with the impulse of the heart, and this murmur may be heard at the back, extending down the course of the aorta. Pulse 74, regular, hard, and jerking, alternating with the impulse at the apex, stronger in the right than the left wrist. Pain in the epigastrium, and * Reported by Mr. David Christison, Clinical Clerk. !}~}S DISEASES OF THE CIRCULATORY SYSTEM. dyspneea on exertion. Xo other pulmonary symptoms. Frequent pain in the left temple, extending down that side of the nose. Giddiness on rising suddenly. Fre- quent muscas volitantes. Progress of the CAse.—Continued to have pain in the epigastrium, and dvspncea at intervals. He was treated by occasional small tropical bleedings, which alwavs relieved the symptoms. Blisters also were now and then applied, and latterly small doses of aconite given. The physical signs underwent no change, but the distressing concomitant symptoms nearly disappeared, and he felt so well that he was dismissed, at his own desire, July 15. Commentary.—In this case aortic incompetency was proved to exist by the same sign as we have seen to accompany it in former cases. The visible swelling, diffuse pulsation, and bellows murmur, synchronous with the dilatation of the vessel, could leave little doubt that an aneurism of the aorta existed. It became a question, however, whether the innominata was or was not involved ; and I am inclined to consider not, from a variety of circumstances, but more especially—1st, Because the pulse at the right wrist wTas stronger than at the left; 2d, Because the pain in the head and face was on the left, and not on the right side ; and, 3d, Because the bellows murmur over the tumour was super- ficial, auterior, and propagated down the back in the course of the aorta. In addition, it could be argued that there was neither dysphagia nor dyspnoea, while the respiratory murmurs are equally loud in both lungs. Now aneurisms of the transverse arch of the aorta press against the most convex part of the trachea, which is least liable to compression, whilst the oesophagus at this point is well protected. Hence the seat of the aneurism explains why deglutition and respiration were not inter- fered with. Case CVL*—Aneurism of Ascending Aorta, immediately above the Aortic Valves— Incompetency of Aortic and Mitral Valves—Hypertrophy of left Ventricle—Waxy Kidneys—Pulmonary Hemorrhage—Anasarca. History.—Kenneth M'Kcuzie, set. 52, quarryman—admitted October 31st, 1853. Has been more or less subject to rheumatism during the last twelve years. Xine months ago, after much exposure to cold and wet, he complained of unusual palpi- tation and dyspneea, and has since been subjected to paroxysms of breathlessm'^, suffocation, and a feeling of extreme anxiety, unattended with cough or expectora- tion. Three weeks ago a mass of earth and loose stones fell upon his back between the shoulders, and since then, his whole body has been painful and stiff, and the other symptoms much aggravated. Symptoms ox Admission.—The impulse of heart is diffuse, raising more espe- cially the fifth and sixth intercostal spaces. The apex beats strongly between the fifth and sixth ribs, in a vertical line below the left nipple. The transverse cardiac dulness begins at the margin of the sternum, and extends three inches and a quarter outwards. On auscultation a loud, harsh, but somewhat musical murmur is heard at the apex with the first sound, immediately followed by the second sound, which is rather sharp and rough, but without mum ur. At the base there is a blowing mur- mur with both sounds, which are particularly marked over the articulation ot the * Reported by Mr. William Calder and Mr. Almeric Seymour, Clinical Clerks. ANEURISM. 559 fourth rib with the sternum. Over the great vessels at the root of the neck, a single blowing murmur is heard synchronous with the pulse at the wrist, and this is heard loudest immediately above the sternal end of the clavicle. At this point a distinct impulse may be felt with the finger, and even seen by the eye, but no circumscribed swelling can be made out. A similar impulse and murmur exists above left clavicle, but not so distinct. Pulse 90, strong and rather jerking. Has frequent palpitation and dyspnoea, sometimes coming on when lying quite still, and always on making any unusual exertion. Percussion over the lungs everywhere good. On the right side, harsh inspiration both anteriorly and posteriorly. Has a copious expectoration of frothy mucus. Breathing somewhat laboured and wheezing. The appetite is not good, but the digestive system is otherwise normal. Has occasional headache and a frequent feeling of dizziness, with muscae volitantes. Palpitation and dyspnoea, when severe, often occasion faintness. Other functions normal. Progress of the Case.—During the month of November there was little change in his condition, although the symptoms were somewhat alleviated by quietude and treatment. December 8th.—Last night was seized with pains in the right chest, accompanied with great difficulty of breathing. To-day on auscultation, crepitating rale is mingled with harsh inspiration, and sibilant and sonorous rhonchi on expiration. Percussion and vocal resonance good. No rigor or fever. Dec. 22d. — Since last report the attacks of dyspneea have become more urgent, and now he cannot assume the recumbent posture. Expectoration is copious and slightly tinged with blood. On the 13th, oedema of the ankles made its appearance, and on examining the urine, ■ it was found to be highly albuminous. Pulse 60, jerking. Dec. 29th.—CEdema of inferior extremities has now extended to the thighs and scrotum, and is rapidly increasing. Amount of urine passed daily much diminished and highly albuminous. Orthopnoea at night, and great dyspneea at all times. Sputum largely mixed with blood. Dulness on percussion over lower third of right lung posteriorly. January ith'.—Since last report there has been general anasarca, with great distension of the inferior extremities and scrotum. Has been unable to assume the recumbent posture, and been obliged to pass the night leaning forward on a table. The urine has con- tinued very scanty, and the pulse, though still jerking, has gradually become weak. He gradually became exhausted, and died Jan. 9th, at 11 a.m. The treatment con- sisted at first of abstraction of small quantities of blood from over the heart or lungs, by cupping or leeches, which always produced temporary relief. Expectorants and anodynes to relieve cough, favour expectoration, and promote sleep. Antispasmodics to diminish dyspneea When the dropsy appeared, diuretics and afterwards hydragogue cathartics caused relief, and for a time diminished the accumulation of the fluid. Srctio Cadaveris.—Twenty-five hours after death. Hkau—Considerable effusion in subarachnoid cavity. Lateral ventricles con- tained I iij of clear serum. Brain otherwise healthy. Thorax.—Heart much enlarged, weighing 28 ounces. This was owing almost entirely to hypertrophy of the left ventricle, its cavity being dilated and walls much thickened. The aortic valves were shortened, thickened, and incompetent. The margins of mitral valve were thickened, and the chordae tendinece shortened and thickened. The lining membrane of the aorta was rough and irregular from athero- matous and calcareous degeneration. Immediately above the sigmoid valve, which is nest the right ventricle, was an aneurismal pouch the size of a walnut. It contained no coagula, was formed by a dilatation of all the aortic coats, and its internal surface was rough from atheromatous degeneration. The entire arch of the aorta was also rough from a similar cause, but the descending aorta was normal. Both lungs were 560 DISEASES OF THE CIRCULATORY SYSTEM. cedematous. In the right lung were several masses of coagulated extravasated blood, generally about the size of a walnut. Abdomen.—The kidneys presented the waxy degeneration. Other abdominal organs healthy. Commentary.—This case is an example of a commencing aneurism at the root of the aorta, although it, like the last, may be regarded essen- tially as a cardiac disease, as the physical signs indicated both mitral and aortic incompetency. It was the loud, single blowing, synchronous with the systole, combined with the distinct impulse felt and seen over the clavicle, which pointed to an aortic aneurism. The size of this aneurism could not be large, as percussion failed to detect any dulness over the chest, and although he at first said that deglutition had been slightly impaired, this symptom was afterwards ascertained not to be present. The aneurism may have assisted in producing the incompetency of the aortic valves, which, with the aneurism itself, was occasioned by the chronic arteritis, and subsequent atheromatous degeneration of the arch of the aorta. At what time the mitral disease commenced was unknown, but it was comparatively subordinate to the aortic disease, and was fol- lowed by hypertrophy of the left ventricle, and the pulmonary compli- cation. The renal lesion came on when he was in the ward, and we need not be surprised at the universal and rapid anasarca which, under such circumstances, proved fatal. Treatment under such circumstances could only be palliative. Case CVIL*—Aneurism of Ascending Arch of Aortd*— Chronic Pericarditis—Disease of Aortic Valves—Great Hypertrophy of Heart—Anasarca. History.—Robert Laing, set. 53, married, a book binder—admitted January 11th, 1854. States that he never had rheumatism, and cannot account in any way for his illness, which he dates from about four months ago ; previously to that time he was in the enjoyment of excellent health. Palpitation and dyspneea were the first symp- toms he noticed, and a strong pulsation in the back was observed by his wife. (Edema of the lower limbs came on about a month afterwards, and has since gradually increased. During his illness he was treated with diuretic remedies, which produced temporary diminution of the dropsy. A few days before admission, the dyspneea became very urgent, but was somewhat relieved by venesection to the amount of a few ounces. Symptoms on Admission.—The impulse of the heart is weak and diffused over considerable part of the fifth intercostal space, being felt most distinctly in a line perpendicularly below the nipple. Dulness on percussion extends from the left nipple across the chest, nearly as far as the right nipple; upwards on the left side it extends as far as to the third intercostal space, but above that line percussion is normal. On the right side, dulness extends from apex to base, over a space bounded by the sternum within, and a line drawn vertically through the nipple externally. The heart sounds are much obscured by pulmonary rales; in the usual situation they are feeble, and their precise character cannot be determined. Over the upper two-thirds of the right side of the chest, as far out as the nipple, there is very loud hoarse double murmur; no impulse can be felt in that region. Pulse Reported by Mr. Robert Bird, Clinical Clerk. ANEURISM. 561 7G, and of jerking aortic character; regular, and of equal strength on both sides. Posteriorly the chest is resonant everywhere, and loud, sonorous, and sibilant rales are heard; expiration is considerably prolonged. Dyspneea considerable; there is some cough with frothy mucous expectoration. The inferior extremities and scrotum are enormously distended, and pit on pressure; the abdomen is swollen, and fluctuation can be detected; the face is pale and somewhat sallow. Appetite much impaired; thirst considerable. He can lie only on his back or his right side. Has considerable difficulty in speaking. Urine very scanty and muddy in appearance. Pkcgress oe the Case.—January 11th to 13th.—Was treated with antispas- modics and hydragogue cathartics, and afterwards with leeches to the praecordia, which last measure relieved the dyspneea considerably. On the morning of the 13th, on awakening he called on the nurse ; immediately afterwards he fell into a state of stupor from which he could not be roused. His pulse was 120, weak ; the pupils were strondy contracted. Brandy and carbonate of ammonia were administered, but he continued in the same state for two hours, and then died. Sectio Cadaveris.—Twenty-seven hours after death. Great anasarca of the body. Thorax.—The veins of the neck greatly engorged, so that on cutting them across, a large quantity of black fluid blood escaped. On removing the sternum, the peri- cardium was seen to extend in a transverse direction from nipple to nipple, so as to measure eight inches across. On being opened, it was found to contain two ounces of serum. Over the anterior and posterior pericardial surface of all the cavities, but especially the anterior surface of the right ventricle, masses of old lymph were attached—in some places smooth, in others rough and shaggy. The heart was enormously enlarged; the cavities of both ventricles, but especially of the right, were increased in size. Their walls also and the septum were much thicker than natural. The aortic valves were thickened, and could not be applied against the walls of the aorta in consequence of masses of calcareous matter deposited at their bases. The whole internal surface of the aorta was rough and thickened by athe- romatous degeneration. Immediately above the semilunar valves was an aneurismal pouch, springing from the aorta. The opening into it was rather larger than a crown piece, and was perfectly round. Above this aneurism, formed by a dilatation of all the coats of the vessel, was another, formed only of the middle and external coats. Into this there were two openings, one about the size of a shilling, the other a fourth of that size. The second pouch was partly filled by coagulated blood. Externally, the aneurism was applied immediately over the right auricle, was of a flattened oval form, aud about the size of a cocoa nut. The mitral valve, and those on the right lide ofthe heart, were healthy. The pleurae on the left side were thickened and uni- versally adherent. At the lower part of upper lobe it was of cartilaginous consist- ence, over a space the size of a crown-piece. The lung was slightly emphysematous at its anterior margin. Bronchi contained muco-purulent matter. The right lung was not adherent anywhere. At the apex were numerous emphysematous bullae the size of peas. Inferiorly and posteriorly, the pulmonar}' tissue was collapsed in several places. Abdomen*.—The liver and kidneys were considerably congested; otherwise healthy. Other organs natural. Commentary.—In this case the aneurism originating from the ascend- ing portion of the aortic arch was the size of a cocoa nut, and was formed on the right side. During the life of the patient it was supposed to be much larger in consequence of the extended dulness, which was 5G2 DISEASES OF THE CIRCULATORY SYSTEM. afterwards determined to be partly dependent on the dilated pericardium. The chronic pericarditis gave rise to no symptoms, but probably assisted in causing the heart's souuds to be obscured, which, bowevcr,\vere suf- ficiently masked by the bronchitic rales. The loud double murmur heard on the right of the sternum was most probably owing to the flux and reflux of the blood into the first aneurismal pouch, for although similar sounds might have originated from the diseased aortic orifice they would be rendered inaudible by the pericarditis and bronchitis. The complications here were formidable, and the man died rather from the heart disorder than from the aneurism. Case CVTII.*—Large Aneurism of the Ascending Arch of the Aorta, causing Ab- sorption of a portion ofthe Third Rib, and bursting into the Pericardium—Chro- nic Pericarditis—Incompetency of Aortic Valves—Hypertrophy of Left Ventricle. Histoky.—James M'Killop, ast. 24, labourer, of intemperate habits—admitted January 12th, 1857. He says that two years and a half ago, while engaged in lifting a heavy weight, he suddenly felt something give way in the region of the left chest. From that period he became subject to a beating in that locality, but suffered no other inconvenience till about four months ago, when he experienced a numbness down the left arm. For the last twelve months he has observed his left chest to be somewhat swollen. Six weeks ago he first felt dyspneea, which was increased on exertion, and was attended with frequent cough. Two weeks afterwards, he observed his lace and neck begin to swell, and this has gradually gone on until now. Continued to work till six weeks ago. Symptoms on Admission.—Apex of heart beats between the fifth and sixth ribs, internal to and below the left nipple. It is feeble and diffused. A heaving pulsation is also felt over the upper part of left chest, synchronous with the cardiac impulse, having also an expansive literal motion. On percussion, at a level with the nipple, cardiac transverse dulness is three inches. Above this there is a dull space, bounded by a curved line, which passes internally to mid-sternum, superiorly to the lower border of the first rib, and externally as far as a line passing vertically through the left nipple. The space measures four inches from above downwards, and five inches transversely. It bulges forward visibly more than the correspond- ing part on the opposite side, especially in the second intercostal space, two and a half inches from the sternum. On auscultation at the heart's apex, a double blowing murmur is audible, which, however, evidently originates at the base, where it is loudest, the first murmur being rough, and the second comparatively soft. All over the region of the pulsating tumour there is a double murmur, the first not so loud as the second. They are most distinct towards the outer margin of the dull space formerly described, especially at a point one inch above the left nipple. Over both clavicles there is a single rough blowing murmur. Posteriorly, no comparative dulness can be made out on percussion. On applying the hand at the base of both lungs, fremitus is perceptible with the inspiratory acts, most marked in the It It side. On auscultation, a double murmur is audible all over the left back, loudest between vertebra and the edge of scapula. Radial pulse 108, small but strong, without any difference in the two wrists. Both external jugular veins are somewhat distended, so that the position of the valves may be readily perceived. On auscultation over both lungs, harsh sonorous rales are audible, with occasional moist sounds. Expira- tion much prolonged. Has tickling in the larynx; occasional cough of a hard and * Reported by Mr. H. N. Maclaurin, Clinical Clerk. ANEURISM. 563 Bomcwhat clanging character; expectoration is mucous, not copious; considerable dyspneea, especially on exertion, and pain in the left chest and shoulder, with numb- ness in left arm ; sleep is disturbed; irides normal; strength diminished; considera- ble oedema of face, neck, and chest only; eyelids puffy; skin hot; appetite good; deglutition unaffected. Ingestive, urinary, and other functions normal. Eight leeches to be applied over tumour in left chest, and to lake a table-spoonful every two hours of the following mixture :—R Sp. vElher. Sulph. ; Sp. Ammon. Aromat. aa 3 j; Tr. Card. comp. 3 iij ; Aquas ad 3 iij- M. Progress of the Case.—January 17th.—Little benefit followed the application of the leeches. Yesterday, 3 v of blood were removed by cupping, and caused great relief. CEdema of the face lessened. Jan. 22d.—Complains of pain passing from tumour to middle of left back. Venesectio ad § x. Jan. 24th.— 3 xj of blood were taken from the arm, causing instantaneous relief from the pain, and tingling in the arm. The relief continued till to-day, when the pain has returned. Pulse 100, sharp. Otlier symptoms the same. Morphia andJEther draught. Jan. 29th.—Pain continues. Dyspnoea and cough have increased. Face and neck again very cedematous. To be cupped over the left chest, and 3 vj of blood taken. Feb. 2d.—Was again greatly relieved by the cupping. Complains of tickling in the larynx. The tumour has extended somewhat upwards, and its pulsation is distinctly felt at the right border of the sternum opposite the second rib. R^ Tinct. Lobelice Infiatm 3 j ; Sol. J fur. Morph. ij; Aipur, ad § vj. M. One table-spoonful three times in the night. Expired suddenly at 7 p.m. on the 8th, the symptoms having undergone little change. Sectio Cadaveris.—Tliirty-tico hours after death. Body not emaciated. Left side of thorax rather fuller than right. Thorax.—There was some oedema of the parietes, greater upon the left than the right side. On reflecting the soft parts, there was an evident prominence in the left mammary region, rounded in form, and about two and a half inches in diameter. The pericardium was much distended, and contained twenty ounces of blood. An aneurism arose from that portion of the ascending aorta contained within the peri- cardium, commencing immediately above the semilunar valves and the origin of the coronary arteries. The aorta below this point was not dilated. The aneurism anteriorly appeared to be divided into two lobes; the left much larger than the right, and of the size of a large cocoa nut, passed upwards and forwards, its long diameter being nearly parallel to the anterior wall of the thorax, to which the greater part of its surface was adherent; the right larger than a turkey's egg, passed back- wards and a little downwards, its long diameter being nearly parallel to the base of the thorax. The anterior extremity of the right lobe did not approach within two inches of the thoracic wall. Posteriorly no such division into lobes could be seen, but merely a single large aneurismal sac divided into two compartments by the aorta. The left pouch was found adherent to the posterior surface of the sternum, between the junctions of the second and fourth ribs, and to the cartilages and part of the bodies of second, third, and fourth ribs. Over this space, measuring about six inches across, and nearly four vertically, the sac could not be separated from the thoracic parietes; on the contrary, the finger introduced into the sac detected rough exposed boue in various situations, corresponding to the prominence observed. Externally there was a gap in the thoracic wall, formed by the absorption of a considerable por- tion of the third rib, external to its junction with its cartilage. The recurrent nerves were displaced and stretched, especially the left, in consequence of the transverse portion of the arch of the aorta being pushed backwards. A rupture of the aneurism into the pericardium had taken place at the most dependent part of the larger sac, 564 DISEASES OF THE CIRCULATORY SYSTEM. nt a point corresponding to the right margin of the sternum between the junction of the fifth and sixth right costal cartilages with the sternum, but about two inches behind it. The orifice was of a linear form, half an inch in length, and immediately overhanging the right auricle. The sac contained chiefly loose clots, hut some imperfect layers of decolorised tough fibrin were in some places adherent to its walls. The heart was displaced downwards and backwards. The larger sac intervened between it and the thoracic walls, so that its base was on a level with the lower margin of the fourth rib, and five inches behind it. The heart was hypertrophied but, as it was kept attached to the preparation, it could not be weighed. The hyper- trophy was most marked in the left ventricle. The surface of the heart was rough- ened by shaggy growths of old plastic lymph, most abundant over the left ventricle. Pericardium not adherent. The aortic valves were evidently incompetent, being opaque, thickened, and shortened. There was a small aneurism of this portion of the arch, between the origin of the innominate and left carotid arteries, and partially involving the commencement of each of these vessels. It was about the size of a large filbert. The lining membrane of the thoracic and abdominal aorta was but slightly atheromatous. The larynx was quite natural. The right bronchus was com- pressed at the point of adhesion between the lung and the smaller sac. The sub- stance of the lungs was quite natural. The right pleura contained a pint and a half of clear serum. Abdomen.—Abdominal organs healthy. Commentary.—In this case the aneurismal tumour developed itself on the left side, and caused a visible swelling with protrusion in the left chest. It was of larger size and of older growth than in the previous cases, and by constant pressure forwards on the ribs, had occasioned caries and interstitial absorption of the bones. In consequence of pres- sure posteriorly on the bronchus and recurrent nerve, it occasioned harsh cough and tickling of the larynx. Although here also the aortic valves were incompetent, the sounds were marked by a loud double blowing murmur, evidently connected with the aneurism, because they were audible in the left back. Only one sound, however, could be heard at the root of the neck above the clavicles, owing to a dilatation of the aorta between the innominate and left carotid arteries. In this, as in Case CVII., a chronic pericarditis existed, whirh was not indicated by any symptoms. The relief to symptoms by small abstractions of blood was particularly well marked, although it is perhaps almost unnecessary to say that the real disease was in no way altered, and contiuued its march towards a fatal termination. (For a case of thoracic aneurism bursting into pleura, see Case LXXIII.) Case CTX.*—Varicose Aneurism of the Ascending Aorta communicating with tin Pulmonary Artery—Jaundice and Nutmeg Liver. History.—Alexander Calder, ret. 33, a teacher—admitted June 11th, 1855. He had always enjoyed good health until the beginning of last February, when he felt a pain under the ensiform cartilage, which felt like the pricking of a pin, and continued for a week. About a fortnight after this, while walking hastily, he felt as if something had given way below the ensiform cartilage, which caused him to Reported by Mr. Robert Byers, Clinical Clerk. ANEURISM. 565 slacken his pace, and produced a sensation of weakness. He continued to feel weak for a fortnight, and then resumed his duties, though far from well. During the next two months he occasionally expectorated a little blood, and experienced cardiac palpi- tation. Two months ago he lost blood at stool (6 or 8 ounces passing at time during three days), which was regarded as dysenteric. He has long been subject to hemor- rhoids. Last April the feet began to swell, and the abdomen to enlarge, symptoms which have continued more or less since. Latterly the palpitation has increased, and there has been considerable dyspneea and cough, with occasional vomiting. Symptoms on Admission.—On percussion, the transverse dulness of the heart measures three inches. Its impulse is diffused, strong, and irregular. On auscultation, a soft blowinc murmur is heard over the apex with the first sound, and the second sound is distant but healthy. At the junction of the third costal cartilage with the sternum the first sound is loud, prolonged, and blowing, the second is short, abrupt, and rasping. Over the manubrium of the sternum there is a rough, continuous blow- ing murmur, occupying the period of both sounds. The same murmur is audible under both clavicles and to the right of the manubrium, but is softer and more distant. Pulse 90, irregular, but of natural strength. He has considerable dyspneea on going up stairs, and a trifling cough. Over the anterior surface of chest the respiratory murmurs are harsh, but otherwise percussion and auscultation furnish no signs of pul- monary disease. Pressure over the stomach is painful. Tongue clean; vomits once or twice a day after coughing. Abdomen rather tumid, but percussion and palpation discover nothing abnormal. The feet, legs, and thighs are cedematous, pitting strongly on pressure. Urine small in quantity, and high in colour. It contains a super- abundance of lithates, but no albumen. Sp. gr. 102f>. The other functions are well performed. He has taken a variety of remedies ; at one time drastic purgatives, and at another the strongest diuretics, all of which have only produced temporary relief. 5 Pp. AUther. Nit. 3 ij ; Tinct. Hyoscyami 3 ij ; Liq. Amnion. Acetat. 3 ij ; Aqua ?vj. J[. Habeat ?j ter die. Progress of the Case.—June 16th—The rest and quietude he now enjoys have apparently benefited him, but he sleeps little. R Spir. JEther. Sulph. min. xv. Sol. Mur. Morph. min. xx. Ft. haustus. To be taken at bedtime. June 19tli.—The breath- ing is more embarrassed, and the oedema of the lower extremities increased. The cough also is more severe, and he has vomited every meal. Pulse 100, weak. R Sp. Aether. Nit. 3j; Sol. Mur. Morph. 3j; Mist. Camphorm =jss. M. Half to be taken at 5 p.m., the rest at bedtime. June 21st.—Since last report the skin has gradually become jaundiced, and the features are now shrunk and anxious, pulse 128, weak. Vomiting was checked by the medicine ordered, but he is unable to take food, or stimulants. R Ammon. Carb. gr. v; Tinct. Carb. Comp. 3 ij; Mist. Camph. Z iss; ha'f to be taken immediately, and the other half in an hour. June 22d.—Con- tinues to sink, notwithstanding the liberal administration of stimulants and nutrients, Died at half-past two on the morning of June 23d. Sectio Cadaveris.—Thirty-four hours after death. External Appearances.—The general surface and conjunctivae of a yellow tinge —lower extremities cedematous, and several phlyctenae, filled with sanguinolent serum, existed on the trunk and upper part of the thighs. Thorax.—The pericardium was natural; it contained 3 ss dark coloured serum. On removing the heart a bulging was observed between the aorta and pulmonary artery. Seen externally it appeared to rise from the latter vessel. It was of a rounded, rather flattened form, somewhat smaller than a chestnut; when, however, the finger was passed down the aorta it entered this bulging, which proved to be an aneurismal 566 DISEASES OF THE CIRCULATORY SYSTEM. sac, rising from the root of the aorta. A stream of water passed down the aorta escaped rapidly at first; but the latter portion was retained by the semilunar valves which proved competent. On laying open the aorta, the aneurism was found to com- mence immediately above the semilunar valves. Its opening into the vessel was circular, and rathev smaller than a florin. The sac itself was of an irregularly roundd form, its greatest diameter (from above downwards) being two inches. Its capacity about that of a large walnut. The sac was empty and contained no trace of a clot. At the apex of the tumour was found an opening, which passed into the pulmonary artery. (The sac, as already mentioned, was closely applied to this vessel.) When the pulmonary artery was cut open the communication became more distinct. This opening was about four lines in length, and the lips a line and a half apart, so that it was oval in form with its margin slightly rounded off. It was situated transversely to the length of the pulmonary artery, and was rather more than an inch higher up than the point of union of two of the pulmonary semilunar valves. The whole of the cardiac valves were natural. The left ventricle was rather more capacious than usual; its walls were of the normal thickness. The right ventricle was also a little dilated; its walls were more decidedly hypertrophied. The heart weighed 15^ ounces. On section of both lungs, they were seen to contain several diffused patches of extra- vasated blood, recent and confined to the air cells. Abdomen.—In the cavity of the abdomen was about a pint of turbid serum. The liver, when cut into, exhibited congestion of the portal capillaries, causing the so-called nutmeg appearance. The spleen, kidneys, and other abdominal organs were healthy. Commentary.—Cases of aneurism communicating with the pulmo- nary artery are very rare, and the physical signs to which they give rise have, so far as I can discover, only been recorded in two instances. Of five cases collected by Mr. Thurman,* there is only one in which the sounds were accurately observed. It was published by Dr. Hope,t and was communicated to him by Dr. David Monro of Edinburgh. In that case the size of the aneurism is not given, it is vaguely called " large," but it " communicated by two openings with the pulmonary artery, the larger capable of receiving the point of the little finger, the smaller of transmitting a crow's quill. The edges of both were regular, round, and cartilaginous. Nearer the arch, a third small opening was dicovered, with thin rugged edges. All the valves were healthy, excepting the semilunar at the mouth of the aorta, which was thickened." We are not informed to what extent the aortic valves were thickened, and whether such thickening produced incompetence in their action. But we are told that " the first sound was accompa- nied by a loud blowing murmur, most distinct at the middle of the sternum, but audible over the whole fore part of the che.-t, and over the back on both sides of the spine. The second sound was short, and much obscured by the first." This account renders it probable that the murmur was synchronous with the ventricular contraction, was caused by the rushing of blood through the laceration of the aneurism into the pulmonary artery, and wTas not owing to the valvular disease. In ; Medico-Chir. Trans., vol. xxiii., p. 349, et seq. t Diseases of the Heart, 3d edit., p. 469. ANEURISM. 567 a ease of Professor Smith's of Dublin,* the pulmonary artery commu- nicated with the aorta by a small opening at the origin of the latter vessel. The edges of this opening were thickened and rounded off. There was dilatation of the aorta at the point of opening, with distinct sijrns of arteritis. The auriculo-ventricular openings were healthy. A loud blowing murmur accompanied the first sound, and an intense pur- ring tremor could be felt over the whole cardiac region. "Where this blowing murmur was heard loudest is not stated, and we are at a loss to determine whether it was owing to the wave of blood rushing throuoh the dilated and roughened aorta, or its passing through the orifice into the pulmonary artery. Of the second so md nothing is said. The pur- ring tremor may have been occasioned by the rapid gush of blood through the small opening ofthe aneurism, and a similar tremor was observed by Mr. Thurnam, Dr. Williams, and Dr. Hope, in a case where an aortic aneurism communicated with the right ventricle of the heart, by two tmall rounded apertures. That such tremor should occur where the opening is large, appears to be improbable. Iu the present uncertain state of our knowledge as to the sio-ns which accompany an aortic varicose aneurism communicating with the pulmo- nary artery, the case of Calder appears to me to be of great value, as the physical signs were examined with great care, and recorded at my dicta- tion by the clerk at the bed side. At the time they were exceedingly puzzling, because the idea suggested by the double sound heard at the base of the heart, which, under ordinary circumstances, would have in- dicated aortic disease with stricture, was negatived by the fact that the second sound was distinctly audible at the apex, clear, and healthy. At the same time, the manner in whicii the disease occurred, the anasarca indicating impeded circulation, the dyspnoea and irregularity of pulse, gave evidence of a profound lesion of the heart, although its nature wa3 very mysterious, the more so as no thrill or tremor could be detected. The case, however, was at once made clear, and the nature of the souuds explained by the examination of the body after death. All the valves were healthy, and hence the double sound must have been entirely owing to the flux and reflux of blood through the communication between the aneurism and pulmonary artery. The murmurs were heard loudest over the seat of the communication, below the junction of the third left costal cartilage with the sternum ; became continuous as they were pro- pagated upwards; but inferiorly at the apex of the heart, only the sys- tolic blowing was audible, together with the natural sound of the semilu- nar valves. The size of the laceration or connecting opening explains the absence of whiz and tremor. These facts appear to me very valuable as distinctive of such a lesion when the valves are healthy. If, as fre- quently happens, they are diseased, there must always exist excessive difficulty, if not an impossibility, of ever distinguishing such a form of aneurism in the living subject. Mr. Thurnam, in his excellent paper, appears to me rather too sanguine on this point. The other phenomena presented by the case are at once explained, by reflecting on what is likely to happen by a considerable quantity of blood being propelled from the aorta through a large opening into the * Dublin Journal of Medical Science, vol. xviii., p. 164, and Stakes on the Diseases of the Heart and Aorta, p. 551. 568 DISEASES OF THE CIRCULATORY SYSTEM. pulmonary artery, and thus sent to the lungs again without havinc passed through the systemic circulation. As stated by Mr. Thurnam the effects are referable to one or more of three circumstances, l^t, Loss of blood to the systemic circulation, and as a result, feeble, occa- sionally jerking pulse, debility, tendency to syncope, and diminution to animal heat. 2d, Impediment of the return of venous blood from the distant veins, and, as a result, venous congestion of the liver, mucous membrane, and extremities, with engorgement and dilatation of the rhdit side of the heart, and as a result, dropsical effusions and especially ana- sarca. 3d, Excessive stimulation of the lungs by the reception of arte- rial instead of purely venous blood, and hence dyspneea, cough, pulmonary congestion, and extravasations of blood. All these effects were observed in the case we have had before us. A retrospective view of the facts and phenomena of this and similar cases must impress upon us the truth that drastic purgatives and diuretics, however they may relieve, cannot be expected to produce any permanent benefit. Indeed, whenever gene- ral anasarca is evidently dependent on organic disease, it seems to us that the mildest remedies should be employed, especially taking care by their use not to lower the general powers of the constitution, so that life may be prolonged as much as possible. Case ("X.*—Aneurism of the Arteria Innominata. History.—Catherine Syme, set. 56, a seamstress—admitted May 2, 1853. She says that her habits have always been temperate and regular. Eifteen years ago she had an attack of acute articular rheumatism, wbich afterwards became chronic, and rendered her incapable of working for eighteen months. For six years past she has been subject to occasional attacks of giddiness and swimming in the head, accompanied by a loud noise like the clanging of machinery. Fourteen months ago, in the night, she was seized with a fit of intense dyspna'a, threatening suffocation and accompanied with a loud crowing noise on inspiration. The attack lasted about eight minutes. Three months afterwards, she experienced a somewhat similar but milder attack, also in the night, during sleep. She now observed that her voice was becoming rough and hoarse ; aud a few months later, she felt slight difficulty in swallowing, at a point cor- responding to the upper border of the sternum. In the early part of January 1853, after unusual exposure to cold, the dyspneea returned every morning, gradually be- came urgent, and generally terminated in the expectoration of a small quantity of mucus. There were also palpitations, and she became subject to sudden startings from sleep. A week ago all these symptoms became so much aggravated that she was unable to leave her bed. Symitoms on Amnssiox.—The cardiac dulness measures two inches across. The apex beats between the fifth and sixth ribs, a little to the inside of the nipple. Heart's impulse is somewhat diffused, rhythmical, and of good strength. A blowing mur- mur accompanies both cardiac sounds, that with the first sound being loi.dest at the apex, and that with the second being loudest at the base. Immediately above and towards the outer side of the right sterno-clavicular articulation, a pulsating tumour, about the size of a hen's egg, is visible to the eye. It is felt beneath the sternal and inner portion of the clavicular origins of the sterno-mastoid muscle, pre- sents a distinctly rounded outline, and anteriorly slightly overlaps the trachea inime- * Reported by Mr. Robert Brown, Clinical Clerk. ANEURISM. 569 diately above the upper border of the sternum. The impulse is strong and diffused, and a loud, clear, abrupt murmur is heard over it, synchronous with the second sound of the heart. The pulse is regular, 106, of good strength, equal at both wrists. There is a paroxysmal cough, harsh, prolonged, and of a clanging metallic character, always worst in the morning, when it is accompanied by urgent dyspnoea, and a loud crowinc inspiration. Sputum scanty and gelatinous, containing a few flocculi of pus. Voice hoarse and weak. Chest everywhere resonant on percussion, but not unusually arched. Respiratory murmurs very faint, but normal in character. Expiration much pro- longed. Appetite impaired. When swallowing solid food, she says the bolus seems to meet some obstruction at a point corresponding with the upper border of the manu- brium of the sternum. The countenance is anxious, face livid, and the superficial veins of the chest and lower part of the neck are very large and turgid. Sleep rest- less and easily disturbed. Other functions normal. Progress of the Case.—The symptoms previously noticed continued, with occa- sional remissions, until the 20th of June. On that day, it was observed that the blow- ing murmur synchronous with the second sound at the base of the heart, was much less distinct, and that the murmur with the first sound at the apex was replaced by one with the second. The veins over the upper part of the chest have been gradually enlarging. On the 6tk of July, a careful examination elicited the following results:— Pulse SS, soft, equal in both wrists. The impulse is very strong over the tumour, and on auscultation there are now heard two sounds, the second being loud, abrupt, and exceedingly clear—no blowing audible. These sounds diminish gradually in intensity as the stethoscope approaches the left edge of the manubrium of the sternum, where the two cardiac sounds are heard quite normal. As the instrument descends towards the heart's apex, the second sound gradually assumes a soft blowing character, which at the apex is loud and distinct. The first sound is quite normal. Posteriorly above the right scapula, the sounds of the tumour are heard at a distance, but disappear towards the centre of the back, and are inaudible along the vertebral column. July 8/A.—For the last few days the dyspneea in the morning has been very urgent, and the cough coarser, and of a metallic clanging sound. To-day the paroxysm continued 15 minutes, and even now at the visit, the breathing is noisy, laboured, and hurried, the dyspnoea urgent, and the paroxysm of cough severe and at short intervals. She can- not expectorate easily. The voice is feeble, and the countenance expressive of great anxiety. To relieve these symptoms tracheotomy was attempted by Mr. Syme ; but, having made two incisions, and cut through the integument and subcutaneous fat, such an amount of venous hemorrhage occurred that he desisted, applied a ligature to the large veins, and declined to perform laryngotomy. July 9th.—The loss of blood caused considerable relief, and she passed a tolerable night. A double blowing murmur is now audible both at the apex and base of the heart. That accompanying the second sound is loudest over the apex, while the one accompanying the first is heard loudest over the ensiform cartilage. July 12th.—Last night, about half-past eleven, p.m., a severe paroxysm of dyspnoea, threatening suffocation, came on. The house-surgeon, Ur. Dobie, enlarged the incision made by Mr. Syme, upwards, and inserted a common- sued tube into the trachea and larynx, after dividing the cricoid cartilage. To-day she is again better, the operation having been followed with immediate relief. She still breathes, however, with difficulty through the tube. The countenance is livid and anxious, extremities cold, pulse feeble and fluttering, surface bedewed with a clammy sweat. Mie now gradually sank, and died at half-past eleven, p.m., on the Hth, the embarrass- ment of the respiration being apparently increased by the difficulty of expectoration. Immediately before expiring, she ejected through the tube about = j of dark grey- coloured foetid pus, of the consistence of thick cream. Ik 570 DISEASES OF THE CIRCULATORY SYSTEM. The *reatment throughout the progress of the case was directed to alleviating the cough and expectoration, by means of anodynes and expectorants, and dimmi-hing the paroxysms of dyspneea by means of diffusible stimuli. Cupping over the sternum and the occasional application of leeches, were employe 1, and for some time these remedies undoubtedly caused great relief. The surgeons of the Infirmary were unanimously of opinion that the aneurism did not admit of relief from any operation. Latterlv the propriety of tracheotomy or laryngotomy was discussed as a palliative, and ultimatelv tried with the effect already described. Secfio Cadaveris.—Thirteen hours after death. The edges of the wound through which the larynx had been opened, were thick- ened, the surrounding muscles discoloured and infiltrated with pus. Tuokax.—The heart, aorta, and parts connected with the aneurism, were removed en masse, and carefully dissected, with the following results :—the heart and its valves quite healthy, with the exception of slight thickening of the margin of one aortic valve- The arch of the aorta immediately above the valves considerably dilated, and the whole of its internal surface thickly studded with atheromatous and calcareous plates. The whole arteria innominata dilated into an aneurismal swelling of a round "and somewhat flattened form, having a diameter of fully three inches. The trachea is pushed by it towards the left side, as represented in the accompanying figure, in con- sequence of which the inci-ion that was made in the median line during the operation was within one-eighth of an inch of the aneurism. The tumour, by pressing on the right side of the trachea, caused much bulging into and diminution of its calibre. The left innominate vein was nearly obliterated. The remains of its interior contained a softened clot resembling pus, which communicated by a small opening through the aneurismal sac with a portion of the laminated clot, which occupied about three-fourths of its internal cavity. The opening into the sac from the aorta was about the size of half-a-crown, and presented a sharp circular margin. Posteriorly the nerves were red- dened, and for the most part enlarged and firmly united to the posterior wall of the tumour. The superior laryngeal nerve was healthy, being above the tumour; but the inferior was compressed and embedded in thickened cellular tissue. The posterior half of right lung was partially covered with recent lymph, not adherent, and the pleural sac contained two or three ounces of sero-purulent fluid. The lower lobe of the right lung was hepatized; and on cutting into it, several abscesses up to the size of a cherry were found. The left lung was cedematous, and its bronchi were filled with muco- purulent matter—otherwise healthy. Aboomfn.—The liver presented the incipient waxy appearance. The spleen was dark in colour and pulpy, almost diffluent in consistence. The kidneys were crowded with minute cysts, and the cortical substance considerably atrophied. Commentary.—This case terminated in the usual way, by pressure on the nerves of respiration, causing dyspnoea, and at length partial latent pneumonia The double clear sound over the aneurismal tumour I have been in the habit of attributing to the flux and reflux of the blood over a sharp vibrating opening into the tumour. In few aneurisms were these sounds more decidedly present than in the case under consideration, and few after death presented an opening having the margin in question better formed. In another case of aneurism of the innominate artery (that of John Hunter), examined at the commencement of the winter ANEURISM. 571 session 1^56-7, the tumour was very distinct in the neck above the clavicle, but without sound of any kind. It was determined after death that the arteria innominata was dilated to the size of a thumb, and irave origin to the aneurism, which was globular, and four indies in diameter, without any circular margin, but rather by means of a narrow neck, as in Fig. 42f). The sounds heard over the heart, however, in the case of Catharine Syme, changed their character as the disease advanced. At first, double valvular disease was suspected, but latterly, when the murmurs became reversed, and it was most carefully determined, by repeated examinations, that the murmur at the apex was with the second, and that at the base was with the first, sound, they were attributed to propagation down- wards from the aneurismal tumour. I am by no means satisfied, how- ever, that this theory is correct with regard to cardiac murmurs so distinct as those in the present case, ussociati'd with aneurismal tumours and a healthy heart. I con- tent myself, therefore, for the present, with placing the facts on record, as their accuracy is undoubted, and they were con- firmed not only by my own repeated examinations, but by those of the clinical class and of the clerks, all of whom took great interest in the case. The question of putting a ligature on the vessel having been decided by the Infirmary surgeons in the negative, the only other question of treatment was the prolongation of life. The source of danger was evidently the dyspneea, and the frequent attacks of spasmodic laryngeal obstruction, so common in aneurismal cases from pressure of the tumour on the recurrent nerve. The trachea was also considerably pressed upon and pushed Fig. 424. Rough sketch of the aneurism and adjoining parts; a, opening into the larynx; b, line of original incision which inferiorly came close upon the tumour; <", aneurismal tumour; d, point where the obstructed vena innominata had ulcerated into the tumour; e, rijrht carotid ; /', ri^ht iuo-ular vein: et, left carotid ; h, left subcla- vian. J ° J ° Fig. 125. Diagram of an aneurism ofthe arteria innominata, in which the tumour sprung from the dilated vessel with a narrow neck, and in which no sounds were audible. Fisr. 425. 572 DISEASES OF THE CIRCULATORY SYSTEM. aside; but this could not have accounted for the paroxysms of suffo- cating dyspneea, for although diminished in calibre, it was still largely open for the admission of air. On the other hand, the recurrent nerve was found after death thickened, and embedded in dense cellular tissue immediately behind the tumour. Under such circumstances, it has been proposed, by passing a tube into the larynx or trachea, to avert the effects of these spasms. In the present case, tracheotomy could not be performed; and whenever the deep-seated venous obstruction is of such a character as to cause enlargement of the superficial veins, laryn- gotomy is the operation that should be attempted. This at length was accomplished with momentary relief; but I have no hesitation in saying that the difficulty of expectoration, and the consequent clogging of the air tubes, led to results equally distressing and fatal as the spasmodic attacks. It has, indeed, been said, that in these cases the operation is generally delayed too long, and that by waiting until there is much secretion of mucus and diminution of strength, no very good effects can be reasonably expected. But in cases of aneurism, it is at best only to be considered as a palliative ; aud considering how very difficult expec- toration must always be under such circumstances, I consider it very doubtful whether it is ever justifiable except as a dernier resort. Cer- tainly the case now recorded is anything but favourable to the practice. In this case, it was observable that after the incisions in the integu- ment were made, without tracheotomy having been performed, great relief was occasioned, which continued upwards of two days.' Was this owing to the few ounces of blood lost during the operation, or to the idea which she had adopted that the operation would cause relief':' However it may be explained, there can be no doubt that the excessive dyspnoea and other urgent symptoms were alleviated as if by a charm, in consequence of the unsuccessful attempts to open the trachea. Cask CXI.*—Aneurism of Transverse Aortic Arch—Chronic Pericarditis with Effu- sion—Tubercular Lungs—Anasarca—Former Pojjliteal Aneurism cured by com- pression. History.—George Fairweather, set. 32, a labourer—admitted January 20th, 1851. Originally a farrier, he entered the army in 1839, and served twelve years. In 1842, while in India, he was laid up with rheumatic pains A year ago, while employed jn the Edinburgh police force, he was obliged to run a great distance in the dis- charge of his duty. Shortly afterwards, an aneurism made its appearance in the right popliteal space. Of this he was cured in the Glasgow Infirmary by means of compres- sion. He has since been troubled with cough and pain in the breast, and between the shoulders. Last August he became very hoarse, and entered the Glasgow Infirmary, where he remained for two months. Towards the close of that period he noticed that his feet were swollen, and began to suffer from palpitation, with pain in the precordial region. He was dismissed from the Hospital as incurable. The swelling in the ankles now increased, and passed up the legs to the abdomen. On the 1st December last he returned to the Glasgow Infirmary, and left it three days ago, without having experi- enced any relief. Since then his urine has become much diminished, and yesterday it was entirely suppressed. * Reported by Mr. Almeric Seymour, Clinical Clerk. ANEURISM. 573 Svmitoms on Admission.—The point where the apex of the heart beats cannot be made out; the cardiac impulse is not felt in its usual position; and. the cardiac rounds are inaudible over the region of the apex. At the base of the heart the sounds arc quite healthy, and also over the centre of the sternum, The transverse cardiac dulness is fully four inches. There is an unusual dulness above the left nipple, extending over a space about the size of the palm of the hand; here the normal cardiac sounds are heard. They are also heard, unaltered in character, all over the manubrium of the sternum as high as the first intercostal space. Pulse 66, very weak and irregular, and somewhat stronger in the right wrist than in the left. Over the rith, 6th, 7th, and 8th dorsal vertebrae were to a great extent absorbed, being apparently scooped out, leaving the intervertebral cartilages prominent between \fc ^W^V^'VVIifl^lS^^^fe^^iL^l them. The caries had also affected the heads i^t^^x^i^^Sl^^^Km^^^fU'/ 0I" the corresponding ribs on the left side. Pos- teriorly the tumour had projected about an inch, presenting an oval, rounded surface, which had compressed the spinal cord for about an inch and a half of its length opposite the 8th and 9th dorsal vertebrae. On removing and bisecting the cord, its medullary substance at the compressed portion was somewhat softened, an alteration much more marked for two inches both above and below, where it was pultaceous, Fig. 426. Fig. 426. View of the thoracic and abdominal aneurisms, the carious vertebrae, etc. ANEURISM. 581 gradually passing into the spinal medullary matter of normal consistence. The softening was white throughout, with no red spots. Abdomen.—The pancreas is stretched over an abdominal tumour, the size of a small cocoa-nut, in front of the aorta, which is moveable, and tolerably resistent and firm. The stomach was healthy, and about a third full of pultaceous lumpy matter smelling strongly of linimentum saponis. The other abdominal organs were healthy. On dissecting the tumour, it was ascertained to be an aneurism formed at the root of the superior mesenteric artery, and partly involving the anterior wall of the descending aorta. It was of an oval shape, with one extremity resting on the vertebras, the other lying immediately below the integuments. Its long diameter measured four and its transverse three inches. On taking off a thin slice on the left of the tumour, so as not to interfere with ihe exit of the mesenteric artery, it was seen to be almost wholly occupied by concentric layers of fibrin, except where a channel, larger near the aorta, but becoming smaller at its distal extremity, allowed a free communication of blood with the efferent vessel, Fig. 423 (University Museum, Prep. 2229.) Microscopic Examination.—Portions of the spinal cord when examined under the microscope, with a power of 250 diameters linear, were everywhere ascertained to consist of broken-up medullary tubes. Many of the varicosities had enlarged and separated, forming round, oval, and variously shaped transparent corpuscles, with double lines, mixed with fragments of the tubes, and numerous molecules, granules, oil globules, and broken-down ganglionic cells. No granular corpuscles were any- where visible. Commentary.—This case was in the Infirmary two years and a half, and during the whole of that time its progress excited unusual interest. We had to do with,—1st, A thoracic aneurism ; 2d, An aneurism of the superior mesenteric artery;* 3d, The treatment of aneurism by Val- salva's method; 4th, Acute passing into chronic pleurisy ; hth, Gradually increasing, and at length complete paraplegia; and 6th, Poisoning by aconite, and the most rapid death by that drug on record. I shall notice the principal facts of his case in succession, point out the difficulties of the diagnosis, the effects of the treatment employed, and state what occurs to me with regard to the mode of his death. The Thoracic Aneurism.—The thoracic aneurism in Smith's case was not suspected during life. On looking back upon the facts observed when he was admitted, I find that, after receiving the injury which pro- duced the disease, he complained of pain in the back, as well as the abdomen. It is also stated that, when admitted into the Infirmary, " the right side of the chest is more resonant on percussion than the left, both in front and behind." These facts were toe vague at the time to enable me to distinguish a thoracic aneurism in addition to the abdominal one, more especially as the respiratory murmurs were normal; there was no rough, expectoration, or other pulmonary lesion. The idea, therefore, of a thoracic aneurism never occurred to me, nor if it had is it likely * For other cases of aneurism of the superior mesenteric artery, see case by Dr. Donald Monro, in "Observations on Aneurism," by the Sydenham Society, p. 130 ; by l>r. Elliotson, in Lancet, August 29, 1835 ; by Dr. Arthur Wilson, Medico-Chir. Transactions, vol. 24 ; by Mr. James Douglas, in Medical Gazette, February, 25, 1842 ; bv Dr. W. Gairdner, in Monthly Journal of Med. Science, January, 1850; by Dr. John Ogle, in Trans, of Patholog. Soc, vol. 8 ; and by Dr. Haldane, in Edinb. Med. Journal, October, 1858. 582 DISEASES OF THE CIRCULATORY SYSTEM. that it could have been confirmed, although now, on looking back, the importance of the facts above stated is apparent, and they prove that such aneurism really existed when he first came into the house. On coin* over the reports which were kept of his progress during the two vears and a half he was in the infirmary. I find it >tated that, on the Oth 0f April, when under the care of Dr. Christison, he " complained of shoot- ing pains in the back, between the shoulders, and down the arms.*' On the '20th of November, in the same year, when under Dr. Alison's care he " complained of a sharp pain under the left clavicle." On both oc- casions the pain was of short duration. I can find no other symptoms which could be attributed to the thoracic aneurism until the L'Mth of January, 1^52, when he was seized with all the symptoms of acute pleurisy. For a long time previously his chest had not been examined, but when, on this occasion, it was percussed, the whole of the left side was found to be dull, both anteriorly and posteriorly. This, as well as all the other symptoms noticed at that time, was ascribed to pleurisv with a large amount of exudation, and on carefully weighing these symp- toms and physical signs, I do not see how we could have arrived at am other conclusion; for a pleurisy did certainly exist, as proved by the friction during life, and by the dense chronic adhesions found after death, although now we can have little doubt that the dulness, increased vocal resonance, and other signs, were for the most part dependent on the aneurismal tumour. Another symptom usually present in thoracic aneurism, was absent, viz., haemoptysis, or bloody sputum. On one occa- sion only was this observed, viz., on February '2d, four days after the pleurisy was established. I remember that it induced me to examine his chest with the utmost care, with a view of discovering if pneumonia also existed; but, as stated iu the report, no crepitation could anywhere be discovered. I am satisfied, from the careful examination at that time, as well as when he first came into the house, that there was no blowing or other abnormal sound in the chest caused by the aneurism. It is not to be wondered at, therefore, that from this period the dulness on the left side of the thorax, unaccompanied with other symptoms, should be referred to chronic pleurisy, rather than to a thoracic aneurism. It mi happened, also, that there was a man in the ward labouring under chronic pleurisy on one side, who presented all the thoracic symptoms and signs which existed in Smith. It appears, therefore, that the detection of the aneurism was almost impossible; for, supposing even that it had been suspected and that attention had been directed to confirm such a theory, I am not aware of any arguments by which it could be supported. An idea, however, that it would be impossible at any time to discover such an aneurism, would be erroneous, and would do discredit to physical dia- gnosis ; for there can be little doubt that had the chest been carefully re-examined—say a short period before the attack of pleurisy—I think it would then have been apparent that a tumour existed in the chest, and if so, that tumour, from its seat and concomitant circumstances, would have been declared to be aneurism low down in the thorax. It was sim- ply because no suspicion of its existence occurred to us, and because no physical examination of the chest was made at that time, that the tumour was not detected during life The Abdominal Aneurism.—When Smith entered the hou-e the ANEURISM. 583 abdominal aneurism was of considerable size. It measured three inches across. Its inferior and lateral margins only could be felt, the superior portions being covered by the ribs. The impression conveyed to me by examining the tumour, however, was that it was about the size of a cocoa-nut. It was prominent, especially when he stood up, and pulsated Btrongly. There can be no doubt that its volume must have undergone considerable diminution ; for, previous to his death, it felt through the integuments about the size of a small hen's egg ;—in some ofthe reports, it is said of a pigeon's egg, and of a walnut. Yet, as you see, it is the size of a large orange, elongated. Its form is a long oval, one extremity of its long axis resting deep upon the vertebrae, the other directed towards the skin. Hence, during life, we could only feel one of its rounded ends. You observe, however, that the whole tumour is dense and resistant,—and on section it presents numerous concentric laminae of coagulated filbrin, with a small canal running through the centre, keeping up the communication between the aorta and the superior mesenteric artery. The man preseuted habitually a jaundiced skin, which was doubtless owing to the pressure of the tumour on the duode- num and biliary ducts. The Paraplegia and Spinal Softening.—He first complained of weak- ness in the lower extremities early in January 1852 ; at the end of that month my period of attendance on the wards ceased. In the report of March 1st, I find it stated that there was decided paralysis of motion in the inferior extremities, while sensation still resulted when they were touched. On April 8th, the paralysis was complete,—that is, volition failed to cause movement in the lower extremities, and stimuli applied to them failed to induce sensation. Involuntary movements, however, occurred, consisting of twitchings and startings, but he never had pain in the limbs. In cases of myelitis the usual symptoms are, pricking and tingling iu the soles of the feet. These symptoms were absent, and the reason of this may, I think, be found in the nature of the softening in the spinal cord. It contained no granular cells, the result of exudation, and its transformation into fatty granules; but the tubular substance ofthe cord was broken down, forming round and oval fragments of the tubes. Hence it was a mechanical softening, the result of gradual pressure merely. These distinctions have not been hitherto sufficiently attended to in pathology. (See p. 310.) You will observe that the aneurismal tumour commenced pressing on the left side, and from before backwards, and the symptoms indicate that weakness was felt in the left inferior extremity before the right one was affected,—and that motion was paralysed first, sensation last. Treatment by Valsalva's Method.-—A short time previous to the ad- mission of Smith, I treated another case of abdominal aneurism by the method of Valsalva, for a period of forty days,—at the expiration of which time, he walked out of the house, with little assistance, to the nearest cab-stand, a distance of nearly 2o0 vards, and left the city.* In the case of Smith, therefore, the bleedings were more frequently repeated, and greater in amount, while the diet was even more dimin- ished; and yet, after nearly a month's treatment, the pulse was of such * See Monthly Journal, February 1850, p. 169. 584 DISEASES OF THE CIRCULATORY SYSTEM. good strength, that I ordered venesection to syncope—an effect that was not produced after the loss of twenty-six ounces of blood—so that the clerk, afraid to proceed farther, bound up the arm. Three days after- wards, twenty-eight ounces of blood were removed, with the effect of only producing a feeling of faintness. Similar bleedings were practised at no distant intervals, besides numerous applications of leeches, and the restricted diet; and yet the report of 21st April 1850 is, " that he was bled to thirty four ounces, at bis urgent request, insisting that he felt nothing, until he fell back in a state of syncope." I am induced to sup- pose, therefore, that in this case, as in the preceding one, the treatment had not been carried out to its full extent. The nurse, indeed, now informs me. that perhaps during the first two months his diet was really limited; but she thinks so simply because, at that period, he suffered great pain and seemed very anxious to follow the advice given to him. Subsequently, there is every reason to suppose that he obtained food from his companions, or from some other source. I find from the re- ports, indeed, that whilst his diet was still nominally at a very reduced amount, up to July, he was at the same time walking about with con- siderable vigour. From my attempts at carrying out Valsalva's treat- ment in these two cases, I conclude that it is impossible to practise it on patients in an open ward, or indeed under any circumstances, without a degree of surveillance that it would be very difficult to obtain. The good effects of the treatment, notwithstanding its imperfect nature, were so evident as to strike all who witnessed it, and to cause the patient continually to request that he might be bled. In fact, after every general bleeding, the dragging pains, and other uneasy sensations, he experienced in the abdomen, invariably left him, and he enjoyed longer or shorter periods of perfect ease ; then, as the pain gradually returned, and it became unbearable, he was again relieved by bleeding; and so on. During the progress of his case, also, it was observed that the abdominal tumour gradually diminished in size, and became harder. In October, the tumour was ascertained by Dr. Christison to be some- what movable ; but in the following December, when I examined it, it was again stationary. During the whole of 1851 he enjoyed compara- tive comfort,—occasionally, however, feeling abdominal pain, which was relieved by leeches or bleeding. At the beginning of 1852, the general opinion of all who examined him was, that, on the whole, this case was a remarkable example of the good effects of Valsalva's treatment. Then, however, the paraplegia came on, indicating that the disease was really not conquered, but, by its pressure backwards, was affecting the spinal cord. Then came the attack of pleurisy and the paraplegia ; and from this period it was evident the disease would terminate fatally. The examination of the body after death was, in this case, not only important, as determining the nature of the aneurism, and iu a diagnos- tic point of view ; but it served, in my opinion, to point out what value ought to be attributed to Valsalva's treatment. It affords an example of a wide generalisation to which the cultivators of rational medicine have been gradually tending,—viz., that not only is the examination ot the body after death necessary for diagnosis and pathology, but that it is essential, in order that we may properly appreciate therapeutics, and the utility of different plans of treatment. Let us suppose, for instance, that ANEURISM. 585 this man had died at the commencement of 1852 from the attack of pleurisy, and that, as so often happens, we had been refused permission to open the body, my conviction is, that under such circumstances this case would have been recorded in the annals of medicine as a successful instance of cure by the method of Valsalva. But now, when all the facts are before us, it is evident that the diminution of the abdominal swelling was owing to the increase of the thoracic one; and that, as the force iif the current of blood became lessened by the enlargement of the aneurismal dilatation above, so the flow of blood was retarded in the tumour below. In consequence, the concentric depositions of fibrin, the lessened size of the abdominal swelling, and the more permanent relief of pain, instead of being attributable to the treatment as we had supposed, must now be more rationally ascribed to the increase of a thoracic aneurism, not detected during life, which had produced these results mechanically, and altogether independently of art. The treatment of internal aneurisms by the method of Valsalva, has for some time been discouraged in this country, on the ground that it gives rise to a general irritability, and to symptoms of a distressing nature, which are often intolerable; whilst, on the other hand, it is seldom attended by a permanently good effect. In the case before us, as well as in that I formerly treated, no unpleasant symptoms could fairly be ascribed to the practice; but, on the contrary, it produced (especially the bleedings) well-marked relief. The question of the permanency of these good effects is, I admit, in no way supported by my experience. But another important practical point, namely, the temporary relief which bleeding causes, without arresting the progress of organic maladies, here meets with an excellent illustration. Poisoning by Aconite,—The facts which I have been able to make out regarding the poisoning of this man are as follows :—On Monday, May 81st, about 11 o'clock in the morning, the attention of Mr. Broadbeut (non-resident clerk) and of Dr. Murchison (resident clerk), both of whom were at the time iu the ward, was directed to Smith by a groan or cry. He was then observed to be sitting up in bed, leaning forward, aud groaning like a man labouring under colic pains. Mr. Broadbeut, who was nearest at the time, went to his bedside, and asked, " What is the matter ? " Smith made no immediate reply, but continued to groan, and moved his arms in a feeble manner, and it was noticed by Mr. B. that his hands dropped considerably when the arms were raised. He then tried to reach the spit-box, but not being able to do so, it was given to him, and he seized it, raised it to his mouth, and spat into it. He then said, with short pauses between his words, " Is there anything wrong with my face ?—it is very painful; what medicine have I been taking ?" On being asked to point out the bottle on the shelf, he did so, saying, " That little bottle there." On looking at it, Mr. Broadbent saw by the label that it was a liniment, composed of Tr. Aconiti, 3 ss.; Liu. Saponis c. Opio, 3 jss. Dr. Murchison, on being informed what had happened, also went to Smith, found him pulseless, and on letting go his arm observed that it fell down powerless at his side. Smith then repeated more than once, " Can nothing be done for mc ?—What can you do for me ?—Can you get me a vomit ? " etc. An emetic of sul- phate of zinc was immediately sent for, and it was further observed that 586 DISEASES OF THE CIRCULATORY SYSTEM. the pupils had undergone no marked change, that there was no lividitv of the lips or other part of the countenance, that no impulse could be felt in the cardiac region, and that the respiration was more slow and laborious than usual. Dr. Murchison now left the patient to get a stomach-pump, and Mr. Broadbent saw Smith retch twice, as if endea- vouring voluntarily to vomit. He therefore went into the side-room to get a feather, or some object to tickle his fauces with, but was immedi- ately summoned back by the intelligence that Smith was worse. On re- turning to the bed-side he found that the patient had fallen on his bed, the head thrown back, face and lips remarkably pale, a little saliva running from the corner of the mouth, the respirations occurring at long intervals with gasping, the pupils neither dilated nor contracted, and the eyelids paralysed, when opened remaining fixed, and not contracting on blowing into the eye. He was now insensible, and consequently the emetic, which at this time arrived, could not be given. About a minute after, Dr. Murchison, on hurrying back with the stomach-pump, found him dead. Notwithstanding, more than a pint of semi-pultaceous matter was immediately drawn off from the stomach, smelling strongly of the liniment, and artificial respiration was kept up in vain for five minutes. The period that elapsed from first noticing Smith's cry or groan until Dr. Murchison's return, when he was dead, is differently estimated by the gentlemen concerned at five aud seven minutes. The liniment con- sisted originally of Liniment. Sapon. c. Opio, ~ jss, Tr. Aconiti, § ss, and it is believed that the whole of this quantity (viz. two fluid ounces) was in the bottle when Smith began to drink it. There were found in the bottle afterwards five drachms remaining, so that the presumption is, that he swallowed three drachms of laudanum, and upwards of two drachms of tincture of aconite. Whether Smith's death arose from accident, or whether he committed suicide, is not likely ever to be known. Those who knew him best in the ward, as well as the nurse, are of the latter opinion, based principally on the character of the man, which was such as to prevent his mistaking a liniment for a draught. It seems, also, that no one was more habitu- ally careful as to the medicines he took,—that the liniment was not ordered for him; that he took it from a patient in a neighbouring ward, and kept it on his shelf for some days ; and lastly, that since the paraple- gia had become complete, he had been unusually despondent and morose. With regard to the phenomena produced, it is most likely that, imme- diately after swallowing the poison, he experienced those violent tingluig and stinging sensations in the mouth and fauces which aconite produces, and hence the pain complained of in his face. . Being already paraplegic, nothing is known as to how far the poison affected the muscles of the lower extremities; but it is evident that, whilst the intelligence remain- ed perfect, the arms became weak, then powerless. Subsequently, he could not support himself iu the sitting posture; and, on his falling back, the muscles of the face and of respiration were paralysed, and he died asphyxiated. Previous to this, however, a powerful sedative effect had been produced on the heart, for when first noticed he was pulseless, and shortly after, no impulse could be felt in the cardiac region. According to Dr. Christison, the least variable symptoms of poisoning by aconite in the human subject are, " first numbness, prickling, and ANEURISM. 587 impaired sensibility of the skin, impaired or annihilated vision, deafness, and vertigo—also, frothing of the mouth, constriction at the throat, false sensations of weight or enlargement in various parts of the body,— great muscular feebleness and tremor, loss of voice, and laborious breath- in^—distressing sense of sinking, and impending death,—a small, feeble, irregular, and gradually-vanishing pulse,—cold clammy sweat, and pale bloodless features,—together with perfect possession of the mental facul- ties, and no tendency to stupor or drowsiness;—finally, sudden death at last, as from haemorrhage, and generally in a period varying from an hour and a half to eight hours."* Although in this case many of the symptoms just mentioned were not noticed, it must be evident that the leading ones, indicative of the physiological action of the drug, were observed. AVhen the large dose of the poison is considered, and the great rapidity of its effects, it may be easily understood how the minor symptoms, and especially those having reference to the sensations of the patient, were not ascertained, if indeed they really existed. Dr. Fleming considers that aconite may cause death, '' first, by pro- ducing a powerful sedative impression on the nervous system ; second, by paralysing the muscles of respiration; and third, by producing Byncope." He observes. " that the second mode of death has never been recognised in man; the quantity of the poison taken in no case having been sufficient to exert such an effect on the nervous and muscular systems, as is necessary to induce it. 'f The case of Smith, indeed, is the only one of this description, so far as I am aware, that has ever occurred, in which the dose of poison was so large, and the death so rapid. It is difficult to separate the effects of syncope from those of asphyxia in such a case, as the first condition must induce the other. Both were apparently combined. It is also difficult to determine how far the effects on respiration were occasioned by paralysis, creeping from below upwards, as in the case of Gow, formerly given (Case XLIV., p. 413). There are some facts, however, noticed by Dr. Christison, which lend support to such a doctrine; and it will be observed that paralysis of the hands and arms preceded that of the muscles of the back and face in the case of Smith. The general diagnosis of thoracic aneurisms has always been con- sidered a matter of great difficulty. When, indeed, a tumour with a distinct impulse is perceptible, we, in the majority of cases, know with what disease we have to do. But even here occasional errors by men of the greatest experience have sufficiently proved that the art of detecting these tumours with exactitude is imperfect. Again, when aneurismal tumours are.seated at the upper part of the thorax, it is important to determine whether they arise from the aorta, or from the large vessels coming from it, and if the latter, which vessel is affected. Then aneurisms originating from the upper part of the descending aorta press upon neighbouring nerves, as the superior and inferior laryngeal and pharyngeal branches of the pneumo-gastric, giving rise to various symptoms; or they compress the larynx, trachea, bronchus, oesophagus, or the lung itself; and so occasion laryngeal, oesophageal, or pulmonary * On Poisons. Fourth edition. P. 871. t An Inquiry into the Physiological and Medicinal Properties of the Aconitum Xapellus. Edinburgh, 1845. P. 42. 588 DISEASES OF THE CIRCULATORY SYSTEM. symptoms. Lastly, when deep in the thorax, their progress is often latent. Hence the signs and symptoms of thoracic aneurisms vary,__ 1st, According to their seat; 2dly, According tj the size of the tumour and its pressure upon neighbouring parts ; 3dly, On the character ofthe aneurism, its formation, and state ofthe vessel. The means at our disposal for detecting these aneurisms are,—1st, Percussion ; 2d, Auscultation ; 3d, Palpation; 4th, Symptoms. 1. Percussion.—That the situation and size ofthe aorta can be accu- rately determined by percussion, was first proved by Piorry.* I have frequently succeeded, in favourable cases, in marking out on the chest the size of this vessel. To do so with accuracy, it is first necessary to limit the margins of the heart in the manner previously explained (sec p. 40), and then carrying the pleximeter upwards in the course of the aorta, and over the sternum, the dulness of the vessel when compared with the resonance of the lung on both sides, may be made very appa- rent. In the same manner the extent of saccular, or simple aneurisms by dilatation, may frequently be determined with accuracy when seated in the ascending or transverse arch. In such cases, however, the exist. ence of pain often renders percussion impossible, and at all times it should be conducted with great gentleness. When an aneurism is seated in the descending thoracic aorta, its limitation is more difficult, as we have then to percuss through the lung anteriorly. But careful manipu- lation, and varying the force of the blow, together with percussion pos- teriorly, will frequently enable us to determine the position and size of the swelling. If, on the other hand, the aneurism be small and deep- seated, while the lungs are healthy, and if, at the same time, no suspi- cion of the disease be entertained by the practitioner, he is very likely to overlook the importance of slight dulness on one side of the chest. 2. Auscultation.—There may be no sounds heard over an aneurism, and when present they may be either single or double. Considerable discussion has taken place, whether, in the latter case, the second sound originates in the tumour, or is propagated along the vessel from the heart. This is a theoretical point which is not yet decided. Whether single or double, they must be judged of according to their character and seat. With regard to their character, they may be,—1st, Soft and blowing; 2d, Harsh and rough (in the latter case the vessel is generally diseased, and its lining membrane more or less atheromatous or calca- reous) ; 3d, There may be a peculiar clink, or abrupt harsh resonance, approaching towards, but never reaching, a metallic sound. It is gene- rally heard when a saccular aneurism, free from coagula, is present, with a small opening, having thin and elastic margins. With respect to the seat of tliese sounds, when near the heart, they are generally synchro- nous with those of that organ, and their discrimination is very difficult. When situated in the arch of the aorta, there is a distinct separate source of sound. This latter can only be successfully studied by care- fully comparing the moment of impulse of the heart with that of the tumour, as well as the character and intensity of the cardiac and aneu- rismal sounds. You should carry the stethoscope carefully from one to the other, and observe the diminution and increase of the murmurs, as * De l'Examen Plessimetrique de l'Aorta, etc. 1840. ANEURISM. 589 you lengthen or shorten the distance from the origin of the sounds. It is necessary also to study the direction in which the sounds are propa- gated, those of a blowing or rasping character having a tendency to pass in the direction of the current of blood. Hence in aneurisms of the innominata, the murmur is prolonged in the course of the right carotid and axillary arteries, while those of the aortic arch, and especially its descending portion, may be heard in the aorta, on applying the ear to the back. In this manner careful and repeated auscultation, conjoined with percussion, will enable you, in the majority of cases, to determine exactly, not only the existence and seat of the aneurism, but in many cases its form and structure. 3. Palpation.—When an aneurism points externally, a tumour and an expansive impulse can be felt by the hand. The position of the tumour varies according to the part of the aorta or the large vessel from which it originates. Thus saccular aneurisms immediately above the aortic valves pass downwards. When situated in the innominata, they manifest themselves above the clavicle on the right side. If originating in the transverse portion of the arch, there is often no external tumour; and when it does occur, it generally appears on the left side of the sternum, above or below the sterno-clavicular arti- culation. Aneurisms lower down in the arch are most common in the left thoracic cavity. These rules are by no means absolute ; for, although an aneurismal tumour for the most part tends to enlarge in the direction in which the impulse, from the course of blood, is applied—this, in seve- ral cases, cannot be determined in the living body. The impulse of the tumour is synchronous with, or follows the systole of the heart. Occasionally there is no impulse, a circumstance most frequently observed when the tumour does not present externally, and is only determined by percussion. The puke of arteries connected with the aneurism may be weakened or retarded. The pulse at both wrists should be always carefully studied; for if one be weaker than the other, it is clear that an interruption exists in the current of the blood in the axillary artery. This may arise from two causes—1st, From the vessel being involved in the tumour; 2d. From its being compressed by it externally. The former condition exists most com- monly when there is aueurism of the innominata, when the weaker pulse will be on the right side. In aneurisms of the arch, on the other hand, the feebler pulse is usually on the left side. The retardation of the pulse, when it occurs, is owing to causes very similar to those which affect its strength. 4. The symptoms, which, are present in cases of thoracic aneurism, vary according to the size of the tumour, and the parts on wi. ich it presses. When seated at the upper part of the chest, it may, by pressure on the larynx, produce alteration of the voice, more or less cough, and stridulous respiration ; by affecting the branches of the eighth pair, occasion increase or diminution of their special functions; impede deglutition by constricting the oesophagus ; or modify the respiratory murmur by pressing on the trachea or larger bronchi. Occasionally there is a crepitating murmur in the lung, with many of the signs an(j symptoms of pneumonia, for which it has often been mistaken, including rusty sputum, dulness, and increased vocal reso- 590 DISEASES OF THE CIRCULATORY SYSTEM. nance. Pressure of the tumour on the axillary vessels and nerves may induce more or less oedema of the extremities, and paralysis more or less complete. Sometimes there are dull, gnawing, or lancinating pains iu various parts of the chest'; but nothing is more remarkable than the size and formidable nature of some aneurisms which have caused little pain. Occasionally there is a feeling of oppression and constric- tion—dyspnoea with or without exertion, and haemoptysis to a greater or less extent. The combination of the results obtained by percussion, auscultation, palpation, and vascular impulse, and the functional symptoms, vary infinitely in different cases, and their careful detection, combined with a knowledge of physiology, will in the majority of cases enable us to form a correct opinion as to the nature of the disease. It must not bo forgotten, however, that there are some cases which have been so obscure as to baffle the efforts of the most able physicians; and that, generally speaking, the deeper the aneurism the greater the difficulty of detecting its exact nature, and the complications connected with it. It is also well ascertained that the symptoms may be simulated by a tumour situated outside and upon the vessel ; and occasional mistakes, made by the most experienced surgeons—men who, during their profes- sional lives, have carefully examined a large number of these tumours— prove the excessive difficulty of detecting aneurisms, even when situated in the limbs or in the neck. How much more difficult must be the appreciation of these symptoms, when the aneurisms are below the sternum or clavicles, not to speak of their occurrence deep in the thorax. Yet these very symptoms, together with the results obtained by percus- sion and auscultation, enable the physician frequently to overcome the greatest difficulties, and to demonstrate what may properly be called the greatest triumph of his art. The physical phenomena most distinctive of an abdominal aneurism are a swelling more or less defined, an expansive impulse on applying the hand, and a bellows murmur synchronous with, or immediately following the heart's systole on applying the stethoscope. This bel- lows murmur is generally loudest over the tumour, and is propagated down the aorta—although, when immediately below the diaphragm, it may be confounded with the first sound of the heart. The symptoms are very various, consisting of dragging, or other pain, more or less acute and prolonged, owing to pressure and stretching of the neigh- bouring nerves, together with functional disturbance of one or more of the abdominal viscera. Various cases on record, therefore, have presented a train of very anomalous symptoms, and at various times been considered as different diseases by medical practitioners. A com- plete re-investigation of the symptoms and signs of abdominal aneurisms is much required. This is a task, however, which will require a thorough knowledge of all that is now known of physical diagnosis and morbid anatomy, combined with great powers of observation, and such opportunities as fall to the lot of few individual members of the profession. Hie pathologg of aneurisms is sufficiently treated of under the heads of "Vascular Growths," p. 181, and of " Fatty Degeneration of Blood- ANEURISM. 591 vessels," p. 220. The latter, by inducing weakness or want of elasticity in the vascular wall, permits of its dilatation by the successive impulses of the blood on the enfeebled tissue. Occasionally the inner coat of the vessel is lacerated by external violence, or by sudden exertions when a similar morbid condition gives rise to like results. As the aneurismal tumour enlarges, it presses more and more upon neighbour- ing parts, giving rise to atrophy, ulceration, and interstitial absorption of parts, and occasioning a great variety of symptoms, according to the situation of the tumour, the organs and tissues influenced by it and the amount and kind of pressure exerted on the textures concerned in the functions of nutrition and innervation. Tlie treatment of aneurism may be curative or palliative. The for- mer is carried out by the surgeon. The general treatment by Valsalva's method has already been alluded to (p. 583), and is now seldom prac- tised. All the physician can do is to palliate symptoms, diminish the chances of rupture, and favour the obliteration of the enlarged vessel; to this end enjoining quietude, especially avoidance of sudden or long- sustained exertion. Occasional local and even general bleeding, topical applications of ice or warmth as may be found most useful, and seda- tives, tend to diminish pain. Constipation should be carefully guarded against, and healthy nutrition secured by attention to the various animal functions, gentle exercise, etc., etc. SECTION VII. DISEASES OF THE RESPIRATORY SYSTEM. In this, as in the preceding section, it will be well to introduce the study of individual diseases by a short enumeration of the general rules established for the diagnosis of lesions of the Respiratory System. They are— 1. A friction murmur heard over the pulmonary organs indicates pleuritic exudation. 2. Moist or dry rales, without dulness on percussion, or increased vocal resonance, indicate bronchitis, with or without fluid in the bronchi! 3. Dry rales accompanying prolonged expiration, with unusual reso- nance on percussion, indicate emphysema. 4. A moist rale at the base of the lung, with dulness on percussion and increased vocal resonance, indicates pneumonia. 5. Harshness of the inspiratory murmur, prolonged expiration, and increased vocal resonance confined to the apex of the lung, indicate incipient phthisis 6. Moist rales, with dulness on percussion, and increased vocal reso- nance at the apex of the lung, indicate either advanced phthisis or pneumonia. The latter lesion commencing at or confined to the apex is rare, and hence these signs are diagnostic of phthisis. 7. Circumscribed bronchophony or pectoriloquy, with cavernous dry or moist rale, indicates a cavity. This may be dependent on tubercular ulceration, a gangrenous abscess, or a bronchial dilatation. The first is generally at the apex, and the two last about the centre of the lung. 8. Total absence of respiration ^indicates a collection of fluid or of air in the pleural cavity. In the former case there is diffused dulness, and in the latter diffused resonance on percussion. 9. Marked permanent dulness, with increased vocal resonance, and diminution or absence of respiration, may depend on chronic pleurisy, on thoracic aneurism, or on a cancerous tumour of the lung. The dia- gnosis between these lesions must be determined by a careful considera- tion of the concomitant signs and symptoms. The general diagnostic indications, now noticed as being derivable LARYNGITIS. 593 from physical signs, admit of several exceptions, which, however, it would be difficult to systematize, and which can only be known from a careful study of individual cases. It is important also to remember that these signs should never be relied on alone, but be invariably combined with a minute observation of all the concomitant symptoms. Thus the signs indicative of incipient phthisis may be induced by a chronic pleurisy confined to the apex, or by retrograde tubercle. In either case, the previous history, age, etc., may enable you to determine the nature of the lesion. Again, it may be impossible at the moment of examination to distinguish between two diseases. For instance, there may be general fever, more or less embarrassment of the respira- tion, and pain in the side, accompanied with no dulness on percussion, but with a decided abnormal murmur, difficult to characterize, as being a fine moist rattle, or a gentle friction sound. Under such circumstances, the progress of the case will soon relieve you from any doubt as to whether a pleurisy or a pneumonia be present. The altera- tions which occur in the physical signs during the progress of the case also will indicate to the pathologist the changes which occur in the physical conditions and morbid lesions of the lungs. Thus the fugi- tive dry or mucous rales heard during a bronchitis, point out the occasional constrictions and obstructions in the bronchial tubes. The fine crepitation of incipient pneumonia, passing into absence of respira- tion, aud this again into crepitation, will satisfy him as to effusion, solid coagulation, and subsequent softening of the exudation. Iu the same way, by an accurate appreciation of physical signs, and a thorough knowledge of morbid anatomy, the practised physician can tell the abnormal conditions produced by phthisis, pleurisy, etc., and judge from the symptoms the effect of these upon the constitution, with a degree of accuracy that to the tyro must appear to be marvellous. All such knowledge can only be acquired by constant examination of the patient on the one hand, and by a careful study of morbid anatomy in the pathological theatre on the other. LARYNGITIS. Cask CXIV.*—Acute Laryngitis—Treated by Topical Applications—Recovery. History.—Alexander Flint, asL 27, a salesman—admitted February 17, 1851, suffered from extensive lupus of the face, severe diarrhoea, Bright's disease, and scro- fulous caries of the left knee-joint. Under appropriate treatment the diarrhoea ceased, the lupus was cured, and the disease of the kidney much alleviated. Symptom, of the Attack.—On the 2ith of May, about three months after admis-ion, he first complained of dry cough and slight pain in the throat, with diffi- culty of deglutition. These symptoms were increased on the following day ; and on examination, the mouth and fauces were unusually red, with minute florid eleva- tions scattered over the mucous surface. Notwithstanding the application of leeches, and sponging the fauces with a solution of the nitrate of silver, the laryngitis pro- gressed. * Reported bv Mr. W. M. Calder, Clinical Clerk. 38 594 DISEASES OF THE RESPIRATORY SYSTEM. Progress of the Case.—On the 14th of June the pain and difficultv of deglu- tition had increased, and his voice had become indistinct and hoarse. The couzh also continued, but was now attended with a difficult expectoration of muco-purulent matter. On the 30th of June, notwithstanding the assiduous use of astringent gargles, occasional sponging of the fauces with solution of nitrate of silver and the application of leeches, he was evidently worse, and he could only speak in a whisper July 6th.—To-day Dr. Horace Green, of New York, who went round the wards with Dr. Bennett, stated that this was a remarkably good example of what he had named follicular disease, affecting the larynx. He passed the sponge, saturated with a solution of nitrate of silver ( 3 ij to r i of water), through the larynx into the trachea. The patient could not take a breath for some seconds afterwards, and described the sensation as like that produced by a piece of food " passing down the wrong way, and causing choking." The immediate effect of the operation was decided improvement of the voice, and more ease in deglutition. From this time his symptoms gradually left him. On the 10th, the sponge was again passed into the larynx by Dr. Bennett and produced the same sense of temporary suffocation ; but immediately afterwards he spoke with perfect clearness of voice. The application was made every second day until the 16th, when all the laryngeal symptoms had disappeared, the voice was normal, and there was no cough, expectoration, pain, or difficulty of deglutition. He now left the house ; the disease in the joint had made considerable progress, but the renal disorder was much alleviated. Case CXV.*—Chronic Laryngitis—Topical Applications—Recovery. History.—Helen Guthrie, aat. 24, married, a fisherwoman—admitted July 4th, 1851. Four months ago was seized with a cough, attended with hoarseness of the voice, dryness of the throat, painful deglutition, and pain in the larynx, which symp- toms have continued with greater or less intensity up to the period of admission. Latterly, there has been considerable expectoration of purulent matter, often tinged with blood. Symptoms on Admission.—On admission, she complains of cough coming on in paroxysms, dryness in the throat, and pain in the larynx, voice cracked and occa- sionally absent. There is no difficulty in swallowing, but copious expectoration of frothy mucus. Can inspire without difficulty. Percussion over chest elicits nothing abnormal. On auscultation, the inspiratory murmur is harsh over superior third of chest on both sides. Over larynx and trachea there is heard a dry snoring sound. On examining the fauces, red patches were observable here and there, with slight erosion on the left side. The fauces and epiglottis were sponged with a solution of nitrate of silver ( 3 j to § j of water). Progress of the Case.—The application was repeated on the following day, and the voice was evidently improved. On the 6th, the sponge, saturated with the solu- tion, was passed into the larynx by Dr. Horace Green, of New York, and produced no feeling of suffocation whatever. It was passed afterwards every day by Dr. Bennett till the 14th, when she left the house, all the laryngeal symptoms having disappeared, and the voice nearly restored to its proper tone. Commentary.—-The two cases above recorded point out to you in a very marked manner the great advantage to be derived from the method of local application to the larynx, introduced by Dr. Horace Green, of New York. This practice consists in the direct application of a solution * Reported by Mr. D. 0. Hoile, Clinical Clerk. LARYNGITIS. 595 of nitrate of silver to the interior of the larynx and trachea, by means of a bent whalebone probe, with a piece of sponge fastened to its extre- mity. -Numerous attempts had been made, with more or less success, bv Sir'C Bell, Mr. Vance, Mr. Cusack, and MM. Trousseau and Belloc, to carry this practice into effect, and the results obtained, even by their imperfect efforts, exhibited the great advantages whbh were to be derived from it in the treatment of laryngeal diseases. Now, thanks to Dr. Green, we can with safety apply various solutions directly to the parts affected, and the two cases you have observed must convince you of the benefit which patients so treated may obtain. In Caso CXIV. you have observed the progress of a tolerably acute case of laryngitis from its commencement to its termination,—the distressing symptoms produced, and the loss of voice occasioned. You have remarked, I trust, the gradual increase of the disorder, from its commencement on the 24th ot 31 ay until the 6th of July, when you saw Dr. Green himself pass the sponge into the larynx, and the immediate effect it occasioned. Lastly, from that moment you saw the case get better, and terminate in perfect cure eight days afterwards. No stronger evidence could be offered you in any single case of the benefit to be derived from a local application, especially when it is considered that the usual treatment had been actively employed, consisting of leeches externally, gargles, and the application of a strong solution of nitrate of silver to the fauces, pharynx, and epiglottis without any benefit. It was only when the application was made directly to the part affected that good was obtained. The second case, though more chronic, and though she went out before a perfect cure was obtained, is also calculated to impress upon you the value of this treatment. The instruments to be employed are, first, a tongue depressor, with a bent handle, such as I now show you, by means of which the tongue can be firmly pressed down, so as to expose the whole of the fauces, and the upper edge of the epiglottis. In doing this, some patients experience no inconvenience, whilst in others there is such excessive irritability, that spasmodic cough or even vomiting is occasioned, which prevents the pos- sibility of seeing the epiglottis. Secondly, a whalebone probang, about ten inches long, having at its extremity a round piece of the finest sponge, about the size of a gun or pistol bullet. The probang, towards the extremity, must be bent iu a curve, which, according to Dr. Green, ought to form the arc of one quarter of a circle whose diameter is four inches. Sometimes the curve must be altered to suit particular cases; and when it is thought necessary to pass it into the trachea, the curve must be considerably less. It is important that the sponge be fine, and capable of imbibing a considerable quantity of fluid; that it be sewn firmly to the extremity of the whalebone, and that this last should not be cut in the form of a bulb, but tapered as much as is consistent with firmness. The solutions of the nitrate of silver which will be found most useful are of^ two strengths. One is formed of 3ij aud the other 3j of the i\>tallized salt to an ounce of distilled water. On some occasions a solution of the sulphate of copper has been found beneficial, and it is very possible that as our experience of this kind of treatment extends, tbe application of other substances in solution may be found capable of 596 DISEASES OF THE RESPIRATORY SYSTEM. meeting particular indications. Some have used Tr. of Iodine, others solutions of various salts, and Dr. Scott Alison, in cases of great irrita- bility, has recommended olive oil. The method of introducing the sponge which I have found most suc- cessful, is as follows :—The patient being seated in a chair and exposed to a good light, you should stand on his right side, and depress the tongue with the depressor held in the left hand. Holding the probang in the right hand, the sponge having been saturated in the solution, you pass it carefully over the upper surface of the instrument, exactly in the median plane, until it is above or immediately behind the epiglottis. You now tell the patient to inspire, and as he does so, you drag the tongue slightly forwards with the depressor, and thrust the probang downwards and forwards by a movement which causes you to elevate the right arm, and brings your hand almost in contact with the patient's face. This operation requires more dexterity than may at first be sup- posed. The rima glottidis is narrow, and unless the sponge come fairly down upon it, it readily slips into the oesophagus. Its passage into the proper channel may be determined by the sensation of overcoming a constriction, which you yourself experience when the sponge is momentarily embraced by the rima, as well as by the momentary spasm it occasions in the patient, or the harsh expiration which follows,— symptoms which are more marked according to the sensibility of the parts. If the probang be properly prepared, and the operation well per- formed, the actions which take place are as follows :—1st, The sponge, saturated with the solution, is rapidly thrust through the rima into the larynx, and frequently into the trachea; for if the distance of the pro- bang be measured from that portion of it. which comes in contact with the lips, the extent it has been thrust downwards can be pretty accu- rately determined. I am persuaded that on many occasious I have passed it pretty deep into the trachea, not only from the length of the probang which has disappeared, but also from the sensations of the patient, although this may be thought by some a fallacious method of determining the point. In this first part of the operation, the rima glot- tidis is, as it were, taken by surprise, and the sponge enters, if the right direction be given to it, without difficulty. But 2d, the rima glottidis immediately contracts by reflex action, so that on withdrawing the instrument you feel the constriction. This also squeezes out the solution, which is diffused over the laryngeal and tracheal mucous membrane. Now, if the sponge be a fine one, it will be found capable of holding about 3 ss of fluid, the effect of which upon the secretions and mucous surface almost always produces temporary relief to the symptoms, and strengthens the tone of the voice,—results at once apparent after the momentary spasm has abated. 3d, The action of the nitrate of silver solution is not that of a stimulant, but rather that of a calmative or sedative. It acts chemically on the mucus, pus, or other albuminous fluids it comes in contact with, throws down a copious white precipitate. in the form a of molecular membrane, which defends for a time the tender mucous surface or irritable ulcer, and leaves the passage free for the acts of respiration. Hence arises the feeling of relief almost always occasioned, with that diminution of irritability in the parts which is so LARYNGITIS. 597 favourable to cure, and why it is that strong solutions of the salt are much more efficacious than weak ones. It may be easily conceived that such (rood effects must be more or less advantageous in almost all the diseases that affect parts so sensitive, from whatever cause they may arise; and that this treatment is not only adapted to one of the diseases of the larynx, but, like all important remedies, meets a general indication of which the judicious practitioner will know how to avail himself. The mucous membrane of the larynx consists of ciliated epithelium externally, a basement layer below this, and areolar tissue internally, richly supplied with blood-vessels. Scattered over its surface are numerous fol- licles, which secrete mucus. It is liable to the same structural altera- tions as all other similar membranes, which may be divided into—1st, Exu- dation, into the areolar tissue between the basement membrane and epi- thelium, or upon the external surface; 2d, Abrasions or desquamations of the epithelial layer; 3d, Ulcerations extending more or less deep into the areolar tissue; and 4th, Obstruction, swelling, and subsequent ulcer- ation of the mucous follicles, a lesion particularly described by Dr. Hor- ace Green, and denominated by him " follicular disease of the air pass- ages." These different lesions may be more or less complicated with each other, and will vary in intensity according to the rapidity of their pro- gress, and the extent to which the mucous membrane is implicated. Some- times the exudation is thrown out quickly and infiltrates the textures, as in oedema glottidis, or in malignant angina. At other times it is poured out on the surface as in croup. More frequently it is partial, occasion- ing subsequent abrasion or ulceration, and the acute disease becomes chronic. Perhaps the most common form it assumes is when it is chronic from the commencement, sometimes dependent on atmospheric changes, at other times on repeated attacks of " cold ;" iu a third class dependent on too much straining of voice, as occurs in public speakers, clergymen, singers, etc., and occasionally it is connected with some general consti- tutional disorder, as syphilis, tuberculosis, or some form of cancer. All these forms of laryngeal disease may be further associated with similar lesions of the fauces, tonsils, uvulae, and pharynx. The symptoms will of course vary according to these different circum- stances. The acute forms are accompanied with general fever, consider- able local pain, more or less obstruction to deglutition and respiration, and loss or alteration in the character of the voice. As a general rule, it may be said that lesions of the fauces, tonsils, and neighbouring parts, are indicated by greater or less difficulty or uneasiness in swallowing, whilst the laryngeal disorder is evinced by changes in the character or power of sustaining the voice. Then, as a general result of the local irritation, spasmodic action is evinced, and we have cough, at first dry, but afterwards attended with mucous or purulent expectoration, and not unfrequently with discharge of blood. Elongation of the uvula may produce these effects. It has been lately supposed that hooping-cough is only an obscure form of laryngeal disease. In the more acute and extensive cases of exudative laryngitis, the spasms are more violent and prolonged, aud the greatest caution is necessary in watching persons so affected, lest, from sudden and continued closure of the glottis, fatal asphyxia be induced. The following case is very instructive in this point of view. 598 DISEASES OF THE RESPIRATORY SYSTEM. Case CXVL*—Acute Oedema of the Glottis—Chronic Pharyngitis and Laryngitis- Sudden. Death. History.—Frances Nichol, se.t. 25, a shoe-binder, married—was admitted in the evening of February 26, 1851, complaining of sore throat, but breathing easily, and otherwise presenting no urgent symptoms. She has suffered from cough upwards of four years, had secondary syphilis, and ulcerations in the throat for twelve months. Symptoms on Admission.—At the visit I found her breathing to be laborious and noisy; cough frequent; expectoration difficult, with frothy sputum tinged with blood • countenance anxious ; lips livid; pulse 130, small and soft; cannot speak, nor can any one give any account of her. On examining the mouth and fauces, the mucous mem- brane was seen to be covered with tenacious muco-purulent matter. The soft palate is perforated by ulcerations the size of a pea in three places; there is another ulcer the size of a fourpenny piece on the roof of the mouth. The tonsils and mucous membrane surrounding the glottis were somewhat swollen, but not unusually red. On percussing the chest, no dulness could anywhere be detected. Respiratory murmurs over the large air-tubes loud and harsh, with occasional mucous rale, but their character masked by the loud snoring noise in the larynx. To have 3 ss of wine every ha'fhour; an anti- spasmodic mixture of sulphuric mther, ammonia, and opium; the ulcers and mucous membrane of the fauces to be sponged with a weak solution of nitrate of silver, and tlie steam inhaler to be used assiduously. Progress of the Case.—These remedies alleviated all her symptoms, so that in the evening she gave a history of her case. Seeing that she was so much better at the even- ing visit of the house-clerk, the intensity of the disease was supposed to have abated, but in the morning she was found dead in bed. Sectio Cadaveris.—Fifty hours after death. Pharynx, Larynx, and Trachea.—The opening of the fauces was considerably- contracted ; and the mucous membrane of the tonsils, soft palate, and from this to the root of the tongue, presented numerous ulcerations, extending to the submucous tissue, and undermining to some extent the mucous membrane. The ulcers were mostly rounded in form, of exceedingly various size, up to a diameter of three-eighths of an inch; the edges not at all elevated, and for the most part smooth, as though scooped out by a punch. The floors of the ulcers consisted of the submucous tissue, perfectly clean and pale, without the least trace of granulations or pus. The neighbouring mucous membrane was scarcely at any point more vascular than natural. The arytenc- epiglottidean folds were hypertrophied—that of the right side being thickened and cedematous, that of the left being flaccid and relaxed. They could be made to lie in apposition, so as almost to close the opening of the glottis. The mucous membrane of the entire larynx was somewhat rose-coloured ; and the submucous tissue of the epi- glottis, the chordas vocales, and the ventricles, considerably infiltrated with fluid. Throughout the trachea, the membrane was of a rose-colour, becoming deeper towards the bronchi, and was everywhere covered with a thick mucus, which lay in semi-trans- parent drops, the size of a very small pin's head, on the opening of the follicles. Thorax.—The tissue of the lungs was for the most part healthy, but here and there a few small portions of its substance were collapsed. The mucous membrane * Reported by Mr. Henry Thorn, Clinical Clerk. LARYNGITIS. 599 of the larger bronchi was congested, and the smaller ones on the right side yielded drops of purulent mucus, on compressing the cut surface ofthe lung. " Abdomen.—There were several small cancerous nodules in the liver, but all the other organs were healthy. Commentary.—In this case I think there can be little doubt that during the night some obstruction occurred to the breathing, dependent on the local disease, which caused asphyxia and death. Neither can we have any hesitation in thinking, that had tracheotomy been performed in time, life would have been saved, inasmuch as the tissue of the lungs was healthy, and the only lesion found in those organs was a trifling bronchitis. No doubt the amelioration of the symptoms which was observed at the evening visit removed the idea of urgency, but this is just the reason I have cited the case, as a lesson to all of us, with regard to the watchfulness which is necessary in the treatment of such disorders. In another case, occurring in a man who entered the clinical ward, labouring under symptoms so similar that I need not detail them, I ordered tracheotomy to be performed at once, and the result was the preservation of life and restoration to health, although the ulceration destroyed the vocal cords, and the aphonia was complete. Case CXVII.*—Chronic Laryngitis and Pharyngitis—Tracheotomy—Recovery. History.—Hugh Martin, set. 35, labourer—admitted Dec. 28th, 1849. Says that six years ago he had gonorrhoea, without any other form of venereal affection. Twelve months since he was treated with calomel for some swellings below his jaw, and shortly after having caught cold, was affected with sore throat. Subsequently he was again treated with mercury in the Glasgow Infirmary, and having again caught cold, his throat became worse. Symptoms on Admission.—His general appearance is cachectic and emaciated. His speech is almost inaudible, and the upper part of a large ulcer is seen deep down in the pharynx. Respiration is evidently impeded and accompanied by hoarse tubular breathing, heard on placing a stethoscope over the larynx. Pulmonary sounds feeble, and resonance good everywhere on percussion over the lungs. Has slight cough with muco-purulent expectoration, not so copious, he says, as it has been. Has pain in deglutition, which often excites violent cough. Pulse 82, of natural strength. Other functions well performed. The urine contains hexagonal plates of cystine, mingled with crystals of uric acid. Progress of the Case.—December 30th.—Topical applications of a weak solution of nitrate of silver internally, and warm fomentations to the throat externally, have failed to cause relief. Breathing still impeded and difficult; voice extinct. Trache- otomy was performed, and a tube inserted. January 11th.—Since the operation, he has breathed freely through the tube, and feels much easier. The ulcer in the pharynx has been touched occasionally with nitrate of silver, and is now healed. Has considerable difficulty in expectorating mucus through the tube. To have steak diet Dec. 20th.—A solution of nitrate of silver (2 gr. to §j of water) to be applied to the inside of the trachea every other day, by means of a sponge attached to a slip of bent uhakbone. Dec. 23d.—Has been greatly relieved by the topical application to the trachea. Strength of solution to be increased to Argent. Nit. gr. v. to - j water, and applied daily. Dec. 26th.—Strength of solution further increased to gr. x. of the salt to * Reported by Mr. Hugh M. Balfour, Clinical Clerk. 600 DISEASES OF THE RESPIRATORY SYSTEM. 3 j of water. From this time the muco-purulent expectoration gradually subsided U Potass. lodid. §ss; Tr. Gent. c. = j ; Inf. Gent. c. I v. M.^j to be taken three times a day. February 10th.—The tube was removed. The voice returned, although it remained very hoarse, and there was every reason to believe that the ulcer in the larynx, if not perfectly cicatrized, was nearly so, when he went out, February 20th, Commentary.—In this case tracheotomy was performed, not so much with the view of relieving urgent symptoms, as to secure rest and immo- bility to the larynx, so that the ulcerations might cicatrize. This object was effected, and the man slowly got well. First, the ulcer in the pharynx healed, and subsequently that in the larynx, although, when the tube was removed from the trachea, it was apparent that the vocal cords had been partially destroyed. At the time this case was treated, the mode of application by means of sponges to the interior of the larynx was unknown. The record shows, however, that in 1849 I applied the nitrate of silver solution directly to the trachea, through the aperture made for the tube, which was from time to time removed for that pur- pose. I then found its use very beneficial in checking the amount of muco-purulent secretion, and increased the strength of the solution from two to ten grains of the salt to an ounce of water. The man complained of no pain or inconvenience of any kind from these applications. He had undergone two courses of mercury, and so far as his own statements are to be relied on, without any other form of venereal disease than that of gonorrhoea, and swellings below the jaw. Even supposing that these latter were originally venereal, it is certain that the mercury produced no benefit, but, on the contrary, while the local disease was making progress, it so affected his general health, as to occasion emaciation and general cachexia. We have seen that the ulcers healed under a non-mercurial treatment, and that his health improved under tonics and good diet. The diagnosis of laryngitis is most important, and must be derived— 1st, From the general symptoms; 2d, From the results obtained by careful examination of the air tubes and lungs by auscultation and percus- sion ; aud 3d, From an inspection of the parts. With regard to the general symptoms, I have already alluded to the relative value to be attached to difficulties of deglutition and of speech. Concerning the difficulties of respiration, the nature of the expectoration, and the cough, we cannot with certainty refer them to the larynx, without a careful study of the condition of the pulmonary organs. Indeed, the attention which has been lately directed to the fauces and larynx, in consequence of the writings of Dr. Horace Green, has demonstrated the important fact, that many of those disorders which have sometimes been called " chronic bronchitis," and others which have not uufrequently been supposed to indicate in young persons incipient phthisis, are really a chronic form of laryngitis, altogether local, and readily removed by topi- cal applications. The distinctiou between them, however, often demands the greatest care in examination, but when a good auscultator fails to detect the signs characteristic of bronchitis or phthisis pulmoualis, whilst, on the other hand there is unusual hoarseness or shrillness of the laryn- geal murmur, dryness of the throat, and hacking cough, sometimes accompanied by muco-purulent expectoration, or even occasional spitting LARYNGITIS. 601 of blood, then his suspicions maybe directed to laryngeal rather than to pulmonary disorder. It is the more important to notice this, because a good authority has lately stated,—" Expectoration of blood in persons labouring under chronic bronchitis, with or without emphysema, but without notable disease of the heart, justifies in itself a suspicion of the existence of latent tubercles."—(Walshe.) In making this diagnosis, however, I must recommend to you the exercise of the greatest caution, and especially not to confound the natural hoarseness heard in the larynx of some individuals Avith the coarse sounds heard in others only when the organ is diseased. The examination of the throat and upper edge of the epiglottis will do much to remove any difficulty you may experience, because in many cases alterations of the mucous membrane of the larynx follow and accompany similar changes in the mucous membrane of the fauces and pharynx. Indeed, it may be accepted as a general law, which admits of but few exceptions, that morbid changes in the mucous membranes of the pharynx and larynx proceed from above downwards, as is well observed in scarla- tina. Lesions often attack the fauces or tonsils and spare the larynx; but if long continued, the latter is affected consecutively. Hence why chronic, syphilitic, and mercurial ulcerations of the throat, have such a tendency to attack the larynx. Again, when the larynx is first attacked, as occurs among clergymen, and in the ordinary croup of children, the follicular disease in the one, and the coagulated exudation in the other, tend to pass down the trachea, and not upwards into the fauces. It follows, that when hoarseness of the voice, cough, and other laryngeal symptoms are accompanied by abrasions or ulcerations in the mucous membrane of the soft palate or uvula, by thickening or irregularity in the epiglottis, and especially by the follicular disease formerly alluded to —presenting elevated pimples more or less numerous scattered over the parts—there is every reason to believe that the larynx is similarly affected. The tongue-depressor previously referred to, will enable you to examine these parts with the greatest ease, and iu most cases the upper edge of the epiglottis will with its aid be brought into view. Still it is only by inference that we can form an opinion of the condition of the larynx. Indeed in many cases, even the summit of the epiglottis cannot be seen, the larynx being so deep-seated that it cannot be brought into view with the tongue-depressor. Hence, as regards the actual examina- tion of the mouth and throat, we only receive exact information as to the state ofthe fauces, uvula, tonsils, and back of the pharynx ; and valuable as such information is, we cannot determine by it with exactitude the condition ofthe glottis. Occasionally, under such circumstances, the fin- ger will give us some notion, however vague, and we may feel swelling, induration, or irregularity in the epiglottis. But to derive information in this manner, tact and habit are necessary. On the whole, although the local examination with the tongue-depressor should never be omitted, it does not in all cases enable us to determine the condition ofthe epiglottis. Iu no case ought you to depend upon examination of the parts alone : it should be conjoined with the knowledge derived from a careful study of the symptoms, and of the physical signs furnished by the air-tubes and lu jgs. With regard to the treatment, you will gather from what has been previously said, that I regard the, mode of applying topical remedies 602 DISEASES OF THE RESPIRATORY SYSTEM. introduced by Dr. Green as a most valuable addition to our other means of cure. The experience of that physician indicates, that the earlier it is applied the greater the chance of success, especially in acute cases of scarlatina and croup. It was first employed in hooping-cough by Dr. E. Watson of Glasgow, and has subsequently been trie-1 in laryngismus stridulus, hay fever, and other diseases hitherto considered spasmodic aud with such success, as to lead to the conclusion that these disorders are essentially connected with local irritations or an obscure form of catarrh. In various kinds of laryngeal disease occurring in the adult, whether primary or secondary, I have employed it very extensively, in many instances with permanent good results, and in a large number with temporary alleviation. Indeed, nothing is more remarkable than the immediate effect it has in clearing the throat and improving the tone of the voice, and hence, in many cases whicii do not admit of cure, it may be employed as a palliative. As such, I have successfully used it in old cases of chronic laryngitis and bronchitis, clergyman's sore throat, spasmodic asthma with accumulation of mucus in the trachea, and so on. In syphilitic and confirmed tubercular laryngitis, though not so beneficial, it is still in some cases decidedly useful. I have, however, met with several instances where it has been very injudiciously employed, and others where the sponge had been passed by unskilful hands repeat- edly down the oesophagus without any good effect, the patient having been persuaded for a considerable period that it had been applied to the larynx. Circumstances of this kind may bring the practice into disre- pute with some, but I trust you will discriminate, and neither lightly abandon it from a few failures, nor be led into the opposite error, of sup- posing, from one or two favourable cases, that it is capable of being inva- riably successful. BRONCHITIS. Case CXVIII.*—Acute Bronchitis—Recovery. History.—Catherine Mulvie, set. 21, a servant—admitted July 21, 1851. She states that two weeks ago, when in a state of perspiration, she took a bath in the open sea. The same evening she was attacked with rigors and other febrile symptoms, and on the next day there was a dry cough, difficulty of breathing, and a sense of oppres- sion in the chest. The cough has continued since with more or less expectoration, but the febrile symptoms have abated. Symptoms ox Admission.—On percussion there is no unusual dulness over the lungs. On auscultation, there is harshness of the inspiratory murmur anteriorly; and posteriorly and iuferiorly, on both sides of chest, coarse crepitation. There is frequent cough, with slight muco-purulent expectoration; general debility; head- ache ; soreness in the limbs; occasional palpitations of the heart, the sounds of which organ, however, are healthy. Pulse 62, full. Digestive aud genito-uriuary systems normal. Progress of the Case.—Under the use of small doses of antimonials with opiates, followed by expectorants, the pulmonary symptoms rapidly diminished. On the 23d the coarse crepitation had nearly disappeared, and the expectoration was much diminished in quantity. On the 25th the respiratory murmurs on the right * Reported by Mr. D. 0; Hoile, Clinical Clerk. BRONCHITIS. 603 Bide were healthy, and on the left side there only remained slight harshness with occasional fine sibilation on inspiration posteriorly. Cough and expectoration were so trifling that she was dismissed. Commentary.—This was an uncomplicated case of acute bronchitis, which had nearly run its course before admission. It presents an average specimen of a class of cases exceedingly common both in hos- pital and private practice. The repose of the house, aided by expecto- rants and opiates, sufficed for the cure. Case CXIX.*—Acute Bronchitis. History.—Martin Conolly, set. 25, a robust labourer—admitted May 15th, 1857. On the 7th of May, after working some days standing in water, he had a rigor, with great heat of skin, followed by profuse perspiration, but no headache. He continued at his work till 10th May, when he was confined to bed, the pain having got worse. Coudi commenced the previous day, accompanied with a thick yellow sputum, and these symptoms with dyspneea have gradually increased in severity up to his admiscion. Symptoms on Ahmissiox.—Form of chest unusually rounded and well developed. Anteriorly, percussion is clear on both sides. On auscultation, inspiration is short- ened; expiration prolonged, and accompanied by long sibilant and sonorous rales. Vocal resorance weak, but equal on both sides. Posteriorly there is clear resonance on percussion on both sides. On auscultation, the same sibilant and sonorous rales accompany expiration, and are occasionally but rarely heard with inspiration, which at the right base is accompanied by moist rales. Cough and dyspneea urgent. Res- pirations 3G per minute. Expectoration gelatinous and muco-purulent. Cardiac sounds somewhat masked, but normal. Pulse 122, strong, full, and regular. Skin hot, but otherwise normal. Tongue moist and clean. Appetite much impaired. Thirst great. Bowels regular. Urine high coloured, otherwise normal. Venesection to It oz. was performed by Dr. Bennett without any immediate relief, and § ss of the following mixture ordered to be taken every four hours. R/ Aquas Acetatis Ammonia; I iss; Spirit. jEther. Nitric. Z ij ; Vin. Antimonial. 3 ij ; Aquas ad § vj. In the evening dyspneea had much diminished. Respirations 24 per minute. Tulse 108. still regular, full, and strong. Heat of skin less. Progress of the Case.—Next day improvement was found to continue. Pulse 116, full, but softer than yesterday. Sibilations no longer audible with expiration. The moist sounds are fainter and less abundant than at last examination. May 18th.—Sibilant and cooing rales accompany both respiratory acts posteriorly. Ante- riorly these sounds are less intense, but are accompanied by fine crepitus. Under the left nipple, crepitus is mixed with a certain harshness, both on expiration and inspira- tion (friction?). Urine rendered turbid by the presence of urates. Pulse 116, of the same character as yesterday. May 19th (twelfth day of the disease).—Patient was found bathed in profuse perspiration. The moist sounds are diminishing in amount. Crepitation still audible under left nipple. Patient still complains of pain in that region, but there is no friction. Cough continues, but is less severe. Sputum still copious and muco-purulent. Pulse 102, soft. Appetite improving. Skin moist. Urine throws down a copious sediment of urates. May 21st (fourteenth day).— Patient still perspires profusely. Crepitation with fine sibilus still heard anteriorly, most distinctly under left nipple. Pain in left side continues, being most severe on * Reported by Mr. W. H. Davis, Clinical Clerk. 604 DISEASES OF THE RESPIRATORY SYSTEM. deep inspiration. Sputum diminished in quantity, muco-purulent. Pulse 100. soft and full. On the 25th, moist rattle had nearly disappeared. On the 29th, sibilatioiis were very faint, the cough was trifling, and sputum nearly gone. June 4th.__He was discharged quite well. Commentary.—This was a case of violent acute bronchitis of both lungs, in a strong vigorous man. On admission, so great was his dyspnoea, that I bled him with a view of determining whether the remedy would relieve that symptom. I satisfied myself that it had no imme- diate effect, and the disease subsequently ran its natural course, termi- nating in perfect recovery on the twenty-first day. Bronchitis, like laryngitis, consists of an exudation infiltrated into the various tissues forming the bronchi, or coagulated upon their mucous surface. It terminates in the transformation of this exudation—accord- ing to laws previously explained, p. 12-4, et seq.—into matters which permit of being either absorbed into the blood or expectorated. At first the lesion causes increased dryness, narrowing, and rigidity, and subsequently moisture, dilatation, and relaxation of the tubes. Owing to these changes, the vibrating sounds caused by the passage of air through the bronchi undergo variations, which indicate pretty clearly the dry or moist nature of the disease, or, as some term it, dry or moist catarrh. Acute bronchitis may differ in intensity, from an affection very trifling and scarcely regarded, to one which very nearly approaches in severity a decided attack of pneumonia. It may be epidemic, and con- stitute what is called influenza. It may follow or precede a similar lesion in the lining membrane of the nasal passages, that is, coryza. These affec- tions are so common as to be generally treated by domestic medicines only, or, it may be, totally disregarded. But there can be no doubt that a disposition to attacks of this kind, though they may often occur for a long time with impunity, frequently leads to the incurable and distress- ing change of pulmonary texture known as emphysema, with its fearful accompaniment of spasmodic asthma and consecutive disease of the heart. (See p. 523.) Bronchitis, therefore, is an affection which, if not checked early, should be carefully assisted through its natural progress. To check the progress of an acute bronchitis or coryza, no remedy seems so good as a full dose of morphia on the first, or at latest second night on going to bed. In the morning the patient should breakfast in bed, and keep himself warm at home during the day. This treatment, which was first recommended by Dr. Christison, has the effect of dimi- nishing the irritation which causes the exudation, and preventing its return. Should, unfortunately, the disease progress, patience is perhaps the best remedy, as the disease will run its course. But if the bronchi become clogged, sudorifics and expectorants, especially ipecacuanha, will be useful, and a blister will sometimes dissipate any lingering trace of the disease. The chief caution to be given should be to get perfectly rid of the disorder before any exposure to cold air be allowed. It is the disregard of this point, and the getting " cold upon cold," which serves so much to keep up the affection, and at length induces the chronic form of the disease. BRONCHITIS. 605 Case CXX.*—Chronic Bronchitis—Acute Peritonitis—Collapse of the Lung. History.—Mary Nichol, set. 21, a servant—admitted July 8th, 1851. She has suffered more or less from cough for the last two years. Occasionally it has been very troublesome, but not accompanied by much expectoration. Seven weeks ago experi- enced severe pain in the epigastrium, and since then the breathing has become short and hurried. Symptoms ox Admissiox.—Anteriorly the lungs are everywhere resonant on per- cussion. On auscultation, the inspiratory murmur is harsh, and towards its termina- tion fine sibilant rales are heard. Posteriorly, the right side is more dull on percussion than the left. This is more marked towards the apex. At this point there is harsh inspiration and increased vocal resonance. There are also, over the whole right back, sibilant rales during inspiration. Cough with trifling mucous expectoration; respira- tions short and hurried; great tenderness over the epigastrium, increased on taking a deep inspiration; appetite tolerably good ; no nausea or vomiting, and, with the excep- tion of constipation, digestive system healthy ; pulse 80, soft; heart sounds natural; catamenia regular; urine voided with pain, and in small quantity, otherwise healthy. Progress of the Case.—The dry rales accompanying the inspiration continued for some days ; but on the 21st they became moist, and coarse crepitation was audible over the inferior third of right back. The cough became more loose also, and the expectoration increased. On the 14th, the moist rattles were converted into deep sonorous murmurs, and great variations were heard from day to day, evidently in con- sequence of the greater or less amount of fluid in the bronchi. The cough and ex- pectoration also varied greatly in intensity. Her principal complaint, however, was the epigastric pain, which, notwithstanding the application of leeches, warm fomenta- tions, opiates, and counter-irritants, continued to increase. On the 28th, there was diffuse swelling of the abdomen, general tenderness of the surface, and all the symp- toms of peritonitis from intestinal perforation, Latterly, there was dulness and absence of respiration over the lower third of right lung. She died August 10th, 1851; but unfortunately no dissection could be procured. Commentary.—This girl laboured under a chronic bronchitis of some standing, which presented, during the progress of the case, most of the physical signs characteristic of the disease. Her chief complaint, how- ever, was a fixed pain in the epigastric region, which proved in no way amenable to treatment, and which, as the event proved, was evidently connected with an ulcer either in the stomach or neighbouring intestinal viscera, probably the former, considering the frequent occurrence of ulcers in that viscus among servant girls. But in the absence of the facts which a dissection only could have afforded, all speculation on such a point is evidently useless. The dulness on percussion at the apex of the right lung, the harsh inspiration aud increased vocal resonance, point to the existence of some condition of the organ at that point, giving it increased density. They constitute the signs of incipient or of cretaceous tubercle. But percussion over the whole of right back was impaired; and towards the close of life, as weakness appeared, there was dulness and absence of respiration over the lower third of right lung. These physical signs indicate collapse of the organ in this situation, or a con- * Reported by Mr. C. D. Phillips, Clinical Clerk. 606 DISEASES OF THE RESPIRATORY SYSTEM. dition which has been variously called by pathologists " condensation " —" infarction "—'' hypostatic pneumonia "—" peri-pueunmnie des ago- nisans,'' etc., etc. In a series of observations on bronchitis, by Dr. W. T. Gairdner,* he points out, as one of the most common results of the disease, more or less collapse of the vesicular tissue, dependent on obstruction to the pa-s;i0. t Reported by Mr. \V. M. Calder, Clinical Clerk. „Fig. 427. Plug of mucus or coagulated blood, so placed that while it admits of par- tial expiration, it prevents inspiration and causes collapse of the pulmonary tissue, to which the smaller bronchi are distributed.—(Gairdner.) Rig. 427. BRONCHITIS. 607 examined, it was soon ascertained that copious coarse moist rales appeared pos- teriorly and inferiorly, especially on the right, but also on the left side. These rales were occasionally absent, but continued tolerably constant. The dry rales also underwent from time to time several variations in tone, intensity, and situation. During February, May, and June, he was tortured by severe and prolonged attacks of dyspneea, during which he gasped for breath, and appeared on the point of suf- focation. The attack generally terminated by violent cough, expectoration, and vomitin", after which he always felt relieved. These attacks came on every second or third night, and were sometimes occasioned by an unusually full meal. In May- there was noticed, in addition to the other physical signs, a coarse moist tracheal rattle, so loud as to mask the pulmonary sounds. On one occasion during this month, the attack of dyspneea lasted four hours, producing partial asphyxia, delirium, and stupor. On the 24th of May he was attacked with sore throat, and difficulty in deglutition, followed on the 30th by laryngitis and partial aphonia, which greatly aiKTavated the asthmatic attacks. During all this time, expectorants, antispas- modics, anodynes, counter-irritants, with occasional emetics and cupping, were employed, with temporary, but no permanent benefit. In April and May the smokinc of stramonium evidently afforded him considerable ease. He also expe- rienced marked relief from a draught containing Z iss each of Tr. Lobelise and of Otlier. Towards the end of June, a sponge, saturated with a strong solution of nitrate of silver, was passed into the larynx several times, with marked benefit; indeed, so much so, that on the eleventh of July, his condition was greatly improved, the attacks of dyspneea ceased, and the cough, expectoration, and other symptoms, were much abated. On the lGth, he was dismissed at his own request, to resume his occupation as cook on board ship. The sore throat and laryngitis had then dis- appeared, but the chest was still unusually resonant on percussion; there was loud tracheal breathing, prolonged expiration, and occasional sibilant rale. Respiration, however, was comparatively easy, and he considered himself, as he certainly was, greatly relieved. Commentary.—This man presented all the physical signs and symp- toms indicative of extensive emphysema dependent on chronic bronchitis, accompanied with the most severe asthmatic attacks. These attacks were of a spasmodic character, referable to irritation of the incident fila- ments of the pneumo-gastric nerve, and to reflex action by means of the excident ones, whereby the bronchial tubes were contracted, the glottis closed, and the muscles of inspiration rendered incapable of dilating the chest. Violent cough and vomiting were always induced towards the close of the attack, followed by relief. The dyspnoea during the course of the disease was alleviated by antispasmodics, and the laryngitis by topical applications, of which I have previously spoken. I consider, how- ever, that his recovery was mainly due to the advance of summer and a change of temperature—circumstances whicii should never be overlooked in estimating the effects of treatment in such cases. Of all the causes which excite asthmatic paroxysms in individuals labouring under emphysema, the effect of certain seasons and changes of temperature is the most unequivocal, and yet the most mysterious. Thus some persons who are martyrs to the disease in winter are per- fectly well in summer, and vice versa. Some are immediately affected by the foggy air of London, and are well in the country; others are 608 DISEASES OF THE RESPIRATORY SYSTEM. attacked when the wind blows from a particular quarter, especially the east. However difficult it may be to explain such idiosyncrasies, there can be no doubt that a knowledge of these circumstances will enable those who can change their residence to alleviate their sufferings in no small degree. Emphysema is characterized anatomically by a permanent enlarge- ment of the air-vesicles of the lung. These may frequently be seen through the pleura, with an ordinary lens, like groups of minute pearls. Two or more of them may break into each other, and produce others of larger dimensions, say the size of a millet seed, and this process may go on, until, by the breaking down of the intervening partitions, every size of emptrysematous cavity may be formed, up to that of a large orange. The walls of such cavities remain permanently open, having lost their elas- ticity. The tissues which form them also are evidently atrophied, and their paleness proves that the capillaries have been so compressed as to be either obliterated or impervious to the passage of blood. In order to account for emphysema, numerous theories have been advanced, of which I shall allude to only the first and last. Laennec supposed that the fine bronchial tubes became rigid and more or less impervious from swelling of their lining membranes or impaction of mucus. He conceived that inspiration was a more powerful action than expiration, so that while air could be drawn through the obstructions, it could not be breathed out. In consequence, it accumulated in the ulti- mate pulmonary vesicles, became expanded by heat, and so acted mechanically as a dilator, distending them from within, and causing them to enlarge more and more according to the duration of the disease, and extent of the respiratory efforts. Dr. Gairdner, however, has pointed out that expiration is a much more powerful act than inspiration, and that there is never any difficulty in causing expulsion of air. It is the inspiration which is laborious in all bronchitic cases, and, as has been previously stated, when the tubes are obstructed, so far are the air-cells beyond them from being dilated that they are in truth collapsed. Emphy- sema, then, does not occur in the vesicles connected with obstructed tubes, but in those healthy ones which are adjacent. When the lungs are in a normal state, the column of air presses equally on all the tubes and vesicles, but when one portion connected with any obstruction is collapsed or otherwise diminished in bulk, then the neighbouring portion is over-expanded, so as to occupy the space previously filled by the former. Hence why emphysema occurs not only as a result of bronchi- tis, but of chronic phthisis, or any other disease which causes contraction and hypertrophy of the pulmonary fibrous tissue. Dr. Jenner also says,* " The atmospheric air moved by the inspiratory effort can exert com- paratively little pressure on the inner surface of the air-cells situated at the extreme margin of the base, the root of the lower lobe (/. e. that part immediately next the spine and below the primary bronchus) or at the part of the apex situated in the furrow posterior to the trachea on the right side. While violent expiration, being chiefly performed or greatly aided by the abdominal muscles forcing upwards the liver, etc., drives the air (in consequence of the highly arched form of the dia- phragm in violent expiration) from the central part of the lung, not only * Medico-Chir. Trans, of London. Vol. xl. BRONCHITIS. 609 through the bronchi towards the larynx, but also towards the circum- ference of the lungs, i, e., towards those parts which are the least com- pressed during expiration." This view is confirmed by all that we know of the usual seat of emphysema, and by the effects of expiration as made visible under particular circumstances. In the case of M. Groux in whom the sternum was deficient, it could be demonstrated that it was only by a forced expiration that the lungs so expanded, as to protrude through the aperture.* The treatment of chronic bronchitis must be directed to facilitate expectoration, by means of various expectorants, and to allay the irrita- bility of the bronchial passages by means of anodynes. I have already alluded to the circumstance, that chronic pharyngitis, tonsillitis, elon- gation of the uvula, and follicular disease of the epiglottis, keep up a cough, often mistaken for chronic bronchitis; and it is in these disor- ders that demulcents, lozenges of various kinds, astringent and stimula- ting gargles, etc., are found temporarily beneficial. In such cases the employment of the sponge, saturated in a solution of nitrate of silver, is, as we have seen in case CXXL, of the greatest advantage. Perhaps there is no disease in which blisters and counter-irritations are more useful than iu bronchitis. When chronic bronchitis is associated with emphysema, and accom- panied by spasmodic attacks of dyspnoea, the various kinds of antispas- modics are most serviceable. Sulphuric and chloric sether often act like magic; and the smoking of stramonium, with or without opium, and other remedies of this class, though it seldom cures, procures great relief. The idiosyncrasy of the asthma should also be studied, aud a change of temperature or locality advised, according to the peculiarities of the case. Case CXXII.f—Chronic Bronchitis—Emphysema—Injection of the Bronchi with a Solution of the Nitrate of Silver. History—Eliza Dawson, set. 24, a servant—admitted 27th May, 1857. About fourteen months ago, after exposure to damp and cold, she was seized with a severe pam in the chest accompanied by cough. The pain in the chest disappeared in a lew days, but the cough persisted, though it was not very troublesome, till twelve months ago, when it again became very severe, the house in which she was living being damp. The pain in the chest at the same time returned. In the middle of last January, the pain and cough increased in severity, and were accompanied by considerable dyspnoea. She derived no benefit from treatment, and was at length compelled to apply for admission, because her weakness was such as to prevent her continuing at work. Stmi'toms.—On percussion over the chest, resonance is very loud both anteriorl find posteriorly. On auscultation, expiration is everywhere prolonged. Sibilant and snoring sounds accompany inspiration and expiration on both sides, anteriorly and posteriorly. Vocal resonance everywhere diminished. Cough and dyspnoea parox- ismal; the respiration being laboured even in the intervals. Expectoration in moderate quantity, consisting of frothy fluid floating over tough gelatinous mucus. Apex of heart cannot be felt. Cardiac sounds normal, but masked by the pulmo- * Edin. Med. Journal, vol. iii, p. 853. 1858. f Reported by Mr. Stephen Scott, Clinical Clerk. DISEASES OF THE RESPIRATORY SYSTEM. nary sounds. Pulse 7-1, of moderate strength. Tongue clean, but somewhat dry Appetite impaired. Feels pain in the epigastrium after taking food. Bowels gene- rally constipated, requiring the occasional use of aperients. Other functions normal. R Spirit. jEther. Nitric. 3 iij j Spirit. Ammon. Aromatic. Z iv; Aquas ad z vi. A table-spoonful to be taken thrice a day. The chest to be dry cupped anteriorlu and posteriorly. * Progress of the Case.—She has experienced great relief from the treatment and on 1st June, the snoring sounds are reported to have disappeared. On that day, however, the dyspneea again became distressing, and on 3d June, the sibilant and sonorous rales had returned. Was ordered Spirit. JEther. Sulphuric. 3 ij ; Sol. Mur. Morph. 3 iss; Decoct. Senega: ad § vi. A table-spoonful to be taken thrice a day. A blister (3 by 4) to be applied over the chest. This was followed by great relief; sibiloi continued audible, but the sputum diminished in quantity, becoming altogether mucous. On the 13th, cough and dyspneea again became severe, with pain in the chest. A blister (3 by 4) was again applied with benefit. 27th June.— The dv> pncea has returned during the last few days, the paroxysms occurring chiefly during the night. During the fit she sits up in bed; the whole chest heaves; the head ia thrown back during inspiration ; the face is unusually pale and moist with perspira- tion ; lips pallid; articulation slow and measured; respiration accelerated with pro- longation of expiration. A drachm of sulphuric (ether, and half a drachm of Sol. Mur. Morph. in a draught, gave immediate relief. The fits now became less frequent, diminishing at the same time in severity and duration. On 13th July, after the pre- vious application for a few days of the sponge to the throat, Dr. Bennett injected, by means of a catheter introduced into the trachea, 3 ij of the solution contabing half a drachm of nitrate of silver to 3 j of water. The operation was repeated next day. There was no return of dyspneea till 15th July, when she had two paroxysms, both followed by vomiting. She had a third paroxysm next morning at 4 o'clock, which left her very weak; respiration at 2 p. m. being still considerably embarrassed. On 17th July, 3 ij of the solution of nitrate of silver were again injected into the trachea. No difficulty is experienced in passing the tube, nor is any inconvenience felt by the patient. The presence of the catheter in the trachea was demonstrated by the propulsion of 2 or 3 drops from the external orifice to the distance of 3 feet during a forcible expiration. After the operation, she passed a much better night, the cough and expectoration being very much less, and the respiration perfectly easy. On 22d July the operation was repeated; she vomited in an hour and a half after it, but remained comparatively free from cough and dyspneea till 30th July, when a re-accession occurred. On 1 st August, 3 ij of the solution were again injected, and on the 4th August, she left the Infirmary to obtain change of air. Commentary.—This also was a case of chronic bronchitis, with em- physema and severe paroxysms of asthma, in which various remedies were tried with the effect of temporarily alleviating the dyspnoea. Dur- ing her residence in the house, much of the bronchitis gradually disap- peared, but the emphysema and asthma continued and underwent little change. It appeared to me a favourable opportunity for trying the new practice introduced by Dr. Horace Green of New York, of bronchial injections with a solution of nitrate of silver. We were singularly favoured in this case by the high position of the epiglottis, and the com- parative insensibility of the larynx. The sponge saturated with the nitrate of silver solution apparently caused no irritation whatever, and on passing the catheter through thcrima glottidis little uneasiness was manifested. Two drachms of a solution (3 ss of the salt to 3 j of BRONCHITIS. 611 water) were injected into the trachea several times, producing only a feeling of warmth in the chest, but, as she frequently declared, greatly diminishing the cough and expectoration from one to two days after- wards. This woman, with the catheter deep in the trachea closed her mouth round the tube, respired through it, and could blow so as to render the expelled air quite sensible to the finger. No one could doubt that the tube was in the trachea, and that the solution had passed into the lungs. After her dismissal, I continued to see her, and subsequently increased both the strength and quantity of the injection. Latterly I have thrown in 5 ss of the strength of 3ij of the salt to 3 j of water. She emigrated to Australia, May, 1858. On Injections into the Bronchi in Pulmonary Diseases. In a publication which I received from Dr. Horace Green of New York in 1856, there is a table of 106 cases of pulmonary disease, which were treated by injections into the bronchi of a solution of nitrate of silver. A flexible catheter was introduced through the larynx, into the right or left division of the trachea, and by means of a glass syringe, the injection thrown into the lung. This bold proceeding was described as producing great benefit in cases of pulmonary tuberculosis, bronchitis, and asthma. Whilst tuberculosis is at first a constitutional disease, its localization in any part reacts more or less on the general health; and the opinion I have long entertained, that any means which could enable the physician to act directly on the tissue of the lung or inflamed bronchi, would assist his efforts at cure—at once led me to take a fa- vourable view of this new mode of treatment. The nitrate of silver ought to act as beneficially on the mucous membrane of the trachea and bronchi, as on that of any other hollow viscus, and we have seen previ- ously that the remedy may be applied to the tracheal mucous membrane, by means of an artificial opening (see Case CXVIL), not only without injury, but with decided benefit. The difficulty was obviously to get it there through the rima glottidis. I therefore wrote to Dr. Green, requesting him to send me the instruments he employed. In a letter which I received from him in reply, dated New York, January 30,1857, he says:— " I would, with much pleasure, send you the instruments I emnloy, but they arc simple, and may be obtained at any surgical instrument maker's shop. They consist of an ordinary flexible or gum catheter, and a small silver or glass syringe. The catheter is Hutching's gum-elastic catheter (Nov 11 or VI), which is 12£ inches in length; and as the distance from the incisor teeth to the tracheal bifurcation is, ordinarily, in the adult, about eight inches, if this instrument is introduced so as to cave only two inches of the catheter projecting from the mouth, its lower extremity must of course (if it enter the trachea) reach into one or the other of its divisions. I first prepare my patients by making app ications with the sponge-probang, for a period of one or two weeks, to the opening of the glottis and the larynx, until the sensibility of the parts is greatly diminished. Then, having the tube slightly bent, I dip the instrument in cold water (which serves to stiffen it for the moment, 612 DISEASES OF THE RESPIRATORY SYSTEM. and obviates the necessity of using a wire), and with the patient's head thrown well back, and the tongue depressed, I place the bent extremity of the instrument on the laryngeal face of the epiglottis, and gliding it quickly through the rima glottidis, carry it down to or below the bifur- cation, as the case may require. It is necessary that the patient con- tinue to respire, and the instrument is most readily passed during the act of inspiration. The tube being introduced, the point of the syringe is inserted into its opening, and the solution injected. This latter part of the operation must be done as quickly as possible, or a spasm of the glottis is likely to occur. Indeed, if the natural sensibility of the aper- ture of the glottis is not well subdued by previous applications of the nitrate of silver solution, or if the tube, in its introduction, touches roughly the border or lips of the glottis, a spasm of the glottis is certain to follow, which will arrest the further progress of the operation. The epiglottis, which is nearly insensible (and this you may prove on any person, by thrusting two fingers over the base of the tongue, and touching, or even scratching with the nail, that cartilage), should be our guide in performing the operation. The strength ofthe solution for in- jecting is from 10 to 25 grains to the ounce of water. Commencing with 10 or 15 grains to the ounce, its strength is subsequently increased, and the amount I now employ is from I to 1£ drachms of this solution. " In cases of bronchitis, asthma, and in phthisis, even the employ- ment of the tube once or twice a week diminishes the cough and expec- torations with great certainty, especially in the two former diseases; and many cases have recovered under the local treatment after other means had failed. The applications of the sponge-probang are continued in the intervals ofthe employment ofthe tube." My period of attendance on the clinical wards having expired in January, it was not until May, 1857, that 1 had an opportunity of making a series of observations on this subject. I was then fortunately assisted by Professor Barker of New York, who showed me the kind of catheter he had seen Dr. Green employ, and demonstrated the manner in which the operation was performed. Without entering into minute particu- lars, I have only to say that I have confirmed the statements made by Dr. Horace Green. I have now introduced the catheter publicly in the clinical wards of the Royal Infirmary, in several patients affected with phthisis in various stages, in laryngitis, and in chronic bronchitis, with severe paroxysms of asthma. In other cases in which I attempted to pass the tube, it was found to be impossible; in some because the epiglottis could not be fairly exposed, and in others on account of the irritability of the fauces, and too ready excitation of cough from pres- sure of the spatula. I have been surprised at the circumstance ot the injections not being followed by the slightest irritation whatever, but rather by a pleasant feeling of warmth in the chest (some have experi- enced a sensation of coolness), followed by ease to the cough, and a check for a time to all expectoration. In making these injections, I have observed very great differences in the form of the epiglottis, as well as in the irritability of the fauces and root of the tongue in different individuals. In some persons the epi- glottis is easily exposed, and on depression of the tongue may be seen standing erect, quite insensible as stated by Dr. Green, so as easily to PLEURITIS. 613 permit the passage of the catheter. In other cases, the top of the epi- glottis can only be reached with the greatest difficulty, and in several is not to be seen at all. In such cases I have not as yet attempted to pass the catheter. Again, while some individuals can bear without diffi- culty forcible depression of the tongue, and considerable freedom in touching the fauces and rima glottidis, others are thrown easily into vio- lent spasms, or exhibit great irritation in the parts, from the mere pressure ofthe spatula. This appears to me to be more constitutional than depend- ent on local disease ; some persons being more irritable or easily excited than others; and I have observed the same difference in individuals who are in all respects perfectly well. On one occasion, I put the sponge through the rima, and allowed it to remain some seconds, completely obstructing respiration, but without causing cough or any other incon- venience. In the case of Dawson (Case CXXlL), very trifling irrita- tion was occasioned by the pressure of the catheter. Whenever great irritability exists, the operation cannot be performed. Further experience of this new practice is required before its perma- nent good effects can be judged of, but my belief is, that, in appropriate cases, it will prove of great advantage. Great care, however, should be taken, especially in phthisical cases, not to make the injection if dyspneea or cough be brought on by the insertion of the tube. In the case of one gentleman who, with a desire to have the operation completed, violently restrained all efforts to cough when I was in the act of injecting the solution, great pain was occasioned in the chest for several days. PLEURITIS. Case C'XXIII.*—Acute Pleurisy—Recovery. History.—Mary Harvey, aet. 21, a robust servant girl, was admitted into the clinical ward July 23, 1T)1. She enjoyed good health until seven days ago, when, after unusual exposure to cold and wet, whilst washing clothes, she was seized with dilliculty of breathing, and a sharp cutting pain in the right side. She shortly afterwards experienced headache, general soreness, and the usual symptoms of fever, but does not remember having had rigors. The dyspneea and local paiu have increased in intensily, although the febrile symptoms on admission had somewhat abated. Symptoms on Admission.—On percussing the right lung anteriorly, there is com- plete dulness over its lower half, and, posteriorly, the dulness extends over the two lower thirds of the lung. On the left side, the lung is everywhere resonant on per- cussion. On listening over the dull portion of right side, there is complete absence of respiration, with loud pealing vocal resonance. In the centre of lung posteriorly OBgophony. Xo friction or crepitating murmur can be distinguished. On the left ode, respiration is puerile. Slight cough, but no expectoration; dyspcena, but not urgent; sharp cutting pain in right side, increased on taking a deep inspira- tion. Considerable headache and general soreness; the skin of natural temperature, but dry. Pulse 100, of natural strength ; tongue furred ; face flushed ; no appetite ; great thirst; functions of the body otherwise well performed. '■ Reported by Mr. C. D. F. Phillips, Clinical Clerk. 614 DISEASES OF THE RESPIRATORY SYSTEM. Progress of the Case.—On the following day the dyspneea and pain had dimi- nished. On the morning of the 25th there was considerable sweating, nnd next day a copious sediment of phosphates and lithates appeared in the urine, and it was observed that the febrile symptoms had dissappeared. The pul>e was 84. soft. On auscultation, a friction murmur could be heard at the upper margin of the dul- ness on the right side. On the 3d of August, the pulse was 72, and weak. The pain still continued, and the physical signs were the same. On the Cth, the extent of the dulness, the cegophony, and vocal resonance began to diminish, and the friction murmur to increase. On the 9th, no friction could be heard, and the respiratory murmurs were audible in the primarily dull portion of lung. On the 2 7th, with the exception of slight dulness, she was quite well, and was dismissed by her own desire. On admission, twelve leeches were applied to the affected side, followed by warm fomentations. Two purgative pills were administered, and a third of a grain of tartrate of antimony, with " ss of solution of morphia, ordered to be taken every four hours. Subsequently a succession of blisters was applied to the rieelfth of a grain of antimony evcru four hours. Had a blister applied last night, which has risen well. Sept. 17th.—Xo pain in the side even on a deep inspiration. Has no fever; appetite good; expresses himself as much better. Pulse 100, small and weak. Dulness has become universal over the right side posteriorly, and anteriorly ascends to the second rib, above which a cracked-pot sound is audible. There is now no difference on percussion, when in the upright and when in the recumbent position. Respiratory murmurs posteriorly are feeble and distant, not healthy; cegophony well marked. On the left side posteriorly, expiration puerile. Anteriorly on right side, respiration exaggerated superiorly, feeble inferiorly, and vocal resonance increased. No friction murmur any- where audible. Sept. 18th.—Dulness has extended higher. Cracked-pot sound more limited, but increased in intensity under the clavicle. Posteriorly an occasional friction sound was detected; ordered to have this part painted with iodine. Sept. 19/A.—Dulness now clearly limited by a line, the convexity of whicii is down- wards, its greatest distance being from the clavicle one and a quarter inch, and its smallest distance one quarter of an inch. Sept. 21st.—Cracked-pot sound—now limited to a spot below the sterno-clavicular articulation—is not so audible. Com- plains of dyspneea when walking. Sept. 22d.—Cracked-pot sound replaced by a somewhat metallic sound. Patient feels so much better, that he is anxious to leave the hospital to resume his labours. 23c?.—Very little expansion of right side of chest even on deep inspiration. A warm poultice to be applied over the whole right side of chest. 26th.—Patient complains that after walking quickly he experienced dyspneea. Hot spongio-piline to be applied to foment the whole side. Patient takes three ounces of wine daily. 27th.— The convex line of dulness anteriorly, which has for seven days been stationary at the line mentioned on the 19th, has now become lower, and not so clearly defined. No cough nor expectoration. Pulse 80 per minute, rather feeble. Appetite pretty good. Fomentations and wine continued. October 2<£—Resonance in front, and internal to the nipple, extends as far down as sixth intercostal space. Dulness to the right of the nipple still remains. The resonant portion at the anterior and upper part of right side may be bounded by a line 616 DISEASES OF THE RESPIRATORY SYSTEM. drawn from the upper part of the axillary region to the nipple. Pulse gradually gaining strength. 4th.—The anterior portion of right side has almost entirely regained its normal resonance. Lateral region of same side is also more clear on percussion. Anteriorly and laterally over fourth and fifth ribs, and posteriorly to a lesser degree, there is heard friction de retour. The palpitation has again returned and on auscultation, a very soft murmur is heard with the first sound. \3th.—Per- cussion perfect over the whole of anterior surface of right side of thorax; still a little dulness posteriorly. Friction de retour is only slightly marked during ordinary respiration. 18th.—Both sides of chest expand equally on deep inspiration. An- teriorly over both sides of chest, resonance equal. Laterally, external to nipple of right side, there is marked sense of resistance and slight diminution of tone on percussion when compared with opposite side. Posteriorly over whole of right side, percussion duller than over left, but still resonance is greatly increased to what previously existed. On auscultation posteriorly, respiratory murmurs equal on both sides; no friction anywhere but on right side ; vocal resonance increased, especially laterally below the axilla. His general health has long been quite good, and he nsisted on going out. Dismissed. Commentary.—On the admission of this man, it was supposed, and I still think correctly, that the comparative dulness which existed on per- cussion over the right back depended on the pleurisy he had had in the previous June, and that the wandering pains and slight fever were owing to rheumatism. Two days afterwards, fresh exudation was evidently poured into the right pleural cavity, and it is a remarkable fact that it continued to increase until the whole of that cavity was occupied, and this without fever, pain in the side, or any of those symptoms which are thought the usual indications of acute pleurisy. In this state the exu- dation remained stationary for seven days, then began to be absorbed, and gradually disappeared. In short, we had the most distinct evidence from physical signs of the commencement, onward progress, and decline of an acute pleurisy, without any functional symptoms whatever, the man all the time maintaining he was in perfect health, and being with great difficulty retained iu the house for the sake of observation. In this respect, the case proves that an acute pleurisy, like an acute pericar- ditis (Case XC), may be altogether latent, and at no period of its pro- gress give rise to those symptoms with which systematic writers have made us so familiar. For another remarkable example of this fact, see Case CXXVII. It is unnecessary to comment in this place on the im- portance of such cases in reference to treatment, and to former views as to the good effects of blood-letting and antiphlogistic remedies. In the case of Stanbroke (Case LXXXVII.), we saw that a pericarditis required no such remedies to enable it to pass through its natural progress, and we have here another illustration of the same fact in reference to pleuritis. Local pain appears to be an accidental occurrence, aud in no way essential to a true inflammation. Case CXXV.*—Chronic Pleurisy on both sides—Bronchitis. History.—John O'Neill, set. 40, a writer—admitted into the clinical ward * Reported by Messrs. Cunningham and Calder, Clinical Clerks. PLEURITIS. 617 Xovember 28th, 1850. Three weeks before admission he was suddenly seized with a severe pain in his left side, which impeded breathing. Three days afterwards feeling better, he returned to bis employment, but in the evening he experienced distinct rigors, and the pain returned. Strong febrile symptoms followed, with cough and expectoration. He has been under medical treatment since then, and now, on admission, is considerably better. Symptoms on Admission.—On percussion there is complete dulness over the whole of left side, anteriorly and posteriorly, with the exception of the infra- clavicular region, where the dulness is incomplete. Over the whole of right side there is unusual resonance. The expansion of the chest is greatly diminished on the left side with absence of vocal fremitus. On auscultation, the respiratory mur- murs are inaudible over left side, except at the apex, where, there is prolonged expi- ration accompanied with sibilant rale. On the right side anteriorly, loud sibilant rales, both with inspiration and expiration. Posteriorly the respiratory murmurs are puerile. Increased vocal resonance, amounting to bronchophony, heard over whole of left side, assuming an cegophonic character over scapular region. On right side vocal resonance normal. Frequent and severe cough, followed by copious expec- toration of frothy mucus. No pain in chest on taking a deep inspiration, but occa- sional "stitches" in left side. No dyspneea. The apex of heart beats in the epi- gastrium, immediately below ensiform cartilage, and its sounds (which are healthy in character) are heard most distinctly on right side of sternum inferiorly. Pulse 68, small. Urine turbid, with deposit of lithates. Appetite good. Other systems normal. Pisogress of the Case. On the 9/A of December a friction sound was heard below the left clavicle, and the resonance on percussion was more diffused. On the 26th, loud friction sounds had extended from above on the left side down to an inch below the nipple, and dulness on percussion was confined to the two lower thirds ofthe lung The bronchitis, also, was diminished, and on the 17th of January ihe cough and expectoration had ceased, and the bronchitic rales had disappeared. On the 23d of February a careful examination showed that there was complete dulness over left lung, from the nipple downwards, and that on auscultation there were loud double-friction souuds with absence of respiration. He now complained of dull pain on the right side of chest inferiorly, and on the following day there was heard in that situation a double-friction sound, which, however, disappeared on the 5th of March. It returned every now and then, accompanied by "stitches" more or less severe. On the 2d of April there was dulness over both sides of chest, anteriorly from the nipple downwards, together with double-friction sounds on both sides. The expansion of both sides of chest is now equal—that on the left side having greatly increased, and the respiration being audible over its two superior thirds. During the whole of April the physical signs underwent no change, and he suffered considerably from dyspneea. In May the dulness was more circumscribed on the left, and more extended on the right side. The dyspnoea, however, was diminished, and his general health so improved that he was enabled to take walks in the gre en. During the months of June and July he continued to improve, but complained of occasional pain in the chest, and cough, with slight expectoration, originating apparently from imprudent exposure to cold. The respiration, however, insensibly extended itself inferiorly on the left side, and towards the end of July the dulness «as greatly diminished on the right side also. At this time he was so well that he was dismissed, August 4. The treatment consisted at first of expectorants and anodynes to mitigate the bronchitis, together with a course of the iodide of potas- sium, and frequent blisters applied to the pleuritic side. In February, pills of calomel and opium were ordered, which caused slight salivation for a period of ten 618 DISEASES OF THE RESPIRATORY SYSTEM. days. On the appearance of pleurisy on the right side, it was combated by frequent application of leeches, followed by counter-irritation. The latter remedy was con- tinued from time to time during his subsequent residence in the house, together with occasional expectorants, anodynes, anti-spasmodics, and purgatives, according as his symptoms required them. Commentary.—In this case the disease ran a more chronic course beginning on the left side, and subsequently attacking the right. As the one declined, the other increased, and in both the physical signs determined with great exactitude the extent of the fluid exudation, its subsequent absorption, the rubbing of the diseased surfaces against each other, and, lastly, their subsequent adhesion. These changes occupied a period of upwards of eight months. Seeing the slow pro- gress of the case, and the indisposition the exudation exhibited to be absorbed, mercury was tried, and salivation maintained for ten days. At this time, such was the state of discomfort it produced, so thoroughly did it destroy the appetite and thereby diminish the vital powers, that it was discontinued. So far from causing absorption, the action of the drug not only failed to do so, but pleurisy on the opposite side actually developed itself while the system was under its influence. Surely facts of this kind ought to disabuse medical men of the notion, still very pre- valent, of the power of this drug in causing absorption of an exudation. (See Pericarditis.) Pathology, Diagnosis, and Treatment of Pleuritis. The physical signs of pleurisy can scarcely be understood without an accurate acquaintance with the appearances which the exudation assumes on the pleural surface. This is essentially the same as has been pre- viously described in the case of Pericarditis, p. 2G6. In very acute cases of pleuritis, which have proved rapidly fatal, 1 have repeatedly observed the following appearances :—On elevating the sternum, care having been taken not to disturb the body for some hours, the pleural cavity on the side affected has been found full of an appa- rently clear fluid of a yellowish or greenish tint. On removing this by means of a small shallow cup, the first portions seem perfectly clear and transparent. On continuing to empty out the fluid, it has been observed that the deeper we descend the more turbid it becomes, until at length nothing but a semifluid mass is removed. It will frequently be fouud that large portions of this mass, although tolerably consistent, are semi- transparent, resembling a light-coloured calfs-foot jelly, whilst other portions present the usual opaque appearance. Sometimes, when the body has been undisturbed for twenty-four hours, the whole exudation is separated into two distinct portions,—the upper, fluid and perfectly transparent, whilst the lower is composed of a pultaceous mass, resem- bling a bread-and-water or oatmeal poultice. In all such cases, the fibrinous portions, from their superior specific gravity, have sunk to the bottom, whilst the supernatant serum remains clear. The semi-traus- parent lymph is the portion most recently exuded, in which very few of the plastic corpuscles formerly described, p. 128, have been deve- loped. PLEURITIS. 619 When the progress of the exudation is less rapid, the coagulated fibrin or lymph assumes a more consistent appearance, and forms over the part inflamed, flocculi of different sizes, or a distinct lining, varying in thick- ness from half a line to an inch. This is always villous, but sometimes it presents a honey-combed appearance, or hangs in the serum in loose flakes of a dentritic character. A serous membrane, when inflamed, re- sembles a mucous surface, and, in point of fact, performs the functions of one for a time, and is very active in absorbing the serum. Occasion- ally also it assumes a lamellar arrangement, attributable probably to repeated exudations of blood-plasma at different times. This may be frequently observed on the pleura, and layer after layer may be readily dissected off. Sometimes there is more or less blood extravasated with exudation, causing it to assume various tints of red, mahogany, purple, etc., according to the amount thrown out, and the period which has elapsed before examination. When the inflammation has been less acute, or is of longer standing, we find, after death, that the coagulated blood-plasma or lymph has become more consistent. It assumes a more distinctly fibrous appearance, often extending between opposed serous surfaces in the form of bands, which have considerable tenacity and strength. These bands have a great disposition to contract, and ultimately become shorter and shorter, and assist in forming a dense substance, which at length firmly unites together the serous surfaces. This uniting substance becomes more and more dense, and not unfrequently resembles ligament in toughness and general aspect. In this form it may frequently be seen in phthisical cases, uniting together the lobes of the lung aud pleural surfaces. Occasionally it assumes even a car- tilaginous hardness, resembling the fibro-cartilage of the intervertebral substance. Iu this state it may fre- quently be observed on the pleurae, and I have seen it thus half an inch thick, intimately uniting the lungs to the ribs. When it has been very slowly developed, it produces white indurated patches, of a glistening cartilaginous appearance, varying in extent, the surface of which has assumed the character of a serous membrane, and in no way interferes with the movements of neighbour- ing organs. Such patches are ex- ceedingly common on the surface of parenchymatous organs, as the lungs, heart, liver, spleen, and kidneys. Occasionally encysted abscesses of the pleura are re- Fis-428- solved, and their walls contracting assume a cartilaginous hardness. Fig. 428. Remains of a pleural abscess. (Markham.) 620 DISEASES OF THE RESPIRATORY SYSTEM. Dr. Markham has recorded a remarkable example where the pyogenic walls in this manner formed a tube surrounded by puckering of the pleura pulmonalis, the lung itself being quite healthy. The hardish gritty particles scraped from its roughened inner surface consisted chiefly of cholesterine and granular matter.* (Fig. 428.) Lastly, false mem- branes on the pleural surfaces, but especially on the costal one, may as- sume a stony hardness, from the deposition of calcareous matter; and patches of this character may be scattered over the serous membrane, or may exist in disseminated points. The minute structure of the coagulated exudation, composed of plastic or pyoid corpuscles and molecular fibres, has been previously described and figured, p. 128. These fibres are more and more aggregated to- gether the more dense the lymph becomes, and, in cases of calcareous deposition, are associated with molecules and irregular masses of earthy salts, mingled with crystals of cholesterine, and, it may be, numerous fatty molecules and granules. It results from our knowledge of the morbid anatomy of pleuritis, con- joined with careful observation at the bed-side, that, if a large quantity of fluid be interposed between the pleurae, the respiratory murmurs will be lost, while the vocal resonance is diminished. If the amount of fluid be small, the murmurs are obscure, and the vocal resonance assumes a peculiar vibrating character, said to resemble the bleating of a goat. This is cegophony. If strings or bands of chronic lymph exist, which are stretched during the movements of the chest, then the rubbing sound will assume a leathery or creaking character; and if there be calcareous deposition, a filing or grating noise may be produced, although this is very rarely heard over the pleurae. Not unfrequently dense adhesions, with thickening of the fibrous tissue uniting the pleurae, may occasion partial dulness, and increase of the vocal resonance, a result not uncom- mon at the apices of the lung, but wbich must be carefully distinguished from the condensation from tubercle. With regard to the treatment, it is essentially the same as that of other acute inflammations. It is rare that a case enters an hospital in its incipient stage, that is, when the serous membrane is unusually dry, and before much exudation has occurred. But in private practice such cases are more common, and occasionally they may come on in the ward of an hospital. At this early period, a general bleeding was for- merly recommended, with a view of cutting short the inflammation, the possibility of which we have discussed at p. 2.">7. When, however, exudation has been poured out to any extent, and has coagulated, bleed- ing is injurious, and we must endeavour to favour the development, absorption, aud excretion of the exudation, by means of warm topical applications, sudorifics, and diuretics. The urine especially should be carefully watched, as the sediments it contains will serve as an index to the amount of exuded matter excreted. Care should also be taken, at this period, not to allow the general strength to sink, for it is only by keeping up the nutritive functions that we can assist the vital powers in making those transformations which are essential in procuring the dis- appearance of the fluid, and adhesion of the solid exudation. By some, calomel is considered to be directly indicated as a means of favouring " Path. Soc. Trans. VoL ix. p. 51. PLEURITIS. 621 absorption from the serous cavity. It was fairly tried in Case CXXV., but was more productive of harm than of good; and although I have frequently seen the drug employed for this purpose, I have not met with a single instance where its good effects have been unequivocal. If there be much local pain, warm applications at first, and subsequently blisters, tend to remove it. On some occasions, when the exudation has been very abundant in the pleural cavity, and the vital powers of the economy are constitution- ally low, and have been depressed by injudicious antiphlogistic treatment or want of rest, the changes described do not occur. The exudation in such cases passes into pus, although some of the fibrous element attaches itself to and lines the membrane. This termination of pleuritis is denominated empyema. Case CXXVI.*—Empyema, with Fistulous Openings between the Lung and Pleural Cavity, and between the Pleural Cavity and External Surface. History.—George Fair, aet. 30, a ploughman—admitted December 10th, 1850, in a very exhausted state. Fourteen months ago had acute pleuritis, on account of whicii he was confined to bed for eight weeks, and was bled several times. Three months afterwards he still felt occasional pain in the right side, which gradually became more constant and severe, and at length was accompanied by cough and expectoration. He now perceived a small swelling below the right nipple, which, at the end of last July, was the size of a hen's egg. It was then opened by incision nnd a quart of purulent matter extracted. About the end of August, two other apertures formed spontaneously in the neighbourhood ofthe previous one. As soon as matter was discharged from the external opening, the amount of expectoration was diminished, Symitoms on Admission.—Thoracic walls much depressed under right clavicle; right side of chest motionless on taking a full inspiration; three apertures still exist in the thoracic walls; the upper one (that made by the incision) is between the sixth and seventh ribs, immediately below the right nipple, the two others a little lower down, and somewhat smaller; from all three there is a copious purulent discharge. Circumference of the thorax, on a level with the right nipple, measures thirty-five inches; from the spinous processes of the vertebra? to the sternum on the right side, measures sixteen and a half inches, and on the left, nineteen inches. On percus- sion, the left side is resonant throughout; on the right side there is dulness every- where, but most marked in the inferior two-thirds ; posteriorly, the dulness is not so marked as in front. On auscultation, the respiratory murmurs on the left side are puerile : under the right clavicle the respiratory murmurs are harsh, and the vocal resonauce increased; a little lower down the respiratory murmurs become more feeble, and there is crepitation with the inspiration; in the remaining lower two-thirds of the right front, the respiratory sounds are inaudible; over the whole right back, the respiratory murmurs are feeble ; the vocal resonance increased and cegophonic ; in the lower third crepitation is audible. Pain over the sternum and under right clavicle; cough neither frequent nor severe; expectoration scanty, partly white and frothy, partly tenacious and muco-purulent. Apex of heart beats feebly half an inch to the left of its natural position. Pulse 92, slightly jerking, but compressible ; gene- ral strength much reduced. * Reported by Mr. J. M. Cunningham, Clinical Clerk. 622 DISEASES OF THE RESPIRATORY SYSTEM. Progress of the Case.—In the beginning of January, he was attacked with vomiting and diarrhoea, accompanied with febrile symptoms, which greatly diminished his strength; his countenance assumed a hectic appearance, and the openings in the thorax became painful and larger, their margins were inflamed and ulcerating, and the discharge continued. On the 17th, it was ascertained by means of the probe that of the three openings the middle one alone enters directly into the pleural cavity, and admits with ease a No. 8 catheter; the other two communicate with the central one underneath the integument. On the 29th, diarrhoea, and purulent discharge from the chest had diminished, his appetite and general health were also improved but he was removed from the house by his friends. The treatment consisted at first of good diet and tonics ; and, when the vomiting and diarrhoea appeared, various remedies to check these symptoms. On the 18th of January, a small canula and Xo. 8 catheter were introduced side by side into the opening into the pleura. By means of a Read's syringe attached to the former, about a pint and a half of distilled water, at the temperature of 90=, was injected into the pleural cavity. The fluid escaped through the flexible catheter, but did not equal in amount what was thrown in, and was at length discharged clear and unmixed with pus. During the half hour imme- diately following the operation, a quantity of clear water oozed from the wound. Commentary.—When this man entered the house his general strength was much reduced; and it was apparent from a careful study of the physical signs and symptoms, that a communication existed between the lungs aud pleural cavity, in addition to the external fistulous opening into the latter. The pleuro-pulmonary fistula had evidently formed before the opening through the thorax was made artificially, as evinced by the marked diminution of expectoration on the evacuation of pus externally. That it continued to exist, I was satisfied, by observing that the sputum was increased when the external discharge diminished, and vice versa. Two errors had been made in the previous treatment. These consisted, —1st, In the " frequent bleedings," which had so diminished the general powers of the system, as to have cheeked those changes in the exuda- tion necessary for recovery; 2d, In making a free incision, instead of a small puncture, to draw off the purulent matter. Of these two errors, the first, however, was the greatest; indeed it was irremediable. The second was probably undertaken with the idea formerly so prevalent, that pus is injurious to the economy, and when known to exist should be let out as soon and as freely as possible. We now know that there is nothing to be feared from the mere presence of pus, either in the lung or pleural cavity; and that the most natural method for its disappear- ance is by absorption and elimination. Still, when large in amount and either pointing externally, or displacing the heart internally, no danger can arise from making a puncture with a small canula, as practised by Messrs. Cock and Syme, and sanctioned by Drs. Hughes and Alison. Indeed there is every chance of producing benefit, for we thereby save the vital powers a considerable amount of unnecessary work, and so faci- litate the disappearance of the exudation and return of expansion to the compressed lung. With regard to the operation of paracentesis thoracis, and the good effects attending it, I refer you to the excellent papers of Dr. Hughes,* and the lecture of Dr. Alison.f * Guy's Hospital Reports, vol. ii. Second Series. f Monthly Journal, August, 1850. PLEURITIS. 623 In the case before us, the difficulty experienced was to rally the gene- ral strength, especially after it had been so much reduced by diarrhoea, and this was to some extent accomplished. My attention was then directed to the cure of the thoracic disease; and it occurred to me that if the pus could be replaced by water, there would be less labour thrown upon tbe weakened absorbing surface. The pleural cavity, therefore, was washed out with distilled water, heated to 90° as directed; and this would have been repeated at intervals, had he not left the house, and thus put an end to every effort undertaken for his benefit. Case CXXVIL*—Chronic Pleuritis and Pneumo-Tliorax, without Symptoms—Arti- cular Rheumatism—Pericarditis—Recovery. History.—William Dow, tet. 33, boot-maker—admitted 26th of January, 1857. States that he has always been a temperate man up to his present illness, and has had pretty good health. On the 12th of last December, after exposure to cold and damp during the day, he was seized with articular pains, which affected most of the joints, and have continued to wander from one to the other up to the present time. On the evening of the 7th of January, independent of any exertion, the patient was suddenly seized with acute pain in the umbilical region, attended with difficulty of breathing; these symptoms were at once removed on taking a powder, which caused the expulsion of much wind. He denies ever having had cough, pain in the side, or any pulmonary symptoms whatever. Symptoms on Admission.— On inspection of the chest, there is less expansion on the right than on the left side anteriorly; posteriorly, the right side bulges considera- bly below the level of the third rib; the measurement of the corresponding sides is slightly different; the girth of the left side being fifteen and a half, that of the right sixteen inches. The movement of inspiration on the right side is very slight; on the left the girth is increased half an inch on a full inspiration. Percussion note over the right side, anteriorly, is tympanitic from apex to base, being flatter at the apex. It likewise extends on a level with the nipple over the left side to about half an inch beyond the sternum. On auscultation, there is slight harshness of respiratory mur- murs at apex of the left lung, the sounds of which are otherwise normal. On the right side, the vesicular murmur is supplanted by loud amphoric breathing, more distinct towards the base. Expiration is much prolonged. In the recumbent pos- ture, both inspiration and expiration are accompanied by a clear prolonged metallic note, exactly like the distant blast of a trumpet, somewhat louder with expiration. Vocal resonance over the middle third is of a loud brazen metallic character. Pos- teriorly on this side, percussion superiorly is tympanitic, but below second dorsal spine, dulness commences, becoming more intense as it extends to the base of the lung. Laterally its extent is bounded by a line drawn vertically from the posterior fold of the axilla. At the apex, inspiration is blowing, with prolonged expiration, and at the close of inspiration a moist click is heard. Towards the base, the respi- ratory sounds are scarcely audible, and inspiration is accompanied with an obscure crepitation (?) Vocal resonance at apex and base is cegophonic, but over the mid- dle third it is normal. No cough, expectoration, dyspneea, pain, or other pulmonary symptom. Impulse of heart's apex felt in the usual position. Transverse dulness and sounds normal. Pulse 108, feeble. Patient is somewhat deaf; has still pain in both knee and ankle joints, and in the right shoulder aud carpo-phalangeal joints. * Reported by Mr. T. J. Walker, Clinical Clerk. 624 DISEASES OF THE RESPIRATORY SYSTEM. Tongue dry and furred, otherwise normal. Copious deposit of lithates in the urine He is much emaciated, and for the last seven weeks has perspired very freely. Habeat Pulv. Doveri gr. xij. hord somni sumenda. Progress of the Case.—January 28th.—Pain in the joints is now bo much relieved, that he can move the limbs with comparative freedom. He slept well last night. IJ. Potass. Nit rat., Potass. Bicarb, aa Z ij-; Aqua; ad 3 vj. M. Capiat z s.«, ter indies. Jan. 29th.—On examining the patient to-day, Dr. Bennett found that. while ly ing on his left side, percussion note was duller over the sternum than when he lay on his back, and the slightly dull tone over the right lateral region became clear. When also the patient is placed in a sitting or recumbent posture, dulness ex- tends from the back forwards to the centre of the right lateral region, and upon being laid on his left side, the posterior part of the lateral region becomes resonant. Jan. 31st.—Physical signs over right side of chest continue as before. Apex of cardiac organ beats with a visible impulse somewhat to the inner side of a line, vertical from the nipple between the fifth and sixth ribs. At the margin of sternum a double rumbling sound is audible, not quite synchronous with the sy-tolie or diastolic move- ments. Transverse dulness of heart on percussion still two inches. Pulse 100, small rather hard. Respirations twenty-two. Feb. 2d.—Friction murmurs at the base of the cardiac organ more audible ; the patient has no pain over pericardium, nor uneasiness, except after cough, over the chest generally; feels very slight tender- ness on percussion over the sternum at the level of fifth and sixth ribs. To hart spongio-piline saturated with warm water, applied over the precordial region. Feb. 5th. —Patient so well as to get up in the morning, and from this time he rapidly reo-ained his strength. The pulmonary signs have undergone no change. The friction mur- murs over the heart gradually diminished, and disappeared on the 12th, while a blowing murmur was gradually established, heard loudest with the first sound over the apex. He was dismissed March 11th. June 22d.—He was re-admitted to-day, having in the interval again lost streugth in consequence of his work being too fatiguing, and his appetite having fiiiled him. The amphoric respiration, metallic notes, and brazen resonance of voice, have now disappeared from the right side, which is dull on percussion, immoveable during in- spiration, with slight trace of respiratory murmur, and great increase in the vocal resonance. Left lung healthy, with peurile respiration. Still a blowing murmur with the first sound of the heart, loudest at the apex. To have nutrients, with ? iv. of wine daily. July 28th.—Since last report his genei'al health has been improving, and he now looks fat and well nourished, and says he is much stronger. Has no pain, cough, dyspneea, or inconvenience of any kind. There is now decided flattening anteriorly over the upper third of the right chest. On deep inspiration it expands much more than formerly. It is still everywhere dull on percussion, with great increase of vocal resonance amounting to bronchophony anteriorly, and pectoriloquy posteriorly and superiorly. Respiratory murmurs are absent over upper third of lung. but inferiorly and anteriorly inspiration is audible but feeble, and posteriorly is much stronger. Discharged. Commentary.—It is no uncommon thing for men who have previously had pleurisy, to be seen walking about the streets with one side of the chest more or less dull on percussion and incapable of action, although complaining of nothing. But this, so far as I am aware, is the only instance on record where pleurisy has come on and proceeded to the formation of extensive pneumo-thorax, not only without symptoms, but without the cognizance of the patient. Yet such is the case before us. For when I demonstrated to the clinical class at the bed-side the tyin- PLEURITIS. 625 panitic sound over the right chest on percussion, the absence of healthy respiration, the metallic notes with the respiratory murmurs, and the brazen amphoric vocal resonance, he himself denied that there was any- thing wrong with his chest, and smiled at the trouble we gave ourselves in examining it. In his case, as in Case CXXIV., after the acute rheu- matism subsided, we had the greatest difficulty in keeping him in the house for the purpose of observation. On his going out, however, he himself at length became satisfied that his breathing was not so good as it outh vomiting recurred, together with abdominal pain and tenderness, as described in the report of the 18th. These continued to become severe till the morning of the 2 2d, when he sunk, with all the marks of great depression of the entire system. He died at 2 a.m. on the 22d. From the moment of the patient's entering the hospital, every effort was made to sustain his strength by means of the most nourishing diet, together with wine. Diarrhira was put a stop to by the use of cretaceous mixtures, and the rigors were successfully treated with quinine. The vomiting was diminished by bismuth and aromatic powder, and towards the end of the case he was greatly relieved by the use of brandy, and ice internally. Effervescing lemonade was allowed latterly to allay the patient's thirst. Sectio Cadaveris.—Twenty-eight hours after death. Body considerably emaciated. On reflecting the integuments, and removing the sternum and ribs anteriorly, so as to expose the thoracic and abdominal cavities, the contained viscera were observed to be dis- placed as follows:—The left thoracic cavity presented an empty space, in consequence of the lung being compressed and tightly bound down to the spinal column (Fig. 4-9, 6). The heart was in the centre of the body, passing somewhat to the right side. The stomach was enormously dilated, ex- tending to the pubes, and concealing all the abdominal viscera, except a portion of the right lobe of the liver and colon (Fig. 429. e). Thorax.—On opening the thorax, there was an escape of frvtid air from the left side. The pericardium was everywhere strongly adherent. The heart and its valves healthy, weighing with pericardium, 8| oz. The left pleural cavity contained about 6 oz. of dirty foetid purulent fluid. The surfaces of the pleurae, parietal and visceral, were covered with a layer of chronic lymph, having scattered throughout its substance opaque yellow spots of the size of millet seeds, resembling tubercle. This layer of lymph could readily be scraped off, and was seen to be about one eighth of an inch in thickness, having a soft pulpy layer internally, and where attached externally, The lung was bound down to the spinal column by firm and Fig. 429 to be highly vascular Fig. 429. Relative position of the thoracic and abdominal viscera, on reflecting the integuments in Allan Brown's case, a, Empty left thoracic cavity; b, left lung; c, right lung; d, heart; e, enormously distended stomach; f, liver; g, colon. PLEURITIS. G29 dense adhesions. Its tissue was compressed and carnified, and its size reduced to :i spindle-shaped body about five inches long, and two inches in its greatest diameter (Fig. 429, b). On insufflation it expanded very imperfectly. At the apex there was a cavity ofthe size of a walnut, having a distinct lining membrane, and filled with soft, cheesy, tubercular matter, evidently of old standing. Scattered through the sub- stance of the lung were numerous small masses of tubercles, but no other cavities. The right lung was universally adherent by dense chronic adhesions. It was mode- rately voluminous, and at the apex were numerous stellate puckerings, corresponding to dense fibrous cicatrices in the substance of the pulmonary tissue, but without con- cretions. Abdomen.—The stomach was enormously dilated as formerly described (Fig. tL'il, e). On opening it, it was found to be distended with air, and somewhat twisted round on itself at the junction of the cardia and oesophagus. All the coats were very thin, apparently from the distension. The mucous coat was healthy, and no abrasions could be discovered in it. But between the serous and muscular, as well as the muscular and mucous coats, numerous bullas of air were visible, which could be moved about by pressure of the fingers, evidently dependent on the existence of some gas in the texture, whicii was in no way putrid, nor was the gas itself of foetid colour. In the ccecum and ascending column were numerous small depressions in the mucous coat, the cicatrices of former ulcers. There was nowhere any trace of recent intestinal ulcerations. The spleen weighed 8 oz.; sp. gr. 1063. Its pulp was healthy, but the malpighian bodies were enlarged throughout, and resembled grains of boiled sao-o. The kidneys were pale, and had two or three small masses of tubercle imbedded in the cortical substance. Liver and other organs healthy. Commentary.—The place for making an opening into the thoracic cavity in empyema should always be chosen with the greatest care. The general rule is, that if the pus causes a prominent tumour, to punc- ture there, but if not, then one of the intercostal spaces between the fifth and seventh ribs should be chosen, but so as to avoid the heart and diaphragm. In the above case, with bulging of the thoracic walls infe- riorly and posteriorly, the opening was made at the most prominent part by a large incision, and the offensive matter it contained replaced by air. This proceeding, which converts an empyema at once into pneumo- thorax, it is argued, can have no ill effect, so long as the aperture remains free, and the air thereby prevented from becoming foetid. The operation was had recourse to more as a palliative than as a curative proceeding in the present case, the phthisical complication rendering ultimate recovery very improbable. My impression, however is, that under more favourable circumstances, the small puncture, avoiding admission of air as much as possible, holds out the best prospect of success. The mode of death in this case was very remarkable, and indeed, so far as I am aware, unique. The man to relieve his thirst was allowed two or three bottles of effervescing lemonade as drink during the day. It would appear, that on the 15th of December he complained of fulness of the stomach, and tympanitic distension of the abdomen, which symp- toms, however, excited no great attention, although they may have origi- nated in the same cause, which apparently produced the more violent complaints that came on subsequently. On the evening of the 18th he was seized suddenly with all the symptoms of perforation of the bowel, 630 DISEASES OF THE RESPIRATORY SYSTEM. and on examining him next day, such was what I believed to have occurred. There was great abdominal tympanitic swelling, excessive pain, vomiting, etc. But on dissection we found that these symptoms depended on great distension of the stomach, with emphysema of its coats, the latter a lesion, which I believe was then observed for the first time. It was not caused by putrefaction ; and the question arose, How was it produced ? It turned out on inquiry from the nurse and neigh- bouring patients, that the man had kept his bottles of effervescing lemonade till the evening, and drank at least the coutents of two of them in quick succession. It is probable, therefore, that the extrication of gas had distended the stomach, and caused it to twist round partly on itself at the cardia, so as to prevent its escape. Hence the distension and pain, and why probably the contained air, not finding a ready exit through either the cardia or pylorus, had forced its way between the coats of the organ itself. With regard to the other facts of this case, they present in a well marked form all the characteristic phenomena, first of empyema of the left side, and secondly, of pneumo-thorax. A disquisition on these two thoracic diseases, their diagnosis and treatment, would lead me too far. There is only one point to which I think it necessary to refer, namely, the cause of metallic tinkling; and I do so merely to say that notwith- standing the ingenious theories which have been advanced to account for it, they all appear to be faulty. I have satisfied myself that the break- ing of bubbles of air on the surface of fluid, or the splashing of water in a cavity containing air, will not always explain the occurrence. On one occasion I heard metallic tinkling most distinct over the lung in a man dying of phthisis. After death I commenced the examination by mak- ing an opening between the ribs cautiously, over the centre of the tym- panitic space, thinking that air wrould escape. But the pleurae were uni- versally adherent. There was no cavity whatever, but simply hard nodules of tubercle, scattered throughout a highly emphysematous lung. PNEUMONIA. " Case CXXIX.* — Pneumonia on Rigid Side and slight Pleuritis—Recovery. History.—Roderick M'Farlane, set. 20, a gardener, of healthy and robust constitu- tion—admitted December 17th, 1856. On the 12th instant felt unwell, with a sensa- tion of cold in the back. On the 13th had pain in the right infra-axillary region, increased on deep inspiration, with hot skin, headache, thirst, and loss of appetite, symptoms which have continued ever since. On the 14th, cough appeared with scanty expectoration. Has taken a dose of castor-oil and some pills. Symptoms ox Admission.—Expansion on both sides of chest equal. Respirations twenty-four in the minute, not laboured. Can lie on either side, but prefers lying on the back. Pain during deep inspiration over right infra-axillary region; slight cough ; scanty expectoration—frothy and mucous. On percussion, cracked-pot reso- nance extends from clavicle to fifth rib on right side. Below this level, percussion is dull. There is also decided dulness posteriorly from spine of scapula to base. Elsewhere percussion natural. On auscultation, puerile respiration over left front; * Reported by Dr. /. Glen, Resident Clinical Physician. PNEUMONIA. 631 over right front superiorly respiration is harsh, without rale; below fifth rib it is suppressed. Posteriorly over two lower thirds, double friction is audible, with fine crepitation at the close of inspiration ; on left side occasional sibilus, with a few moist rattles at close of inspiration over lower third. The vocal resonance is increased and sharp on right side anteriorly, but greatly increased and cegophonic posteriorly over area of dulness. Pulse 104, incompressible and full. Skin hot and dry. Tongue in centre, brown, dry, and cracked; edges moist and clean. No appetite • great thirst; bowels always regular, but have been opened by laxatives. Urine natural. Other functions normal, fy So!. Antim. Tart. 3" ss; Aqua; Amnion. Acet. ;j; Aqwel viss. M. Habeat sextain partem quartd qudque hord. Progress of the Case.—December 18th.—Grazing friction audible over the right infra-mammary region. Crepitation distinct over right back inferiorly. Pulse 120, soft. Sputum scanty, consisting of orange-coloured gelatinous masses. Other- wise the same. Dec. 20th.—Crepitations very coarse over right back. Fever abated. Tongue moist and clean. Pulse 72, of good strength. Temperature of skin natural. Omitt. mist. Dec. 22d.—Crepitation and friction disappeared from right back. Abundant sediment of lithates in the urine. IJ Sp. /Ether. Nit. Z iij; Yin. San. Colchici, 3 j; Aquas ad 3 vj. M. Two table-spoonfuls to be taken every four hours. Dec. 24th.—Dulness over right back and cracked-pot sound anteriorly greatly diminished. For the last three da}-s has had profuse diaphoresis. Urine again natural. Omitt. mist. To have steak diet. Dec. 26 Solve. One ounce to be taken everg three hours. Progress of the Case.—June 5th.—Says he feels better; pulse 90, full and com- pressible, but in the evening it fell to 80, and became soft. June Oth.—Pulse 78, soft, breathing more easy. On percussion, the lower half of right lung is dull, but the upper half is resonant, with distinct cracked-pot sound. Fine crepitation audible over the whole of right chest. June 8th.—The whole of the right lung in front has become resonant on percussion ; otherwise the same. Faint traces of chlorides in the urine. June 9th.—Chlorides abundant in the urine. June 10th.—Percussiou resonant and equal over both sides of chest anteriorly. Under right-clavicle, cracked-pot sound still audible. Crepitation much less inferiorly, but continues at the apex, with increase of vocal resonance. Posteriorly, percussion over right lung dull inferiorly, with loud crepitation and cegophonic resonance of voice. The patient feels much better, though weak. Respiration free. Pulse 72, soft and regular. Considerable diaphoresis. Urine deposits on cooling a large amount of lithates. IJ Antim. Tart. gr. ij: Tinct. Camph. co. 3 ij ; Decoct. Serpent. § iij. M. 3 j to be taken (very three hours. June 14th.—Physical signs of right lung, with the exception of cracked-pot sound, much diminished. Has been taking, during the last three days, good diet, with 5 iv. of wine. From this time he improved slowly, the crepi- tation and dulness posteriorly gradually disappeared, but the cracked-pof sound con- tinued with great intensity up to the 29th of June. His strength was not sufficient to admit of his discharge until the 3d of July. Commentary.—This was a case in which nearly the whole of the right lung became pneumonic, and where we had an opportunity of con- vincing ourselves that full and repeated bleeding, although practised so early us the second and third days, had no beneficial influence on the pro- gress of the disease. It should also be remarked, that these bleedings were practised in accordance with the rules laid down in systematic 634 DISEASES OF THE RESPIRATORY SYSTEM. writings, that is to say, not only early, but when the pulse was accele- rated, hard, and incompressible, with all the characteristic symptoms of the disease. Surely, if bleedings could cut short or diminish the dura- tion of a pneumonia, it might have been expected in this case. Yet so far from proving beneficial, they appear to me to have assisted in pro- longing the case, and preventing resolution and recovery. For although the critical diaphoresis, and discharge of lithates by urine, occurred on the fourteenth day, the subsequent weakness was considerable. On his admission into the house, the eighth day of the disease, the chlorides were observed to be absent from the urine. This fluid was tested daily for these salts, which returned in small quantity on the twelfth, and were abundant on the thirteenth day of the disease. If, as we shall subsequently see, it is probable their reappearance indicates a cessation of fresh exudation, then it was observable that on the day fol- lowing, excretion of the morbid products commenced by the skin and kidneys. The interval between the return of chlorides to the urine and the critical period, varies considerably in different cases ; but the careful estimate of these facts in future will, I think, furnish us with valuable hints as to the vital power of the exudation. If, for instance, it should ultimately be shown that the return of chlorides indicates stoppage of exudation, and the presence of lithates or other critical discharge, the commencement of excretion of the exudation, then we shall possess evidence not previously discovered, as to when the pathological lesion is checked, and when the reparative changes in the economy commence. Another fact, which excited considerable attention in this case, was the characteristic cracked-pot sound under the right clavicle. The physical signs sufficiently proved that the pneumonic condensation com- menced at the base of the lung, and proceeded upwards, where, poste- riorly and anteriorly, a considerable amount of air was retained in the air vesicles, so that percussion was never dull, although crepitation and increased vocal resonance existed. This presence of condensed lung, covered with or surrounded by air, or of a cavity containing air, surrounded by condensed tissue, seems to constitute the condition under which this peculiar noise is elicited when the mouth is open. Hence the occurrence of the cracked-pot sound (bruit de pot fele) is common in pneumonia and in a variety of diseases which present similar physical conditions.* Case CXXXII.f—Erysipelas ofthe Face followed by Pneumonia ofthe Right Side- Recovery. History.—Margaret Armstrong, vet. 28, wife of a shoemaker, of robust healthy appearance—admitted December 7, 1855. She states that she was quite well up to Wednesday evening last (December 5th), when, after being engaged for some time in washing, she was seized with rigors and febrile symptoms. Next morning her face felt painful aud swollen, and has continued so up to the time of admission. When examined in the ward, the whole of the face and forehead was of a fiery red * See the Author's clinical investigation into the diagnostic value of the erac.u-d- pot sound—Edin. Med. Journal, vol. i., p. 789 1856. f Reported by Mr. G. Robertson, Clinical Clerk. PNEUMONIA. 63J colour, the integuments, and especially the eyelids, greatly swollen, with a few bullae on each cheek, full of yellow lymph; the skin everywhere hot, and in the face giving rise to a severe smarting sensation. Tongue and lips dry, covered with black sordes; great thirst; no appetite; cephalalgia; pulse 130, soft; bowels not open. Urine natural in quantity, turbid from pinkish sediment, containing a considerable amount of albumen, and a very scanty quantity of chlorides. To have 3 ss of castor oil, and the face to be covered with cloths wrung out of warm water. Progress of the Case.—December 11th.—To-day the face is assuming its natu- ral colour, the epidermis desquamating. There is no albumen in the urine, and the chlorides are abundant. Dec. 13th.—The erysipelas has now disappeared, but there is a general aspect of prostration. She has had a short cough for the last two days, which cannot be ascertained to have been ushered in by rigors. Breathing hurried and laborious. Pulse 92, small. On percussing the chest posteriorly, there is com- parative dulness over ri<>ht back inferiorly. On auscultation, a fine crepitation is audible there on inspiration, with sonorous and sibilant rales and increased resonance (almost pealing) of the voice. Dry rales are also heard anteriorly on this side, causing deep inspiration, with c>i rse moist rale. There is no expectoration. Urine abundant, of brick dust colour, which disappears on the addition of heat; sp. gr. 1022, r.o albu- men, and the chlorides have disappeared. To have beef tea, and 3 vj of wine daily. Dcc 17//,.—The pneumonia, since last report, has produced complete dulness, with bronchophony in the lower third of right lung, which is, however, now disappearing. To-day, chlorides in urine are more abundant. Dec. 19th.—Diseased lung more resonant on percussion. Breathing more natural, free from moist rale. Still increase of vocal resonance. Chlorides abundant in urine. Diminish wine to 3 iij daily. Ihc.2ith.—To-day can breathe without difficulty; respiration on right side normal, but still some increase of vocal resonance; pulse 66, of good strength. Expresses herself as being quite well. Has been for the last few days on good diet, and walking about the ward. Wishes to leave the hospital. Dismissed. Commentary.—The erysipelas in this case was very severe, but occur- ring, as it did, iu a healthy young woman, gave us little concern, and was allowed to take its natural course. Warm water applications only were employed to relieve the smarting. The disease, in consequence, had disappeared by the seventh day. The chlorides in the urine were diminished during the accession of the fever and presence of the erup- tion, and returned abundantly when the erysipelas had disappeared. The ward at this time was very cold, from some of the ventilators, which allowed the admission of frosty air, not having been closed. Pneumonia on one side came on, and the chlorides again disappeared from the urine. The attack supervening on an acute febrile disease was characterised by great prostration of the system and weak pulse throughout. But, under the careful exhibition of nutrients and six ounces of wine daily, she made t a rapid recovery. The pneumonia was detected on the 13th. The chlorides had returned on the 19th, and she was dismissed at her own request, quite well, on the 24th. The pneumonia was only of seven days' duration, up to the time of commencing resolution. Case CXXXIII.*—Double Pneumonia—Treatment by Mercury, which caused Profuse Salivation before Admission—Prolonged Recovery. History.—Robert Jude, set. 36, a bricklayer—admitted ICth December, 1855. * Reported by Mr. John Glen, Clinical Clerk. G36 DISEASES OF THE RESPIRATORY SYSTEM. On the 1st instant, while engaged building bricks round a boiler, the weather being very cold and windy, he suddenly felt a pain in the chest, deep-seated, half way between the ensiform cartilage and umbilicus. The pain rapidly grew worse, and caused nausea, but he could not vomit. He immediately went home, took some gruel and went to bed. On the 4th, a medical man gave him some pills, one of which he took every third hour. On the Gth his teeth were loose, the gums very tender and the tongue swollen to twice its natural size, so that he could not spit out the excessive nmount of saliva that was secreted, and which consequently flowed from his mouth. He also had pain in the loins. Symptoms on Admission.—On admission, the excessive salivation had much diminished, but there is still tenderness and redness of the gums, with considerable discharge from the mouth. The breath foetid, the tongue covered with a dense dirty white coating. The bowels, while taking the pills, were open from six to seven times a day; they are now regular. His diet has been confined to farina- ceous articles. On percussing the chest anteriorly, it is everywhere resonant, but posteriorly it is dull on both sides, most so on left side. On auscultation anteriorly nothing abnormal, but posteriorly respiratory murmurs are harsh and shrill, with occasional sibilation. At the base on right side, there is crepitation on inspiration; on the left side respiration is tubular. Vocal resonance equal superiorly and ante- riorly, but posteriorly everywhere increased, on the left side amounting to broncho- phony. Pulse 96, weak; heart sounds normal; skin hot, moderately dry, but there has been profuse perspiration; there is dull pain in lumbar regions; urine opaque from the existence of a reddish cloud; sp. gr. 1024, not coagulable, but clear on the addition of heat; chlorides diminished in quantity. \\ Sp. jEther. Nit. Z iij ; Potass. Acetat. Z ij; A quae ad 3 vj. M. One table-spoonful to be taken every four hours. If. Liquor. Soda; Chlor. 3 j ; Sp. Vini Gallic. 3 ss; Infus. Rosar. c. ad 5 vj. M. Ft. gargarisma. Progress of the Case.—December 11th.—Crepitation more diffused over right back. On left side respirations still dry and harsh. Chlorides absent from urine. Dec. 12th.—Crepitation now audible over left back. Lithates in urine more abun- dant. Discharge of saliva still copious, hut greatly diminished in amount. Pulse 80, weak. Habeat vini 3 iij per diem. Dec. 13th.—Chlorides in urine again percep- tible. Dec. 14th.—Chlorides in urine abundant. Crepitation posteriorly diminishing, sputum still copious, frothy, and somewhat gelatinous. Breath continues to give off the mercurial fcetor. Dec. 15th.—Last night had copious diaphoresis, followed by great relief in his breathing. Still a few crepitations posteriorly, increased vocal resonance, more marked on left than on right side. Urates very abundant in urine. From this time he gradually improved. On the 21st all moist rale had disappeared, but respiratory murmurs harsh posteriorly, and vocal resonance still increased. Dec. 26th.—Still a coppery taste in the mouth. Yesterday felt hungry for first time, and was ordered an egg for breakfast and steak for dinner. From this time he rapidly recovered, and he was dismissed January 2, 1856. Commentary.—In this decided case of pneumonia, with absence of chlorides from the urine, we had an opportunity of observing the effects of mercurial salivation on the progress of the disease. If it be con- trasted with mauy other cases of the same kind previously recorded, it will be seen that the disease itself was in no way shortened by the exhibition of mercury. Ilesolution commenced on the fourteenth, but was not completed till the twenty-first day. On the other hand, the unpleasant effects produced by the mercury, the severe swelling of the tongue, soreness of the gums and profuse salivation, must not only PNEUMONIA. 637 be regarded as so many increased evils and unnecessary symptoms nuperadded to the original disease, but as being the cause of prolonging the convalescence. For although the leading physical signs had 'dis- appeared on the twenty-first day, he could not eat until the twenty-sixth day, in consequence of the coppery taste in his mouth. But as soon as nutrients could be taken, he recovered rapidly. No fact could better demonstrate the utter uselessness of the drug, and its occasional mis- chievous effects. i ask CXXXIVY*—Pneumonia of Right Side—Critical Diarrhoea on ihe Twenty-first Day—Recovery. History.—James Murray, set. 53, a hawker—admitted June 30th, 1851. Has been much subject to coughs and colds, from exposure to the weather, when follow- ing his employment. On the 24th inst., at noonday, he was seized with rigors, sharp cutting pains in the right side, anorexia, thirst, and headache. These symp- toms confined him to bed, and became so severe that he says he was occasionally delirious. The treatment has consisted only of a blister, which was applied to the right side of the chest. Symptoms on Admission.—On admission, percussion over the chest anteriorly is i;orrnal, but posteriorly there is marked dulness over the lower two-thirds, on ri-riit side, where there is much pain on coughing, and on taking a deep inspiration. On nuscultation over the dull portion, crepitation is audible, especially at the base, with tubular breathing above* and bronchophony. No expectoratiou. Pulse 112, of good strength. Tongue furred, great thirst, loss of appetite complete. Severe headache, urine of a reddish colour, and contains no chlorides. Other oro-ans healthy. R Antim. Potass. Tart. gr. iij ; Sol. Mur. Morph. 3 j ; Aqua; ad "% vj. M. One ounce every second hour. Also at bed-time to take a draught containing a drachm and a half of the Tincture of Hyoscyamus. Progress of the Case.—July 3d.—To-day the chlorides have appeared in the urine in small quantity; pain in side diminished. Puhe 110, soft. Physical sio-ns the same. To have ^ ij of wine—discontinue Tart. Antim.— IJ Potass. Acet. 3iv; tip. Al'her. Nit. Z ij ; Aqurc | iv. M. 3 j to be taken three times a day, July 4th.— Urine contains abundance of chlorides. July 9th.—Still dulness, crepitation, and bronchophony over right chest. No expectoration. July 13th.—Blister to be applied to the right side. July 15th.—This morning he was seized with vomiting, followed by purging. He had 7 or 8 stools. To-day he is much better. The right chest unfortunately could not be examined on account of the soreness of the blis- tered surface. But from this time he rapidly improved. On the 24th, still slight crepitation. Has never bad expectoration. On the 26th the crepitation still con- tinuing, I ordered him to lie on the abdomen. On the 30th crepitation absent. August 4th.—Dismissed cured. Commentary.—This case exhibited.a rare negative symptom in pneu- inouia, viz., the complete absence of expectoration, all the other symp- toms and signs being present. In this and the two subsequent cases I looked for the usual critical appearance of lithates in the urine about the fourteenth day, but in vain. It is somewhat remarkable also that in the>e cases, instead of presenting the usual signs of crisis by urine, * Reported by Mr. Almeric Seymour, Clinical Clerk. G38 DISEASES OF THE RESPIRATORY SYSTEM. they were seized with sudden diarrhoea, of a severe character, but of short duration, which ushered in convalescence. Whether this was at- tributable to any choleraic disposition, or peculiar state of the atmo- sphere, must be unknown ; but I had never previously seen diarrhuu so uniformly critical in cases of pneumonia as during the summer of 1S54. The crepitation continued to linger in the minute bronchial tubes lono- after the pneumonia had disappeared. This I attribute in such cases to congestion from decubitus, and find it easily removable by causing the patient to lie as much as possible on the abdomen. Case CXXXV.*—Pneumonia of Left Side—Critical Diarrhoea on the Fourteenth Day—Recovery. History.—Thomas Shepherd, set. 23, a brassfounder, a strong healthy man— admitted July 11th, 1854. He states that, on the third instant, when rising in the morning, he was seized with rigors, dull pain in the left side and loins, thirst, ano- rexia, headache, and cough. On the previous evening he had walked far, perspired much, and gone to bed exposed to a draught from his window. On the 5th, a medical man administered purgatives and other medicines, probably salines. On the 8th, dyspnoea became urgent, and the feverish symptoms were augmented. He was then bled to the extent of 18 or 20 oz., and experienced much relief. Symptoms on Admission.—On admission, the left side of chest does not expand equally with the right. Anteriorly, the left lung is resonant, but posteriorly it is dull on percussion over its two lower thirds. On auscultation over the dull part, loud tubular breathing, with crepitation and broncophony, are heard. Respiration 24 in the minute. Sputa scanty, of gelatinous consistence, tinged of a rusty colour. Pulse 84, soft, but of good strength. The tongue red and dry; appetite diminished; urine contains no chlorides. Other functions healthy. To take a quarter of a grain of Antim. Tart, and five minims of Sol. Alar. Morph. every second hour. Progress of the Case.—Jxdy 13th.—To-day the tubular breathing is gone; crepitations abundant and coarser. On adding a drop of the solution of Nitrate of Silver to the urine, a faint white haze is visible. July 14th.—Urine to-day contains abundant chlorides. Pulmonary signs the same. July 16th—To-day was seized with pains in the abdomen and diarrhoea. July 20th.—Diarrhoea has continued until to-day, but has now ceased. No pulmonary crepitation; no expectoration, only slight bronchophony and dulness. From this time he rapidly recovered, and was dismissed well, July 31. Commentary.—The bleeding on the fourth day in this case, though, according to the patient, it caused temporary relief, evidently pro- duced no modification in the progress of the pneumonia, which ran its natural course, and terminated, like the former one, by a critical diarrhoea. Case CXXXYT.f—Double Pneumonia—Critical Diarrhceaon the Twenty-first Day- Recovery. History.—James M'Naughton, set. 34—admitted June 30, 1854, a shoemaker. * Reported by Mr. Almeric Seymour, Clinical Clerk. t Reported by Mr. Almeric Seymour, Clinical Clerk. PNEUMONIA. 639 States that he has been much addicted to the use of intoxicating liquors. From the 21st to the 2I?d inst. he was in a continuous state of intoxication" and on the morning of the 24th he awoke with dull pain in the chest, great dyspnoea, cough, and ex° pectoration of matter, which, he says, resembled pure blood. He has undergone no medical treatment. Symitoms on Admission.—On admission, the respirations are 44 in the minute. Sputum copious, of deep prune juice colour. On percussing the chest anteriorly^ there is slight dulness on the right side inferiorly, but posteriorly the dulness is very marked over the inferior 3-4ths of both lungs. On auscultation, dry tubular breathing is heard over the dull parts, with bronchophony, but on taking a forced inspiration coarse crepitation, deep-seated, is audible; respiration at both apices and over chest anteriorly puerile. Pulse 120, weak. Tongue covered with a yellowish fur, thirst no appetite, headache ; general appearance sallow—indicative of exhaustion ; he com- plains of great weakness. Urine of deep cherry-red colour; sp. gr. 1020, contains no albumen or sediment, and no chlorides. Other functions normal. To have one-third of a grain of Antim. Tart, every three hours; 3 iv of wine daily. Progress of the Case.—July 3d.— The wine was increased to 3 vj daily, his symptoms having undergone no change. July 4th.— To-day chlorides have appeared in small quantity in the urine, which presents the same cherry-red colour. Crepita- tion audible in left lung posteriorly, right lung as before. Sputum lighter, with less ofthe prune juice appearance. July 7th.—Since last report there has been marked improvement. To-day the urine contains abundant chlorides. Crepitation over both sides of chest posteriorly. To have forty minims of Sp. ^Ether. Nit. and twenty grains of Potass. Acet. in solution thrice daily. July 10th.—Over the whole of back posteriorly coarse crepitation; still bronchophony, and abundant sputum, tinged with blood. July 15th —Last night was seized with diarrhoea. He had six copious watery stools. To-day no crepitation audible; respirations natural, except in left Bupra-scapular region, where bronchophony is still audible, but not so harsh as formerly. Urine now clear and in every way normal. From this day he rapidly improved, and was dismissed, August 2d, quite well. Commentary.—This was a very severe case of double pneumonia, in a broken down and dissipated individual, who was saved by wine, and ia whom a choleraic diarrhoea, accompanied by vomiting, proved critical on the twenty-first day. Cask CXXXVIL*—Pneumonia, ushered in by Violent Vomitiny and Gastric Pain— Recovery in five days. History.—Edward Nugent, ast. 28, a waiter—admitted November 8th, 1858. Has always enjoyed good health until about three weeks ago, when he went to Liverpool from Glasgow by water, and suffered very severely from sea sickness. Three days afterwards, on the return passage, he was again very sick, and for a few days after felt soreness in the epigastric region. He then became quite well until .buiday the 8th, at 1 p.m., when, whilst cleaning plate, and about ten minutes after eating a hearty dinner, he was suddenly seized with severe pain in the epigastrium, cold sweats, vertigo, desire to vomit, but inability to do so. He was immediately con- veyed to the Infirmary. Symptoms on Admission.—The patient-was pale and livid, almost pulseless, and complained of sickness, cold, profuse clammy perspiration, and great pain in * Reported by Mr. Arthur Garrington, Clinical Clerk. G40 DISEASES OF THE RESPIRATORY SYSTEM. epigastrium, increased on pressure. Shortly after admission he vomited what he had taken at dinner, but was not relieved; warm bottles were applied to his feet and hot fomentations to the painful part. His suffering continued; at 4 p.m. six leeches were applied to the epigastrium, and 3 ss of Morphia administered. The.se remedies gave some relief, and he remained in comparative ease till about 10 p.m. when some Magn. Sulph. was given, as the bowels had been costive for some davs previously. Progress of the Case.—November 9th.—He had no sleep during the nifriit, and bis symptoms have remained stationary. He has had three or four dark-coloured stools. Early in the morning he was ordered for the vomiting r} Creasoti gtt. ij; Sol. Mur. Morph. 3 ss; ft. haust; also a table-spoonful of Port wine every hour. At the visit (noon) his symptoms had in no way abated, and he was ordered to con- tinue the wine; to take beef tea iu small quantities; and a tea-spoonful ofthe following mixture every hour until the pain decreased:—1} Sol. Mur. Morph. 3 ij; Sp. A^th. Sulph. 3 vj; Ft. mist. The mixture caused great relief, and in the afternoon he was able to bear further examination. The cardiac sounds were indistinct; pulse 58, extremely feeble and intermitting. Respiration laboured, and the pain in epigastrium increased during inspiration. There was slight harshness of inspira- tion, and increased vocal resonance under both clavicles. He had great pain at the back of his head, and some giddiness; tongue dry and furred; no appetite; great thirst; no perceptible swelling in epigastrium; abdomen tender and hot; urine natural in colour and quantity, but only a slight trace of chlorides. In the evening he was better, the pain had greatly subsided, and there was less sickness; he was able to retain some small quantities of beef tea. Slight dulness, increase of vocal resonance, and crepitation, were detected at the base of the left lung pos- teriorly. Nov. 10th.—He passed a tolerably good night, and had some sleep; the epigastric pain and sickness still further diminished. Pulse 98, weak. The physical signs observed in left lung last evening were not audible at visit, hut were again heard in the evening. Ordered to discontinue the mixture, and to continue the wine and beef tea in small quantities. Nov. 11th.—He passed a good night; he still has slight sickness and tenderness over epigastrium. He complains of pain in the left breast, increased during inspiration; he has some shortness of breath, troublesome cough, and a greyish, tenacious sputum containing a few rusty-coloured masses. Marked dulness, with increased vocal resonance, and clear crepitation, audible over lower third of left side posteriorly. Pulse 88, tolerably full; tongue loaded. The patient says he has had rigors every day since admission, and yester- day was so cold that be had warm bottles applied to his feet. On examination of the urine, the chlorides were still diminished, and there was a deposition of triple phosphates. Nov. 12th.—Now sleeps well. His appetite is much improved. The epigastric pain and tenderness and the sickness have disappeared. Pulse 90, full and regular. Crepitation very fine; vocal resonance still increased. Cough not so bad, no rusty masses in the sputum. Nov. 13th.—The crepitation has disappeared; there is some harshness of inspiration. Sputum muco-purulent. Chlorides abundant in the urine. His bowels being confined, he was ordered an enema of warm water. Nov. 15th.—Respiration quite natural. He says he only feels a little weak, but n otherwise so well that he insists on being discharged. Commentary.—In this case of severe gastric irritation, pneumonia came on in the Infirmary—was well characterized by all the symptoms and physical signs of that disease, was limited to the posterior third ot the left lung, occurred in a healthy young man, and was treated by stimu- lants and nutrients from the beginning. The result was recovery on PNEUMONIA. 641 the fifth day and discharge from the hospital at his own request quite well on the seventh day. It is the most rapid recovery from decided pneumonia that has ever fallen under my notice. The facts of this case are also entirely opposed to the notions of those who consider that inflam- mation is in some way connected with a sthenic or excited state of the system. The man was in perfect health when seized with the gastric spasms, and was by them reduced to a pulseless and exceedingly pros- trated state, with cold clammy sweats. It was in this weakened condition that the pneumonia arose, and its limited extent and short course I ascribe to the stimulants, nutrients, and quietude with which it was treated from the first. Case CXXXVIII.*—Double Pneumonia, with urgent Symptoms, and full, strong Pulse—Pleuritis on Left Side—Recovery in Nine Days. History.—John M'Farlane, set. 30, a railway labourer—admitted Nov. 12, 1858. Has been subject to a slight cough and expectoration, sometimes tinged with blood, for the last ten winters ; otherwise he has enjoyed good health. On Nov. 9th, whilst workin" on a railway bank, which was much exposed to wind and cold, he was sud- denly seized with great pain in his lower extremities ; he, however, continued at his work till the evening, when he experienced a sharp pain in his left side, with diffi- culty of breathing, and general febrile symptoms. He went to bed, and on the 10th, feeling no better, he sent for a medical man, who ordered a blister to be applied to the left side; he also gave him a powder, and a mixture which made him very sick. The pain was slightly relieved after the application of the blister, and he felt much easier on the 11th, but on the 12th the pain increased, while the difficulty of breath- ing and of expectorating became so bad that he was brought into the Infirmary. Symptoms on Admission.—His face was much flushed ; skin hot and dry; tongue moi.< and with a white fur; great thirst; pulse 95, full and regular; urine orange- coloured, with a copious sediment of urates, only a slight trace of chlorides, and a brace of albumen. His respirations were quick and laboured. Expectoration very tenacious, with numerous rusty-coloured masses iu it. Cough frequent and painful. On the left side anteriorly percussion was good, but crepitation was heard all over the front, with the exception of a space 2^ inches below the clavicle, where the re- spiratory sounds were very harsh. Posteriorly on this side there was marked dulness from the spine of the scapula to the base of the lung, over which space loud crepita- tion was heard, and pealing vocal resonance, more especially about the centre of the lung. On the right side anteriorly there was slight comparative dulness over a spacs extending from the clavicle two inches downwards. Posteriorly on this side there was slight comparative dulness at apex, where expiration was prolonged, and the inspiratory murmur harsh. fy Pulv. Dover!, gr. x., to be taken immediately. IJ toI.Antim.l'y, Potass. Acet. 333; Aqua; ad § viij ; Ft. mist. Two table-spoonfuls evei-y four hours. Progress of the Cask.—Nov. 13th.—Passed a sleepless night. Cough incessant, and dyspnoea urgent; face livid. Pulse 112, full and strong; sputum very copious, rusty aud gelatinous. In addition to physical signs formerly reported, there was faint crepitation all over right back posteriorly (most distinct at apex), but no great increase of vocal resonance; friction over left side anteriorly below nipple, both with expira- tion and inspiration, but loudest with former, and posteriorly marked dulness over * Reported by Mr. Arthur Garrington, Clinical Clerk. 41 642 DISEASES OF THE RESPIRATORY SYSTEM. inferior two-thirds, with loud crepitation and bronchophony. Ordered to be cupped to 3 v over region of pain < n left side, and to take only one table-spoon ful of the mixture to which is to be added Sp. AVth. Nitr. 3 ij- To have strong beef-tea and milk. Nov. 14lh.—Patient says he felt relieved by the cupping for 3 or 4 hours, but the pain returned afterwards as bad as before. There is still great dyspneea and lividity of face; expectorates about 18 oz. of punilent, gelatinous, frothy matter, tinned with rusty-coloured blood, during the twenty-four hours. Pulse 98, soft and irregular. To have a table spoonful of wine every hour. Omit mixture. Nov. 15th.—Dyspneea and pain in side much diminished. Sputum less rusty. Pulse 100, stroii" and rcmlar Very coarse crepitation (amounting to mucous rattles) heard over left side anteriorly. Respiratory murmurs harsh and dry over right side anteriorly. There is still marked comparative dulness over left back, and also in upper third of right back. Tubular breathing over upper fourth of right back, harsh inferiorly. Crepitation over left back, but more feeble than before. Vocal resonance the same. Urine quite clear and no deposit. Chlorides have been increasing since the 13th, but are not yet in normal proportion. Still thirsty and feverish. 1}. Sp. A?th. Nitr. 3 iij ; Potass. Acet. 3 ss : Aqua1 ad 3 vj ; Ft. mist. To be taken as before. To continue the milk, wine, etc. and to have 6 oz. of beefsteak. Nov. 18th.—Patient says he feels very much better. All crepitation gone, but there is slightly increased vocal resonance on left side. Urine loaded with urates. Convalescent, but steak to be increased to 8 oz., and wine o be diminished to 3 iv. daily. Nov. 24th.—Has been getting gradually stronger nee last report. Yesterday he got up for some time, walked about the ward, and exposed himself to draughts in the passages. This led to an attack of acute rheu- matism, for which he was again confined to bed, and ordered Potass. Bicarb. 9j three times a day. He gradually got better, and was quite free from muscular pains on Dec. 4th; he got up on the 7th, and with the exception of slight weakness, felt quite well. 2 oz. extra beefsteak were ordered on the 11th, and he left the Infirmary on the 13th in perfect health. Commentary.—This is what some former writers would have called an " exquisite " case of pneumonia, occurring in a man who, with some emphysema, was accustomed to have attacks of bronchitis and bloody expectoration every winter It presented all the symptoms of the disease, including pain in the side, great dyspnoea, lividity of the face, strong and full pulse, with copious rusty sputa. Physical signs also proved it to consist of hepatization of the two inferior thirds of the left lung, and of the superior half of the right lung. Occurring in the year 1858, it dis- poses of two theoretical statements which have of late been much dis- cussed, viz.—1st, That such cases are now not to be met with ; aud, 2d, that if they should occur, bleeding would again be required for their treatment. In this respect the case resembles that of Roderick MTar- lane, Case CXXIX. ; and in severity that of Peter Robertson, Case CXXX. In consequence of the dyspneea and evident engorgement of the right side of the heart, he was cupped, and 3 v of blood extracted, with the effect of relieving his symptoms, but for a time only, as they returned with equal intensity in a few hours. This is the result which usually followed large venesections, and which misled practitioners as o its utility. I have no doubt that a large bleeding in this case, if it had not proved fatal, would have seriously prolonged his recovery, which took place under an opposite treatment on the ninth day. The case inculcates another caution, viz., the necessity of avoiding exposure to cold during convalescence, as in the debilitated condition which then PNEUMONIA. 643 exists there is very likely to be a relapse, or some other form of febrile disease, again proving that these are the results of weakness rather than of strength. It is unnecessary to multiply proofs, or to give stronger evidence of the correctness of those principles of treatment, which have already been given at length, p. 264, et seq. (For other examples of pneumonia, variously complicated, see cases IV., XXL, XXII., XXIII, XLIX' L., LVIII., LXXXIX, XCIV., XCIX.) On the Diagnostic Value of the Absence of Chlorides from the Urine in Pneumonia. Simon and Redtenbacher first stated that chloride of sodium, a salt always present in healthy urine, was absent from that fluid during the onward progress of pneumonia, and returned to it when absorption of the exudation was about to commence. This statement was confirmed by Dr. Beale of London, who, in the 35th vol. of the Transactions of the Medico-Chirurgical Society of London, furthered our knowledge regarding it by additional valuable researches. My attention was di- rected to this remarkable fact during the Session 1853-4, by Dr. Rob- ert Cartwright, a gentleman attending the Clinical Wards of the Infir- mary, who informed me that he had seen it occasionally of great service in a diagnostic point of view, in the clinical wards of Professor Oppolzer at Vienna. It so happened that a man, John M'Donald, set. 25, had just been admitted, labouring under well marked simple pneumonia at the apex of the right lung. He was a labourer, who had enjoyed perfect health until two days before admission, when, on being exposed to wet and cold, working in drains, he was seized with shivering, followed by fever and the usual symptoms and signs of pneumonia. On adding a drop of nitric acid to some of his urine in a test tube, and then dropping into it a little of the solution of the nitrate of silver, the fluid remained clear, although so great is the delicacy of this test, that a white cloudy precipitate is at once formed, if a very minute quantity of the chloride of sodium be present. It was on the fourth day of the disease that the observation was first made, and the chlorides remained absent during the fifth and sixth days, during which period the disease extended from above downwards, until it occupied the upper two-thirds of the right lung. Ou the seventh day a slight haze was observed in the urine, indi- cating that the salt was returning to that fluid, and the man expressed himself as being much better. On this day there was great dulness on percussion, all crepitation had ceased, the breathing was tubular with bronchophony. Ou the eighth day, slight returning crepitation was audible, the dulness had diminished, but the urine, owing to some acci- dent before the visit, had been thrown away. On the ninth day, how- ever, the chlorides were abundant in that fluid, together with lithates; loud crepitation was now universal throughout the lung, and the dul- ness had nearly disappeared. From this time the man made a rapid recovery, never having been bled, and was discharged quite well on the sixteenth day. I now requested Mr. Seymour, one of the clinical clerks, to test the 644 DISEASES OF THE RESPIRATORY SYSTEM. urine of all the patients in the ward, and others who might subsequently be admitted, which he did, and thus collected a large number of obser- vations, the results of which I shall allude to immediately. In the mean time another case entered, which seemed to point out the value of this test in a diagnostic point of view. It was that of a man, Donaldson ret. 26, labouring under typhus fever, in whom the disease ran its usual course to the tenth day, when chlorides were demonstrated in it. On the eleventh day, however, pulmonary symptoms came on, and the chlo- rides were entirely absent from the urine. This led me to make, with the clinical class, a careful examination of the chest, when all the signs of pneumonia were detected in the lower half of the right lung. On the fourteenth day the chlorides reappeared, the pneumonic signs dimin- ished, and the fever ceased with a critical sweat. A third case was even more satisfactory in proving the moment of commencing and departing pneumonia by testing the urine for chloride of sodium. A man called David Murray, sat. 43, entered with pneu- monia of the lower two-thirds of the right lung. No consistent account could be obtained from him as to when the disease commenced, and it was impossible, therefore, to determine whether the coarse crepitation which was audible over the inflamed lung was the advancing or returning crepitation; but the chlorides were absent from the urine, which indicated that the disease was advancing. The following day complete consolidation had occurred, with dry tubular breathing and absence of crepitation, and a minute quantity of the chlorides was found in the urine. The patient, however, instead of getting better, showed no im- provement, and the next day the chlorides had again disappeared, indi- cating an extension of the pneumonia. On the evening of this day he was seized with acute meningitis, of which he died. On dissection, in addition to universal cerebral meningitis, the whole of the right lung presented the usual characters of grey hepatization. (See Case IV.) It will be observed in all the preceding cases, thirteen in number, that with the exception of Case CXXIX., the absence or decided dimi- nution of chlorides marked precisely the onward march of the pneumo- nia, whilst their presence indicated its cessation, and was generally ac- companied by the returning crepitation and commencing absorption of the exudation. It still remains to be determined whether the absence of the salts is a cause or a result of exudation into the lungs—whether the interference to the respiratory function, by diminishing the amount of oxygen absorbed, gives rise to those chemical changes in the blood which react on the urinary secretion. If so, what is the nature of these changes ? Indeed, a crowd of questions will be suggested to the mind of the physiologist, from the establishment of the remarkable clinical fact of which we are now speaking. That such is an important diagnos- tic sign I have now no doubt, and it was singularly well tested in the following case, in which there were many signs and symptoms of pneu- monia, complicated with heart disease. The question on admission was whether, with heart disease and bronchitis, pneumonia might not be conjoined, and I was assisted in answering in the negative by the abun- dance of chlorides which the urine contained. PNEUMONIA. 645 Cask CXXXIX.*—Bronchitis and Pulmonary Congestion, from Morbus Cordis, resembling Pneumonia, but no absence of Chlorides in the Urine. History.—John Dickson, aet. 44, pensioner—admitted July 21st, 1854. Says that on the evening of the 19th he was seized with chilliness, followed by sweating, heat of skin, thirst, impaired appetite and expectoration of a frothy fluid, resembling liquorice juice. He has for some time felt an uneasy sensation in the epigastrium, which, since his recent illness, has amounted to pain. Yesterday he experienced great dyspneea aud anxiety, symptoms which have continued until now. Symptoms on Admission.—On admission there is excessive dyspnoea, with expec- toration of a tenacious sputum, of a reddish-brown colour. On percussion, there is no comparative dulness, but posteriorly the resonance is impaired on both sides. On auscultation anteriorly, the expectoration is everywhere much prolonged, and posteriorly there is considerable crepitation with bronchophony. Pulse 92, of good strength. The heart's sounds are entirely masked by the prolonged wheezing expiration and agitation of the chest. He cannot lie on his back or left side, is easily agitated, frequently ex- periences palpitations, and cannot sleep. Abundant chlorides in the urine. Other functions normal. I£. Sp. JEther. Sulph. §ss; Aq. Cassia; § iv. One table-spoon- ful to be taken in water occasionally. To have one quarter of a grain of Antim. Tart. in solution every two hours. Progress of the Case.—July 25th.—Since last report the dyspneea has dimi- nished, the crepitation posteriorly continues, but the wheezing anteriorly is less. Still gelatinous sputum, speckled with rusty-coloured blood. The apex of the heart cannot be felt, but a double blowing murmur is now recognizable, accompanying both the first and second sounds—the systolic, loudest at the apex, and the diastolic, loudest at the base. Omit the Antimony. July 31st.—The pulmonary symptoms and signs have now greatly subsided, whilst the cardiac lesion has become more distinct. For this latter he remained in the house until the commencement of November, when he was dismissed greatly relieved. Mr. Seymour tested with great care, and at repeated times, the urine of upwards of fifty other cases in the wards, embracing a great variety of disease. He found the chlorides absent in one case of phthisis, with inter- current pneumonia, but in no other. They were also absent in one case of peritonitis, and in all the cases of small-pox. Further investigations will probably discover these salts to be absent in other diseases, which, although it may diminish the importance of the sign as distinctive of pueumonia, leaves unaffected its value as pointing out the onward pro- gress of that disease. In one or two cases of pneumonia, in which the disease was progress- ing, traces of chlorides were seen in the urine. This was discovered by Mr. Seymour (clinical clerk) to depend on an adulteration of the nitric acid, which, for testing urine, must be pure. The nitric should be tested according to the directions of the Edinburgh Pharmacopoeia for hydro- chloric acid, with which it is very apt to be mingled. It is of impor- tance that white nitric acid be added to the urine in the first in- stance, otherwise the nitrate of silver is very apt to throw down phos- phates, which, however, may be distinguished from chlorides by being * Reported by Mr. Almeric Seymour, Clinical Clerk. 646 DISEASES OF THE RESPIRATORY SYSTEM. dissolved in an excess of nitric acid, which does not affect the latter salts. What is very remarkable with regard to the absence of chloride of sodium from the urine, is that it appears in the sputum of pneumonic persons, and as it returns to the urine, it disappears from the sputum. I have not myself, however, made many careful observations on the chemical reactions of the sputum in this disease, but propose doing so, in the hope that it will throw further light on its diagnosis and patholoo-y. The General Pathology and Treatment of Acute Pneumonia. The pathology of pneumonia is comprised in what has been formerly said on exudation, p. 130, and more especially p. 2G5, the lesion consist- ing of liquor sanguinis poured into the air vesicles, minute bronchial tubes, and parenchyma of the lung. It may be well, however, to dwell a moment on the fact that the exudative process may be very limited, indeed con- fined to a few vesicles, and the minute bronchial tubes connected with them. This is vesicular pneumonia. We know it may be confined to a lobule or occupy an entire lobe, constituting the so-called lobular and lobar pneumonia. In either case the essential phenomenon of inflamma- tion, that is, exudation, has occurred, distinguishable on careful examina- tion of the pulmonary tissue, by the blocking up of air vesicles in the form of minute granulations. Occasionally the vesicular exudation may be felt on handling the lung in the form of minute indurations, varying in size from a millet seed to that of a pea—often red, but occasionally yellow, and in the latter case very liable to be mistaken for tubercles. Such small indurations, however, at length soften, and are converted into pus, like the lobar and lobular forms of pneumonia. Microscopic examination of the pulmonary tissue shows us, in the first instance, that the air vesicles, the minute bronchi, and the areolar tissue, are infiltrated with a molecular and granular exudation, which often forms a complete cast or mould of the vesicles and bronchi, easily separated mechanically by washing and pressure. Not unfrequently, as shown by Remak, these moulds are expectorated entire, and may be disengaged from the gelatinous matter with which they are associated, by throwing the contents of the spit-box into water, and teazing out the branched alaments. These, when magnified, present a fibrous exudation, in which fire embedded commencing pus corpuscles, with a greater or less num- ber of epithelial cells. Such portions of exudation as remain in the lung are transformed into pus in the usual manner (Fig. 378, p. 2G5), become ultimately disintegrated and absorbed into the blood, where they are chemically changed, and at length excreted from the system, principally by the kidneys. If, from the extent of the disease, or weakness of the patient, this process is checked, the patient may die, either from inabi- lity to excrete the effete matter in the blood, or from interruption to the respiratory functions. If the exudation be limited in extent, or have been poured out slowly from the commencement, it may become what is called chronic. Under such circumstances, the epithelial and pus cor- puscles of the pulmonary tissue may undergo the fatty degeneration, aud numerous compound granule cells be the result. If blood should have PNEUMONIA. 647 been extravasated, mingled with the other formations described, there will be often found red crystals of haematine, blood corpuscles surround- ed by an albuminous layer, and presenting the numerous transformations which they are known to undergo after extravasations. (Fig. 391, p. 375) Dr. Todd* observes, " When a patient suffers from pneumonia, the tendency is for the lung to become solid, then for pus to be generated, and at last for the pus-infiltrated lung-structure to be broken down and dissolved. Such are the changes when matters take an unfavourable course. On the other hand, recovery takes place, either through the non-completion of the solidifying process, or by the rapid removal, either through absorption, or a process of solution and discharge, of the new material which had made the lung solid." Now I have directed especial attention to the method in which the exudation is absorbed, and have frequently examined lungs after death in the stage of red hepatization, where death had occurred from cerebral haemorrhage or other disease.^ In some lun<*s there has been a pneumonia in all its stages, incipient in some places, solidified and red in others, grey and purulent in a third. In all these places, a gradation in pus formation has been observable. In the most solid hepatization, young pus cells may be observed some- where beginning to form, so that I am convinced that the exudation is always broken down through the agency of purulent formation—in short, that this is the normal process. I have never seen any evidence that a coagulated exudation is simply disintegrated and absorbed without the development of pus cells, and I conceive that all analogy as well as direct observation is opposed to the supposition. It follows that, so far from the formation of pus being the evidence of an unfavourable course of the disease, it is the normal and necessary transformation of the solid exudation, whereby it is broken up and caused to be absorbed. See Fig. 37S. p. 2G5. I have previously, at some length, endeavoured to point out that the principles which have hitherto guided the profession in their treatment of internal inflammations are erroneous (p. 257, et seq.). An inquiry into the results of the past treatment of acute pneumonia (p. 209, et seq:), shows that an antiphlogistic treatment, as formerly practised, was attend- ed with a mortality of 1 case in 3 ; that the treatment by large doses of tartar emetic led to a mortality of 1 case in 5 ; that the result of more moderate bleedings is a mortality of about 1 case in 7 ; but that a treatment directed to further the natural progress of the disease, as I have explained it, has been in my practice 1 case in 26. The three fatal cases, however, as previously explained (p. 274), were complicated ones, so that I have arrived at the conclusion, that pneumonia occurring pri- marily in healthy persons, so far from being a dangerous malady, will almost always get well, if exhaustion be prevented, by securing rest, avoiding lowering remedies, giving slight salines and diuretics to favour excretion of the morbid products, and wine nutrients should the pulse be weak. Local pain will be best relieved by warm fomentations or poultices. While such is what I now believe to be the best practice in acute pneumonia, it is not to be denied that many cases have got well rapidly * Beale's Archives of Medicine. No. l,p. 2. 648 DISEASES OF THE RESPIRATORY SYSTEM. who have been moderately bled. If, indeed, from twelve to eighteen ounces of blood be taken from a strong, vigorous individual, during the first two or three days of the disease, it frequently for a time diminishes dyspnoea and other local symptoms, by relieving the engorgement ofthe right cavities of the heart. But if pneumonia really exist, that is if exudation has occurred, we have no proof whatever that the disease has ever been shortened or otherwise permanently benefited by the practice. Whilst, then, it seems to be of no real advantage, there can be little doubt that in many cases, where weakness or want of stamina exists, it prolongs convalescence, and, if this be excessive, may render the disease fatal. Still, as a palliative, blood-letting to a small amount, say five or eight ounces, may be had recourse to, always taking care to avoid it in individuals with a weak and soft pulse, or feeble frame, while at the same time nutrients are given, and the other treatment described is practised, A case, however, requiring even such modified depletion must be regard- ed as a great rarity. In the same way, some pneumonic patients may escape any evil fixm mercurial salivation, but that this is ever beneficial or shortens the disease has not yet been shown. (See p. 276.) Case CXL.*—Chronic Pneumonia of Upper Third of Right Lung—Gangrenous A bscess—Recover g. History.—Betsy Brown, set. 48, married, a washerwoman—admitted September 12th, 1856. Had always enjoyed good health until the 22d of last month, when, in consequence of exposure to cold and wet, she experienced rigors, followed by heat, but without headache, thirst, or loss of appetite. This was followed by cough and expectoration, symptoms which have continued ever since. Two days ago she brought up a tea-spoonful of blood. Symptoms on Admission.—She complains of pain in the right hypochondrium, under the false ribs, not increased by inspiration. On percussion there is dulness over right apex anteriorly, and upper third of the right lung posteriorly. Inspira- tion heard over dull area is harsh, with occasional snoring during expiration. Vocal resonance greatly increased. Sputum scanty, tenacious, puruleut, with brownish streaks. Other portions of lungs healthy; no friction audible. Slight giddiness, tinnitus aurium, and feeling of weakness. Pulse 80, equal, and of moderate strength. Hepatic dulness normal. Other functions well performed. R^ Tr. Opii Camph. 3 ss ; Via. Ipecac. Z ij j Mist. Scillai ad § vj. A table-spoonful to be taken three or four times a day. Progri ss of thi: C.\:-e.—September 14th.—Expectoration more free.—A blister to be applied to upper part of right chest anteriorly. Sept. 29th.—There has been little change, except on the day before yesterday, when she vomited her food, complained of headache, and presented slight febrile symptoms. Pulse to-day is 80, and weak ; no shivering. Bowels costive. A saline mixture, with § iv of wine, and to have i ss of Castor Oil. Oct. 2d.—Sputum and breath during the last few days have been of an offensive odour. Sputum is copious, purulent, of a somewhat dirty yellow colour. Fine crepitation is now audible on inspiration under the clavicle, and down to third rib, with sibilus during prolonged expiration. Posteriorly over dull region, respiration is feeble. Over lower two-thirds of right lung, respiratory murmurs greatly exaggerated ; patient feels very weak. To have 3 vj of wine daily. * Reported by Mr. John Glen, Clinical Clerk. PNEUMONIA. 649 Oct. 5th.—Over right lung posteriorly, moist rales are now heard; below spine of scapula they are very coarse. Expiration is prolonged, loud and tubular. Vocal resonance amounts to bronchophony immediately below spine of scapula. Oct. 10th.— Since last report has continued to be very weak, with feeble pulse at 80, notwith- standing employment of nutrients and wine, which she has no appetite to avail herself of. Cheeks flushed; skin hot, with general febrile symptoms. Sputum copious, still foetid, and considerably stained with dark blood. No evidence of lung tissue on microscopic examination. Posteriorly, immediately below spine of scapula, the moi:-t rattles are very coarse, with bronchial resonance of the voice approaching pectoriloquy. Continue nutrients and wine. Oct. 20th.—The amount of sputum has gradually declined since last report, and the coarse moist rales also have slowly disappeared from right back. There is now dry cavernous breathing, with pectori- loquy below spine of right scapula. Dec. 11th.— Since last report she has been alternately better and worse, the sputum being sometimes copious, and at others scanty, but not fcetid. Moist rales also have occasionally, on the former occasions, returned in the right back, with more or less sibilus on expiration. For some days there has been harsh inspiratory murmur at apex of left lung, and prolonged expiration, without dulness on percussion, but with considerable increase of vocal resonance. Has been taking cod-liver oil. Dec. 26th.—Since last report there has been a gradual improvement in her general health. Appetite has returned, and her strength permits her to sit up during the day. No moist rales are audible in right back, but loud tubular breathing, with increased vocal resonance. Jan. 20th—Has been for some time apparently quite well, and says she enjoys perfect health. Tubular breathing and bronchophonic resonance of voice, with dulness on percussion, are still present over upper third of right back. At left apex, also, inspiration somewhat harsh, with increase of vocal resonance. Dismissed. Commentary.—In this case a woman, 48 years of age, who tells us she had always enjoyed good health, is attacked with moderate fever, cough, and expectoration, with all the physical signs of a pneumonia in the upper third of the right lung. The sputum becomes foetid, and a gangrenous abscess forms, from which she slowly recovers, under the action of nutrients and wine, leaving, however, as traces of the disease, evidence of condensation in the pulmonary tissue affected. In all such cases there is extreme difficulty in separating the disease from phthisis. Indeed, there is little pathological distinction between a chronic pneu- monia and pulmonary phthisis. Moreover, the latter, though the real disease, may supervene upon the former, of which the following is an example:— Case CXU.*—Chronic Pneumonia of both Lungs, with Ulceration—Death—Great Condensation, with Cavities and Pigmentary Deposits in the Lungs—Chrome Tubercle in various Organs—Disease of both Supra-renal Capsules, without bronz- ing of the skin. History.—John Cunningham, set. 52, married, a shoemaker—admitted December 8th, 185G. He states that having previously been in the enjoyment of good health, three months ago while walking he became heated, and took off part of his apparel. On his return home he was attacked with shivering and severe pains in the breast • Reported by Mr. YV. Guy, Clinical Clerk. 650 DISEASES OF THE RESPIRATORY SYSTEM. and lumbar regions. A violent cold ensued, but be continued his employment. Three weeks ago he was obliged to give up work. A blister applied to the chest to-day, before admission, has mitigated the pain there. Symptoms on Admi>.->ion.—Percussion over left front of chest gives almost tym- panitic resonance, but the tone is flat, with a strong sense of resistance. Cracked-pot sound is elicited in second intercostal space. Over right side resonance more full aud less tympanitic, but still somewhat flat. Posteriorly same flat tone, with a resonance not fully clear. On auscultation, marked increase of vocal resonance over left apex, also over left supra-scapular region; elsewhere normal. At left apex, inspiration and expiration are blowing and cavernous in character, and expiration is prolonged. After cough, fine moi-t sounds are heard at close of inspiration. Laterally large moist sounds are more or less heard with inspiration, and coarse in character, while expiration is loud in tone. On right side the same moist sounds are heard, coarser in character, with both inspiration and expiration. Posteriorly respi- ratory murmurs somewhat loud. No moist rales, except over right supra-scapular region. Expiration is everywhere prolonged. Cough is violent, accompanied with a great quantity of frothy, tenacious, and somewhat dirty and blackish-looking sputum, with a few streaks of blood. Pulse 88, small and weak. Urine, sp. gr. 1020 ; voided in small quantities, of a high colour, throwing down a large quantity of lithates. Chlorides plentiful; other functions normal. Progress of the Cask.—December 11th.—Under left clavicle to-day, hoarse cavernous rales, with both respiratory murmurs, accompanied with faint but distinct crepitation and bronchophony. Posteriorly at left apex, loud tubular breathing, with both murmurs; inferiorly fine crepitation, mixed at the termination of inspiration with a loud sibilant murmur. Dec. 15th.—To have a blister applied over sternum. Dec. 17th.—Complains of indigestion and feverishness. Pulse 100, hard, but com- pressible. R Ace'atis Potass. 3j; Aquw Acet. Amnion, rj; Aqiue ad 3 vj. M. A table-spoonful to be taken every three hours. Dec. 18th.—Feverishness had disap- peared ; sputum of a dark -brow 11 colour; is not foetid. On microscopic examination, numerous well-formed pus cells are seen, but no pulmonary tissue. Dec. 23d.— Takes nourishing diet with f iv of wine. Says he eats all his food. Anxious to go out, but cannot on account of weakness. January 2d.—Countenance expres>ive of great weakness, sallow and pale. Tongue covered with a brown crust; dry, hard, and cracked. Pulse 108, weak; cough at night severe, preventing sleep. Physical signs unaltered; cannot rise to sitting posture without aid. Jan. 8th.— Died at 1 o'clock, p.m. Sectio Cadaveris.—Forty-seven hours after death. Thorax.—The upper lobe, and upper half of middle lobe, of right lung condensed and indurated. On section, the cut surface presented an iron-grey passing into a black colour. At the apex there was a cavity resembling a tubercular one about the size of a walnut. The inferior portion of this lung also somewhat condensed, but more spongy. The whole of left lung condensed and indurated. On section the same iron-grey colour was everywhere observable except at the base, where there existed masses varying in size from a hazel-nut to that of a chestnut, of a dirty red-coloured hepatization. Portions of the condensed tissue everywhere sunk in water. At the apex and at the back of this lung below the pleurie which were adherent, there was a cavity four inches lon2. He states that he has been troubled with slight cough for many years back, * Reported by Mr. W. M. Calder, Clinical Clerk. 652 DISEASES OF THE RESPIRATORY SYSTEM. Eight weeks ago he experienced rigors without any obvious cause, followed by increase of the cough, looseness of the bowels, severe griping pains in the abdomen and frequent desire to go to stool, with much straining and tenesmus. He observed a small quantity of blood in the stools, which sometimes consisted only of ab"iit a table- spoonful of blood mixed with frothy mucus. The calls to stool were at first so nume- rous that he cannot state even the probable number in the twenty-four hours. They abated somewhat under treatment at one of the dispensaries, but the diarrhoea has continued more or less ever since. During the last eight weeks the cough has become much aggravated, and the sputa increased in quantity. Two days before admission, he observed that the sputa were of a dirty-red colour, having formerly consisted of thick purulent masses without any tinge. He states that for the last eight or ten weeks he has been losing flesh and strength to a great degree, though he does not pre- sent a very emaciated appearance. His diet, also, during that period, has been very defective, both in quantity and quality; but previously he had always been able to procure good food. He is addicted to the immoderate use of spirits, and has several times had delirium tremens. Symptoms on Admission.—On admission, the chest on percussion appears resonant throughout, except over the upper third of right lung, where very slight dulness can be detected. The respiratory murmur is heard all over the chest, but under the right clavicle it is harsh and exaggerated, and the vocal resonance greatly increased. Posteriorly there is comparative dulness on percussion, and increased vocal resonance over the whole of right side, but most marked at the apex. Over the lower third, on the same side, fine crepitation can be heard during forced inspiration, Sputum in large quantity, consisting of frothy tenacious mucus, of a dirty brown colour, becoming more fluid upon standing, and of very offensive odour. When examined by the microscope, numerous pus-cells, some blood corpuscles, and large quantities of disintegrated epithelium can be detected. Has no pain in chest. Breathing is not laboured, but cough is troublesome, especially at night, occurring in paroxysms. Expectoration difficult. The tongue is dry, with slight dirty-yellow fur; troublesome thirst, but appetite good. No nausea, but frequent inclination to vomit when the cough is severe. No uneasiness in the bowels when at rest, but griping pains are generally present when at stool. There is distinct tenderness on percussion in the right iliac region, over a space of about two inches. The bowels have been open six times during the last twenty-four hours. The stools are very copious, of thin fluid consistence, and of a brownish red colour. They contain numerous blood-corpuscles, as determined by the microscope. The urine is parsed in small quantities, but otherwise normal. There are slight tremors ofthe hands, but no other symptoms of delirium tremens. Other functions normal. I£ Tinct. Opii, 3 ij ; Tinct. Catechu, 3 ss; Confect. Aromat. Z ij ; Mist. Cretce, ; v. M. A table- spoonful to be taken every four hours. Habeat enema, cum Tinct. Opii, Z j- U A?th. Sulph. m, xl; Mucilaginis, 3 ij ; Mist. Camph. zi- Fiat haustus. To be taken at bed-time. Ordered also nutritious diet and 4 oz. of wine. Progress of the Case.—November 26.—Bowels open nine or ten times during the twenty-four hours ; stools watery, having distinct traces of blood. Much griping pain when at stool. Cough severe. Expectoration copious. Dec. 1.—Diarrhoea continues, notwithstanding he has taken regularly the astringent mixture and opiate enemata. Today the skin is hot and dry, the appetite bad, with great thirst. To have a 5 gr. pill of lead and opium every third hour. Dec. 2.—Has had four or five stools .^ince last night. Tliey are fceculent, but of very thin consistence, unmixed with blood. He feels very weak, and complains much of pains in the che.-t, espe- cially on the right side. Dulness on percussion is increased over the whole of the right side posteriorly, and is most marked over the lower third. There is great PNEUMONIA. 653 increase also of the vocal resonance, amounting to pectoriloquy in the supra-scapular region; loud moist rales, like gurgling, are heard over the right back. On the left side the respiration is harsh and exaggerated, and the vocal resonance is also loud. Breath and expectoration foetid. Omit the lead and opium pill, and continue the me- dicines ordered on the 24th. Dec. 6.—Diarrhoea abated ; but he feels very weak, and the cough is troublesome; crepitation, with increased vocal resonance, pretty general over the left back. To have three oz. of spirits. Dec. 9.—Diarrhoea has returned—stools thin and foecal, containing a good deal of blood. To have a starch injection with Tinct. Opii ' iss. Dec. 14.—Diarrhoea abated somewhat until to-day, when it has again re- turned as severely as before. Much pain in lower part of abdomen; considerable griping and tenesmus; pulse 100, small and weak, but regular. The opiate enema has been continued every evening since last report, and he has been taking a chloric cether and morphia mixture to relieve the spasmodic cough. Apply a blister (4 by 3) to the abdomen. Increase the wine to 6 oz. Dec. 18.—Has rallied greatly since last report, but to-day the diarrhoea has again returned. The cough is very troublesome—sputa tinged with blood; over the whole of the right back there are harsh gurgling rales, with a noise approaching to a metallic character when he coughs; mucous rattles heard over left back; the offensive odour of breath and sputa has increased since last noticed. To have the following draught at bedtime. Py. Sol. Mur. Morph. 3 j ; and continue the time oz. of spirits. Tinct. Catechu 3 j ; Mist. Cretce § j ; Spir. Ammon. Aromat. iss. M. Sumat hora somni. Jan. 1.—Died this morning at five a. m. Little change took place in the symptoms after last report. One day he appeared to sink, but he rallied again the next. Diarrhoea continued, averaging about twelve stools in the twenty- four hours. The stools consisted of very small quantities of dark matter, with mucus, and occasionally a little blood. He continued taking the mixture of ammonia, etc., and the astringents with an opiate enema, which latterly was administered twice a day. Sectio Cadaveris.—Thirty-one hours after death. Body much emaciated. Thorax.—Heart and pericardium normal. Right lung united to thoracic walls by firm and universal pleuritic adhesions. On its being removed and bisected, a black gangrenous cavity, five inches long and four broad, was exposed, occupying the upper and middle lobes. It contained an extremely fcetid olive-green diffluent matter, having no distinct structure. The walls of the cavity presented a firm lining membrane of condensed fibrous tissue, internally of pulpy consistence and blackish-brown colour. The surrounding pulmonary tissue, posteriorly and inferiorly, was hepatised and friable, with a few anfractuous cavities also gangrenous. Anteriorly the lung was emphyse- matous, with here and there portions of collapsed tissue. The left lung adhered to the thoracic walls posteriorly by pleuritic adhesions. On being removed and bisected, the lower lobe and inferior portion of upper lobe was congested, and presented a brick-red colour; hepatised and dense in various places, with irregular cavities containing fcetid brown sloughs, varying in size from that of a pea to a pigeon's egg, and communicating more or less with each other. Abdomkx.—Mucous surface of ccecum and ascending colon closely studded with irregular-shaped ulcerations, varying in size from a pin's head to a sixpence. Some of these were evidently chronic, and in process of healing, with a thickened worm-eaten edge and a bluish granular base ; others contained a sloughing centre, involving more or less ofthe muscular coat. Similar ulcers were scattered, but more sparsely, through the transverse and descending colon. Other abdominal organs healthy. 654 DISEASES OF THE RESPIRATORY SYSTEM. Commentary.—In this case we have an example of pneumonia in both lungs, which passed into gangrene, associated with acute dysentery, occur- ring in an individual whose constitution had been impaired by addiction to intoxicating drinks. Dysentery generally prevails during the autumn months, in Edinburgh, to a greater or less extent; and in the case of Marshall it came ou without any obvious cause in September, and was ushered in by rigors, followed by bloody and purulent discharges at stool, with tenesmus and abdominal pain. About the same time, also, pectoral symptoms were complained of, although it is not probable that decided pneumonia was then occasioned. Even when he came into the house it was limited in extent, and ran a tolerably acute course subsequently. The febrile symptoms, therefore, which existed previous to his admis- sion, were most probably connected with the dysentery. This ran its usual course, producing sloughing ulcers in the mucous membrane ofthe large intestines to a considerable extent; and by the irritation and con- tinued discharge they occasioned (which could not be checked), gradu- ally prostrated the patient, aud was the chief cause of his death. It is seldom we have an opportunity of seeing a more illustrative case of gangrene of the lungs, than this man presented—large and circum- scribed on the right side, extended and diffused on the left side. That, in both cases, the gangrene was preceded by pneumonia, there can be little doubt, as all the functional signs of the lesion were present during life, whilst after death the gangrenous cavities were everywhere surrounded by distinct pulmonary hepatization. There is every reason to suppose that the same general causes which produced the sloughing sores in the intestines, occasioned the gangrenous cavities in the lungs. A deficiency of vital power in the organism prevented those transformations necessary for the absorption ofthe exudation, and thus it died and underwent pu- trefaction. Inflammatory gangrene and ulceration both depend ou death of the exudation, but in the former case there occur those peculiar che- mical changes which induce putrefaction. The only symptom whicii indicates this change is foetor of the breath or of the sputum, which was very apparent in Marshall on his admission to the house, and was greatly increased afterwards. In the following case which entered the ward in 1S48, and was the subject of careful examinatiou, I diagnosed a gangre- nous cavity in the right lung, and separated it from phthisis, partly on account of the foetid odour, and partly on account of the situation and limitation of the cavern. Case CXLIII.*—Gangrenous Abscess of the Right Lung, caused by the Swallowing of a piece of Chicken Bone four and a half years previously. History.—Thomas Neal, aet. 27, a footman, of sober habits—admitted December 4th, 1848. He says that he was quite well up to four years and a half ago, when, while eating part of a chicken, and laughing, he was suddenly seized with coughing and a sense of suffocation, producing lividity of the face. He thinks he swallowed a portion of chicken bone, but is by no means sure. At all events, he experienced a severe pain at the time across the lower part of the chest, followed by a short, dry, Reported by Mr. James Struthers, Clinical Clerk. PNEUMONIA. 655 tickling cough, accompanied by a wheezing noise in the throat. In an hour he re- covered and went about his usual employment. The cough, however, continued, and after three months was accompanied by a frothy expectoration, which gradually increased. About three years ago he entered St. George's Hospital, London%ut was dismissed in a fortnight. Shortly after, he observed blood in the sputum, which now became fcetid. He has laboured under constant cough, with expectoration of fcetid pus and more or less blood ever since. Symptoms on Admission.—On admission he complained of frequent couo-h and profuse expectoration of a viscid, slightly frothy matter, stained with blood "and of gangrenous odour. He was pale, but by no means emaciated. On percussino- the chest, there was considerable dulness over the two inferior thirds of the rio-ht luno- both anteriorly and posteriorly. At a point a little below the right nipple, the dulness was more marked than either above or below. On auscultation there was great in- crease of the vocal resonance over the whole right side of the chest, most so over the dull spot below the nipple. Posteriorly about the middle of the lung, there was a circumscribed gurgling rale, heard over an extent about two inches square, and not audible above or below it. At this point also there was perfect pectoriloquy. The respiratory murmur over the other parts of the lung was harsh, and here and there accompanied by mucous and sibilant rales. These signs were less evident at the upper than over the lower two-thirds of the organ. Over the left lung the percussion was normal, the respiratory murmurs puerile but otherwise healthy. All the other func- tions were well performed, if we except the occasional loading of the urine with lithates, and trifling perspiration at night. Progress of the Case.—The treatment was directed to supporting his strength, giving cough and antispasmodic mixtures, and introducing a seton below the right nipple. This produced considerable local irritation, but caused diminution in the gurgling rale, expectoration, and cough, so much so, that he insisted on leaving the Infirmary, February 8, 1849. He continued, however, to be attended by the clinical clerk, now Dr. James Struthers of Leith, from whose report the following account is taken:—" Towards the middle of March his appetite and strength began to fail; he lost flesh and became feverish, thirsty, and restless; was obliged to confine himself to the house ; and suffered from shortness of breath, eveu when at rest; the cough and expectoration continued much the same; he had no rigors, and was free from pain. On the morning of the 24th, he awoke suffering from great increase of cough and shortness of breath, and continued during the day to expectorate, at intervals of a few minutes, large quantities of frothy sputa, deeply tinged with blood, and much more fetid than usual. I was asked to visit him at his own house on the 25th, and found him much weaker than when I had last seen him some weeks previously. The cough was constant, the expectoration profuse, the sputa frothy and mixed with florid blood; the breath and sputa had a gangrenous odour which was verj' perceptible on approach- ing the bed. He had no pain, his chief complaint being of great weakness, dyspneea, and occasional feeling of suffocation. The respirations were 45 ; the pulse 130, weak and wiry. On examining the chest, the right side was found scarcely to move on inspiration, and was universally dull on percussion ; all natural respiratory sound was absent; gurgling was audible over its greater part, both in front and behind, with coarse mucous and subcrepitant rale towards the upper and lower parts. Although the voice was weak, the vocal resonance was much increased, and there was very distinct bronchophony over the inferior two-thirds. There was no friction sound audible. The left side was very resonant, and, with the exception of puerile respira- tion, and some subcrepitous rale, inferiorly, presented nothing unusual. During the next three days, he became rapidly weaker; the cough and dyspneea increased; he could speak only in monosyllables; the respirations rose to 68, and the pulse to 140 ; 656 DISEASES OF THE RESPIRATORY SYSTEM. and he expectorated daily about two pints of thin bloody sputa, which had a strong gangrenous odour, and latterly flowed in an almost continuous stream from the month On the 29th, he became typhoid, had hiccup and slight delirium, and died in the evening " Scctio Cadaveris.—TJiirty-six hours after death. The features were much collapsed; there was some yellowness of the skin- and a copious discharge of thin brown fluid from the mouth and nostrils. Percussion of the chest elicited the same sounds as during the last days of life. Thorax.—The right lung, with the exception of the lower part of the anterior border, was found firmly adherent to the walls. The adhesions were short dense and of a white colour. The lung was removed without laceration; it was some- what diminished in bulk, of a dark red colour, and had a pulpy feel. The apex was occupied by a closed cavity, the size of a small orange, which was distended with a brown dirty-looking fluid of the consistence of cream, and having a most intense gangrenous odour. The wall of this cavity approached the pleura superiorly; its inner surface was very irregular, presenting numerous shreds of disorganized pul- monary tissue. At the middle of the lung posteriorly, and about half an inch from the surface, there was another cavity, the size of a walnut, lined with a dense grey- coloured membrane, one line in thickness, and broken up in several places; it was partially filled with a dirty-coloured fluid, and opened directly into a bronchial tube, the size of a crow quill, at the other extremity of which the foreign body was found at a future stage of the dissection. In the Fig. 480. neighbourhood of this cavity, and throughout the whole of the inferior and posterior parts, the lung was riddled with numerous small cavities, varying in size from that of a hazel nut to that of a pea. Some of these were closed and filled with a fluid similar to that found in the one at the apex; others were nearly empty, more or less anfractuous, and communicated freely with the bronchial tubes; the walls of some were formed of a thick dense membrane ; those of others were soft and ragged. The middle part of the anterior, and a small portion of the inferior border were in a state of grey hepatization, and were the only parts free from cavities. On laying open the right bronchus, a small piece of bone was found at the bifurcation of the middle primary division -r it was lying almost loose,' and came away without any force being used; it was quite clean, and bore a strong resemblance to part of a vertebra of a small animal, being of an irregular elongated form, and presenting several sharp spicula. The mucous membrane at the part W0--V-.-.:'.- iZ&qcfxo: •■!•(<- :0-' -4^ ^% *'■""■' dj "'■' -'•C ^©0 Fig. 431. was thickened, but quite free from ulceration, and not more vascular than that of the other bronchi. The trachea and the bronchi of both lungs were stained of a dark grey colour, but otherwise presented nothing abnormal. In the left p'cura there Fig. 430. Fragment of chicken bone found in the right bronchus, in Neal's case. Fig. 431. Fluid in the chronic abscess ofthe right lung in Neal's case, a. Fibrous tissue; b, broken down pus cells ; c, crystals of triple phosphate; and d, urate of am- monia.—(James Struthers.) 250 diam. PNEUMONIA. 657 were three or four ounces of clear serum. The lung was healthy, except a small portion at the inferior border which was hepatized, and studded with small, grey, indurated nodules, the size of corn-pickles. These consisted, as ascertained by the microscope, of accumulations of altered epithelium, with much granular fatty matter. The apex of the lung was free of deposit, and there was no tubercle in any part. The bronchial glands, especially those on the right side, were greatly hypertophied, several of them being as large as pigeon's eggs; they contained no foreign matter. The heart was of the normal size; its muscular and valvular structures were healthy; and all the cavities contained both firm decolorised and dark loose spots. The blood examined under the microscope, presented the red and white corpuscles in the usual proportions. Abdomen.—The abdominal viscera were in all respects normal. Microscopic Examination.—The fluid from the abscess at the apex of the rioht lung, on being examined under the microscope, was found to contain small shreds of fibrous tissue, broken down pus globules, and a large number of crystals of the triple phosphate and of the urate of ammonia. Fig. 431. Commentary.—The physical signs in this case clearly indicated the existence of a cavity in the right lung, which, from its position, and from the general history of the case, was not likely to be tubercular. On the other hand its gangrenous character was revealed by the peculiar odour, and his account of its origin rendered it probable that the cause was a foreign body impacted in the bronchus. At the same time, he was never very certain as to the fact of having swallowed the piece of bone, and, in many conversations I had with him on that point, he invariably stated that such was merely his impression, but he was not sure. It is of importance to notice this fact, because it seems very probable that when in St. George's Hospital, his account may have been a doubtful one there also, and may have prevented recourse to an operation which then might possibly have been undertaken with success. It would be inte- resting to know whether at that time his chest had been carefully examined by auscultation, or whether general symptoms only were attended to, and, in consequence of these being slight, he was dismissed in a fortnight. Certainly, it cannot be imagined that if any certainty existed as to the impaction at that time of a foreign body in the lung, no effort would have been made to extract it, especially when the uniform ultimate fatality of such an occurrence is taken into consideration. At all events, this case points out how, in a young man of perfect health, structural disorganization slowly, but surely, proceeds after such an occurrence, and it strongly inculcates the necessity of early careful examination and of operative interference. Another cause of gangrene in the lung, is the occasional impaction of clots of blood, whether the result of phlebitis or from floating coagula coming from the right side of the heart. As an example, we may cite a well-marked case given by Mr. Gr. W. Callender, in the ninth volume of the Pathological Society's Transactions. One of the tertiary divisions of the pulmonary artery was occupied by a layer of decolorized fibrin in the form of a hollow globule. Its diameter was about two lines greater than that of the artery below, so that at this point the vessel seemed to have undergone some slight dilatation. Just beyond the place at which this clot had obstructed the canal, the artery bifurcated. The 42 658 DISEASES OF THE RESPIRATORY SYSTEM. blood had penetrated one of its divisions by means of a short and narrow channel, formed by the side of the above-mentioned clot, which was prolonged into the vessel, occupying about half ils-eatibre. Tlie other division at the point where it again bifurcated, had one of its divisions obstructed by another clot, which, unlike the others, was solid through- out. The portion of pulmo- nary tissue with which this artery communicated, was in a state of gangrene, as also was its pleural covering. In this case various masses of coagulated fibrin were ad- herent to the tricuspid valve, Fig. 432. and the clots found in the branches of the pulmonary artery in the lung, were most likely derived from them, as the vein itself was healthy. The hollowing out of the nearer of these coagula to the heart also was probably owing to the sub- sequent action of the current of blood, whilst the one further distant remained solid, and completely arrested the circulation. PHTHISIS PULMONALIS. Case CXLIV.*—Phthisis Pulmonalis in its last Stage, with Incompetency of the Aortic Valves—Cod-Liver Oil and Nutrients—Complete Recovery. History.—Patrick Barclay, set 15, admitted June 25, 1849. His previous history indicated that he had been of scrofulous habit from infancy. He attended the indus- trial school regularly until a week ago, but could not take mucft exercise on account of a sore leg, which originated twelve months previously in a fall. His diet has for a long time been very poor. On the 18th he was attacked with cough, and this has continued till admission. He also complains of dyspneea on exertion. Symptoms on Admission.—On admission, he is excessively emaciated. He complains of cough, which is sometimes very prolonged, but has no pain nor difficulty of breathing. The chest expands well on inspiration. Cough easily excited, and occasionally severe. Sputa viscid, frothy, and tinged with blood. On percussion, there is great dulness of the right side, especially under the clavicle; the left side is also dull to a slight extent. On auscultation, distinct bronchophony, loud friction rale, and mucous rale, approaching cavernous, are heard in the upper right side in front; and these become more faint towards the lower part of the lung. On the left side, friction rales are also heard in the upper part in front. Behind, on the right side, vocal resonance not so distinct, but rales the same as in front. Pulse 114, strong and sharp. The heart's apex beats below sixth rib; * Reported by Messrs. Hugh Balfour, Sanderson, and Dewar, Clinical Clerks. Fig. 432. Part of the left lung, with clots occupying branches of the pulmonary artery.—(Callender.) PHTHISIS PULMONALIS. 659 impulse increased; but percussion does not indicate lateral expansion. On auscul- tation, a chirping musical murmur is heard over the apex of the heart, at the end of the first sound. This murmur becomes much more faint towards the base. To the left ofthe manubrium ofthe sternum, a bellows murmur takes the place of the second Bound. This murmur is quite concealed by loud friction rales, when respiration is going on, but is immediately perceived when the patient holds his breath. Tongue (lightly furred ; appetite good ; some thirst. Bowels regular. Urine natural; sp. gr. 1020—not coagulable. The chest, face, and arms are covered with an eruption of prurifo, which he has had several times. On the right thigh, towards the lower part, there are several cicatrices, and three sinuses, which communicate with dead bone. Is much troubled with sweating, which at night is very profuse. To have good diet with tweet milk morning and evening, and a dessert-spoonful of Cod-Liver Oil three times a day. IJ Mist. Scilla; 3 iv; Tinct. Opii Amnion. 3" ss; Aq. Cinnom. § iss; Aquie 3 iij. M- Half-an-ounce three times a day. Progress of the Case.—June 30th.—Friction rale less. Gurgling rale on right side. Upper part of chest to be rubbed with Tartar Emetic Ointment. July 2i__Chirping murmur has become faint, and occasionally is inaudible. Has vomited his food several times. Half a drachm of Naphtha to be added to mixture ; to have beer for drink. 5th —Chirping murmur quite gone. 8th.—Chirping murmur re- turned. Cough severe, causing vomiting. Eruption, brought out by ointment, pain- ful. Omit the Ointment and mixture. Re Pulv. Tragacanth. Co. Z i; Naphtha M die "A; Sol. Mur. Morph. 3 iij ; Syrup. Aurantii 3SS; Mist. Scillce 3 v. JI. A table- spoonful thrice a day. 21st.—A seton was introduced beneath the right clavicle. Still vomits in the morning, but takes food and medicine better. Aug. 6th.—The expiratory murmurs under right clavicle are now quite dry. Vomiting is dimi- nished. Omit the mixture, fy. Ferri Citrat. Z ss; Tinct. et Syrupi Aurantii, aa jss; Infus. Calumba; 3 vi. M. ^1 table-spoonful three times a day. 12th.—The seton discharges freely, causing great irritation, and is to be withdrawn. Sept. 7th.—Appearance of patient much improved. Sounds of cavity in chest continue dry. Takes now again a table-spoonful of the oil three times a day. Oct. 28.— Musical murmur has entirely disappeared. He is becoming quite fat, and is able to go about the ward all day. Complains only of slight cough at night, and palpitation on exertion. The right infra-clavicular region is becoming flat. Omit the mixture and also the Cod-Liver Oil. Nov. 18th.—Cough has returned, with slight mucous expectoration; and on auscultation, mucous and sibilant rales are heard all over the chest. Ordered to recommence the oil. R> Mist. Scilla; 3 vss; Vini Ipecac. 3 ij; Sol. Mur. Morph. 3 i. M. A table-spoonful three times a day. From this time he rapidly improved. The cavity became perfectly dry, and respiration over it was accompanied by blowing murmurs. Cough and expectora- tion greatly diminished. His general appearance is healthy, and he is very stout. On January 13th, it is noted that, on percussion, a distinct cracked-pot sound is heard in the right infra-clavicular region, and faintly also on the left side. On auscultation the heart's sounds are loud all over the chest, the second sound being accompanied with a distinct bellows murmur. Musical murmur has never returned. There is bronchophony and prolonged expiration in the right infra-clavicular region, but no moist sounds. Sleeps well, and is very little troubled with cough. Does not sweat; is very fat; appetite good. This boy, as far as all general symptoms are concerned, may be regarded as having been in good health for the l«st two months. Feb. 27th.—On percussion, the chest was tolerably resonant on both sides; but there was slight dulness under the right clavicle. On ausculta- tion, the inspiration is loud, and of a blowing character, in right infra-clavicular region; but the murmur is much softer than formerly. Expiration is still prolonged, 660 DISEASES OF THE RESPIRATORY SYSTEM. and there is considerable vocal resonance, but not amounting to bronchophony—no moist rales. In the corresponding situation on the left side, the inspiration is some- what harsh, and respiration slightly prolonged; vocal resonance normal; loud bellows murmur, with the second sound of the heart, heard over nearly the whole chest. His general health is good; he expresses himself as being quite well. He appears stout and strong; but his countenance is somewhat sallow and cachectic. He has no ex- pectoration or sweating, and the cough is trifling, and only present in the morning. He is about to return to the Industrial School, and resume the learning of his trade as a shoemaker. Dismissed. He was re-admitted August 26th, 1850. Since leaving the house he has been at the Industrial School, but has been frequently exposed to cold; and latterly the cough and expectoration, which he says had quite left him, have returned, and been gradually getting more severe. The sweating returned with the cough. A week before admission, he, with the other boys of the school, went to Portobello to bathe, and, notwithstanding his remonstrances, the master insisted on his going into the water, saying it would do him good. He, however, became much worse. On admis- sion, the physical signs were coarse moist rale under the right clavicle, imperfect pectoriloquy, and creaking friction noises, harsh inspiration, and prolonged expira- tion under left clavicle ; but the dulness in this position is very slight, when com- pared with that of the opposite side. He again, by means of cod-liver oil, good diet, and counter-irritation, became strong and stout; again the cough, expectoration, and other symptoms ceased, and he was discharged March 7th, 1851. The report on that day is, " marked dulness and increased vocal resonance under right clavicle; the inspiration is harsh but dry." Once again admitted July 5th, 1851.—He says that on leaving the ward in March last, he had two detached pieces of the right thigh-bone extracted by Mr, Syme, and remained in the surgical hospital for five weeks. Since then he has been constantly employed in light garden work, and, notwithstanding poverty of food, he continued in tolerably good health till a week ago. On percussion, there is slight dulness only under the right clavicle, and posteriorly the resonance is good and equal on both sides. Under the right clavicle, the inspiration is heard to be har>h and blowing—no moist rale. There is also loud double friction murmur over the upper fourth of right lung, especially at the apex, and slight frktiou may be detected here and there over the whole of the right side. Under the left clavicle, inspiration some- what exaggerated in tone, but the breath sounds everywhere normal. He looks pale and thin. There is severe cough, with mucous expectoration, but the appetite is good, and there is, on the whole, a marked improvement in his general appearance. Impulse of the heart and loud blowing murmur at the base still present. Wound in the thigh nearly healed. Furthkr Progress of the Case.—He has continued to do well since his admis- sion into the house. The cough rapidly diminished, and is now only present in the morning on waking. His bodily functions, he says, are in every respect perfectly well performed. The wound in the thigh is cicatrised, and were it not for tlie car- diac disease, this lad might be considered in robust health. The following is the result of a careful examination of the chest, made December 23d, 1851:—"On per- cussion, slight dulness under the right clavicle. On auscultation, inspiratory murmur somewhat harsh under both clavicles, but most so on right side. The vocal resonance uxso is slightly exaggerated over the apex on right side. In every other respect, the lungs appear to be healthy. There is givat impulse of the heart still, and over the apex there is heard, with the second sound, a blowing murmur, which is very loud at the base. He remained in the house until March 7th, 1852, when he was dismissed in all respects perfectly well.] PHTHISIS PULMONALIS. 661 August 9th, 1852.—-Presented himself at the visit to-day. Since his dismissal in March, has been employed by a dyer, and during his occupation has been greatly exposed to wet and cold. He has^ only been able to earn five shillings a-week, so that his diet has been very poor, both in quantity and quality. His health, not- withstanding, has been tolerably good, although he is now much thinner than when he left the Infirmary. On percussion there is clear resonance under both clavicles, but on the right side very slight dulness with increased resistance is perceptible. On auscultation, the inspiration under right clavicle is somewhat harsh, but the re- spiratory murmurs on the whole are very good. Vocal resonance slightly increased. Under the left clavicle there is harshness, with fine sibilation and friction during inspiration. The expiration is prolonged, and there is also slight increase of vocal resonance. The blowing murmur at the base of the heart with the second sound still very distinct. Otherwise is quite healthy. He has a sister settled at Philadelphia! and has formed the intention of joining her in the United States. February 6th, 1853.—Presented himself at the Infirmary to-day, and was carefully examined by Dr. Bennett, Dr. Christison, the various clerks, and students. The phy- sical signs are the same as at last report, the breath sounds, however, being more soft and natural. He has been prevented leaving for Philadelphia, as he intended last August, and since then has been carrying on the occupation of light porter to a dyer. His general health has been good, although be has undergone much exposure to cold and wet. He leaves for Philadelphia to-morrow, taking with him a letter recommend- ing him to the care of Professor Wood of that city. In a letter from Dr. Wood to Dr. Bennett, dated March 28th, 1853, it was stated that Barclay had presented himself a week previously. " Being at the time extremely busy, I gave the boy, who told me that he was quite destitute, a small sum of money, telling him to use it for his support; in the mean time to look out for employment, which is not difficult to be had in this country for persons of his class, and to call ou me again before long. He promised to do so. I have not seen him since.'' In a subsequent letter (185G) from Dr. Dunglison, who at Dr. Bennett's request a^k'.-il Dr. Wood concerning him, it appeared that he had not since been heard of. Commentary.—I am not acquainted with any recorded case, which, throughout its progress, has been examined with more care, in which phthisis, in its last stage, was more unequivocally manifested, and which was more decidedly the subject of a complete cure, than the one now given. The lad was under my observation from June, 1849, to February, 1853, a period of forty-three months, and during that time he was respectively examined in the clinical ward by four winter and two sum- mer classes of students, as well as by my professional colleagues. Of the facts and accuracy of the record in the ward book there can be no doubt; and it is equally certain that we watched the arrest of tubercular condensation at the apex of the left lung, and the cicatrization of a large tubercular excavation in the apex of the right lung. Moreover, a care- ful study of this case will show that this result was not brought about by the mere spontaneous efforts of nature. On the contrary, great diffi- culties had to be surmounted, numerous symptoms removed, and most important complications guarded against. Indeed, the effects of treat- ment could never be more unequivocally manifested in any case than they have been in this. On admission, he presented the wasting charac- ters of the disease in its last stage. The emaciation was extreme; the cough and sweating most distressing; and the physical signs demon- strated a cavity as large as the fist, in the right lung. Under the use 662 DISEASES OF THE RESPIRATORY SYSTEM. of the oil his strength rallied. After a time it was given up, on account of his becoming so fat. Gurgling rales, and other signs of softened exudation, however, once more became apparent, and again disappeared when the use of the oil was resumed. He continued to take it from time to time afterwards, and it became apparent that the pulmonary signs varied according to his ability of digesting the oil. The same fact was demonstrated throughout the progress of the case, clearly showing the intimate relation which exists between the local disease and the general nutritive powers of the economy. During no part of the time this boy was under treatment did he ex- perience any difficulty in taking the oil. On the contrary, it occasioned no uneasiness in the stomach, and was readily digested, and this, although the food was at one period frequently vomited, owing apparently to the violence of the cough. Its influence on his general health was most re- markable, as well as upon the local disease in the lungs. From a state of extreme emaciation he became so stout that it was feared the oil would occasion obesity ; and was therefore, for a time, discontinued. His ap- petite was always good—a circumstance I have noticed as being very favourable, not only for the beneficial action of cod-liver oil, but for the successful treatment of phthisis generally. Indeed, it is the anorexia, nausea, and dyspeptic symptoms which constitute the great difficulty the physician has to overcome in the management of the disease, as is well illustrated in the following case :— Case CXLV.*—Phthisis Pulmonalis—Amendment from Treatment and Disappear ance of Symptoms—Tlieir Subsequent Return—Death. History.—Jane Hamilton, a dressmaker, ret. 18—admitted September 12, 1849 She stated that last April her general health began to fail; the appetite was bad ; cough with expectoration came on; cold sweats appeared on the face, hands, and feet; the catninenia, which had never been very regular, were suppressed; and she became so weak that she could not stand. Since then there has been a temporary improve- ment ; but for some time back she has become worse. • Symptoms on Admissiox.—On admission she was pale and emaciated, and so weak that she was unable to sit up above a few minutes at a time. There was copious perspiration during sleep, a severe cough, with abundant yellowish viscid sputa—no pain in the chest, which was well formed externally. The tongue was covered with a brown fur; appetite capricious and bad; bowels opened every second day. The treatment consisted of tonics, expectorants, and counter-irritation to the chest, which produced considerable amendment. I took charge of the case in the middle of October, and found, on careful percussion, dulness below the right clavicle, with loud mucous rale over the upper third of right chest. There were also sonorous and sibilant rales over the greater part of both lungs, anteriorly and posteriorly. By means of expectorants and counter-irritants, the bronchitic symptoms and signs were subdued by the 1st of November; but the dulness and moist rales under the right clavicle still continued. A table-spoonful of cod-liver oil was then ordered to be taken three times a day. Progress of the Case.—The remedy was suspended on the 8th, on account of a febrile attack she then experienced, which was ushered in with headache and * Reported by Mr. Alexander Struthers, Clinical Clerk. PHTHISIS PULMONALIS. 663 rigors, and accompanied with accelerated but soft pulse, heat of skin, loss of appetite, frequent nausea and vomiting, and considerable spinal irritation. It was not until Xorember 30th that these symptoms were so far removed, and the tone of the stomach augmented—by means, first, of antimonials, and subsequently of naphtha, alkalies, vegetable bitters, and stimulants—that the oil was again ordered. It produced con- siderable nausea, however, so that, after persevering in its use for ten days, it was again suspended. It was once more had recourse to on the 14th of December, and was readily retained on the stomach. A few days subsequently, the dose was increased to four table-spoonfuls daily. December 30th.—There is now a very evident improvement in the general health. Her strength is so far increased that she sits up a considerable portion of the day. The perspirations have nearly disappeared. The expectoration is still thick and purulent, but not so copious. She is evidently much stouter, and the skin is of a more healthy colour. The catamenia have also reappeared. There is still dulness under the right clavicle on percussion. The coarse moist rale has disappeared, and a fine crepitating murmur only is heard with the inspiration towards the acromial end of the clavicle.—There is prolonged expiration and increased vocal resonance. From this time she continued to improve. On the 1st of January the oil was reduced to three table-spoonfuls daily. A small blister was occasionally applied to the upper part of the right chest anteriorly, and an expectorant mixture given to facilitate the expectoration, which, though diminished in quantity, retained its viscid and purulent character. On the 30th of January the inspiratory murmur had acquired a certain degree of harshness, but here and there very fine crepitation could still be detected. She left the Infirmary on the 24th of February. I examined the chest carefully on the 7th of March. There was still dulness, but not so marked as formerly, under the right clavicle ; no crepitation on auscultation, but harshness of the inspiratory murmur, prolonged expiration, some friction noises, and increased vocal resonance. She was stout, of healthy appearance, and expressed*her- self as being quite well; but the expectoration of purulent matter still continued to a slight degree, with occasional cough. Shortly afterwards she went to Dundee to carry on her occupation as a milliner, when the confinement, late hours, and irregular food, soon caused a return of her more urgent symptoms. She again entered the Infirmary, and once more, after a few months, was dismissed relieved. On the last occasion, she was admitted under another physician, August 19th, 1852, the disease having pro- gressed to its last stage during the interval. She died September 8th. No examination of the body could be obtained. Commentary.—In this case, the local disease had not, on admission, proceeded to the advanced stage observable in the former one, for the physical signs in the girl exhibited at most bronchitis, with softening of the tubercular exudation at the apex of the right lung, whereas in the boy they demonstrated that a large cavity existed in one lung, whilst the other was also affected. There was the same general prostration, how- ever, and the same emaciation, excessive weakness, profuse perspiration, purulent expectoration, and distressing cough. But there was this dif- ference in the antecedent circumstances of the two cases—namely, that the boy had a good appetite, but had been subjected to an insufficient diet, whilst the girl had no appetite, although she possessed the means of gratifying it. In the first case nutrition was imperfect from deficient quantity of food, the digestive organs being tolerably healthy; in the second, it was imperfect on account of the dyspepsia and disordered i-tate of the stomach rendering it impossible that a sufficient quantity 664 DISEASES OF THE RESPIRATORY SYSTKM. could be consumed. The result in both was the same,—namely, impov- erishment of the blood, and tubercular exudation into the pulmonary organs. The practical management of these two cases was considerably modi- fied by the circumstances to which I have just alluded. In the boy, there was no difficulty in overcoming the imperfect nutrition. We have seen that he took the cod-liver oil, and digested it and his food with the greatest facility. In the girl, all thoughts of food caused disgust, and the cod-liver oil produced nausea, and for some time could not be tolerated. For a considerable period, therefore, the treatment of this case was preparatory, and directed to the diminution of the dyspeptic symptoms, and removal of those complications which prevented any successful attack on the more important di?ease. Thus my first efforts were directed to alleviating the bronchitis, which was accomplished by means of expectorants and counter-irritants. Cod- liver oil was then ordered, but it occasioned nausea, and was suspended on account of a febrile attack she now experienced. On her recovery from this, the nausea, vomiting, and dyspeptic symptoms were treated by means of naphtha, alkalies, vegetable bitters, and carminatives, with appa- rent benefit; but, on recurring to the oil, they again returned; so that, after persevering for ten days, it became again necessary to give up its employment. In a few days, however, it was once more tried, and on this occasion with success. It was then taken readily; a marked amend- ment followed ; the dose was increased to four table-spoonfuls daily, and it was astonishing to see how rapidly she improved. Her strength increased, the emaciation and cachectic look disappeared, the skin assumed a healthy colour, and she became positively stout and fat, so that she was scarcely recognisable. The cough almost ceased, the expectoration greatly diminished, the perspirations did not appear at night, the cata- menia returned, she sat up the entire day, and at length considered her- self so well, that, on being allowed to leave the hospital for a day, she did not return. She called on me a few days afterwards, when I found that, although the constitutional symptoms had almost entirely disappeared, and her general health might be called good, traces of the local disease were still apparent, as stated in the report. This case, therefore, exhibits the obstacles which the physician has not unfrequently to overcome before he can carry out that line of treatment by means of which the abnormal nutrition is to be' obviated, and the tubercular exudation checked; but it also inculcates the importance of perseverance, and exhibits the good effects which may result from persisting in a treatment dictated by cor- rect pathological principles. Notwithstanding the great benefit produced in this case, a return to imperfect diet and a sedentary employment once more induced all the symptoms and dangerous effects which in the hospital were removed with so much trouble. Nor, unless we could convert such institutions into establishments for the permanent support and surveillance of phthisical cases, is it easy to see how this can be prevented. Certain it is, that we are very seldom enabled to retain a case so long under treatment, as we did that of Barclay. Although, by means of judicious treatment, we frequently check the progress of phthisis, and restore the patient to a good state of health, it most commonly happens that the patient, if he PHTHISIS PULMONALIS. 665 be in a public hospital, insists on going out, and, if a private case, he abandons those remedies and precautions which are absolutely necessary to his existence. Hence it too frequently happens, that, even after such considerable amendment as we have seen take place—after restoration from a state of the most complete prostration to one of almost vigorous health—the causes which originated the disease induce its return, and the patient sinks, after one or more relapses. It is of all things most im- portant, therefore, to keep a careful watch over phthisical cases long after the constitutional symptoms have disappeared, and, in fact, so long as the physical signs indicate any traces of the disease. This, for obvious rea- sons, can be accomplished much better in private than in hospital practice. Case CXLVL*—Phthisis Pulmonalis—Large Vomica on Left Side— Caries of Left Wrist-Joint—Febricula—Scrofulous Neph ritis. History.—John Finlay, aet. 19—admitted into the clinical ward December 20th, 1850. Says that he has been troubled with cough and expectoration, more or less, for the last six years, accompanied by occasional diarrhoea. For the last three weeks he has been in the surgical clinical ward, under Mr. Syme, for scrofulous caries of the left wrist-joint. He has spat blood now and then, but to no great extent. Symptoms on Admission.—On percussion, the right chest is everywhere resonant; but there is marked dulness over the whole of left chest, most complete in the sub- clavicular and supra-scapular regions. On auscultation, loud mucous rales are heard over the whole of left chest anteriorly, with gurgling and pectoriloquy under the clavicle. Posteriorly and inferiorly on this side, there is a harsh tubular breathing, with prolongation of the expiration. There is puerile respiration on the right side, but otherwise nothing abnormal. His external appearance is pale, presenting all the so-called characters of the scrofulous diathesis. There is great emaciation, and development seems to have been arrested, as he does not look above 12 years of age. The left wrist joint is immovable, considerably swollen, with several carious open- ings discharging pus. Frequent cough, with copious muco-purulent expectoration. Pulse 80, feeble. Tongue clean. Considerable nausea, and total loss of appetite. His diarrhoea has recently been checked by lead and opium pills. (For treatment. see Commentary.) Progress of the Case.—For the next three months the loss of appetite, sickness, and vomiting occurred at intervals, and the physical signs remained the same. From this period, however, his general health underwent gradual improvement, the cough was not so severe, and the expectoration became more mucous. The sweating greatly diminished, and he took food more readily. Towards the end of May, he had evidently gained much in flesh, and the discharge from the scrofulous sores in the wrist was trifling. The physical signs were so far altered, that the mucous rales over greater part of left side were not so coarse or diffused, and the gurgling under the clavicle was now of a splashing character, and more limited. Pectoriloquy in this situation was complete, and there was absence of expansion during respiration. There could now also be heard harsh inspiration, with prolonged expiration under the right clavicle; the resonance on percussion also was here slightly impaired. During June, he was much troubled with nausea and vomiting. On the 21st he was attacked with rigors, followed by all the symptoms of continued fever, which terminated by diaphoresis on the seventh day. Shortly after, he was attacked with * Reported by Messrs. Sanderson and Dewar, Clinical Clerks. 666 DISEASES OF THE RESPIRATORY SYSTEM. variola, which ran its usual course. During July and August, there was gradual but marked improvement of his general health. At the end of the last-named month, the left wrist-joint was firmly anchylosed, and all the carious openings had closed up. He still had occasional diarrhoea. There was still dulness on left side but the mucous rales were not heard so low down anteriorly. Fine crepitation with increased vocal resonance was now audible under the right clavicle. Up to the middle of October he continued slowly to improve ; the sweatings and diarrhoea had ceased, and the cough was much less severe. He now complained of considerable pain during micturition, and on examining the urine it was found to contain nume- rous pus-corpuscles, and to be coagulable by heat and nitric acid. He continued to feel pain on urinating, and to pass pus by the urethra during the month of October, On the 3d of November the report is:—" Marked dulness on percussion over the left chest anteriorly, and under the clavicle cracked-pot sound. Posteriorly it is resonant. On auscultation, loud friction is heard from below up the level of the nipple, and above this, loud mucous rattles passing into gurgling under the clavicle. Perfect pectoriloquy in this situation. On right side, puerile respiration; and pos- teriorly sibilant rale at the termination of the inspiration. No sweating or diarrhoea. Still occasional nausea and vomiting. General strength much improved, and now walks about the ward, sitting up a great portion of the day." The report on the 21st of December is:—" Still marked dulness over the whole of left side, except under the clavicle, where it is tympanitic, with cracked-pot sound. Resonance on right side good. Under acromial end of left clavicle feeble, and distant gurgling is heard—the respiration having more of a blowing character than formerly, with perfect pectoriloquy. The moist rales over the other parts of this side have disap- peared. On right side, puerile respiration is heard over the inferior half of lung; otherwise, the breath-sounds are normal. Posteriorly dulness of the whole of left side, but there is no cracked-pot sound. On auscultation, the signs are the same as are heard anteriorly. His general health has much improved. Still complains of occasional nausea and vomiting, but on the whole takes his food well. Urine limpid, containing small shreds, which, on examination -with the microscope, are seen to be composed of numerous pus-corpuscles embedded in mucus; slightly coagulable on the addition of heat and nitric acid. Pain on micturition diminished." From this time he continued, on the whole, to improve steadily, and was so well during the summer of 1852, as to walk about constantly in the open air, and went out of the house, by his own desire, on the 1st of the following August. About the middle of October, however, having been well in the interval, he fell down and injured his back. On the following day, he experienced rigors, followed by febrile symptoms, total loss of appetite, and hematuria. He was re-admitted November 1, when it was ascertained that considerable quantities of pus were passed with the urine, which, he says, had also been occasionally tinged with blood. There was pain on micturition, but none in the lumbar region. On examining the left lung, loud gurgling was heard both with inspiration and expiration, extending from the clavicle down to the upper margin of the third rib. There was great dulness on percussion. Below the clavicle, loud pectoriloquy, and lower down, cegophony. Under the right clavicle there was fine moist rale on inspiration, and increased vocal reso- nance, but the chest expanded well on this side, and was otherwise normal. The fever, prostration, and discharge of pus by urine continued without intermission, and he died December 4, 1852. Sectio Cadaveris.—Forty hours after death. Body greatly emaciated; the right carpal bones anchylosed, with marks of nume- rous old sinuses on the skin in their neighbourhood. , PHTHISIS PULMONALIS. 667 Chest.—Pleurae on the right side adherent at the apex, by loose bands of chronic lymph. The right lung indurated at the apex over an extent the size of a hen's egg, and strongly puckered externally. On section, this indurated portion was seen to con- tain several encysted cretaceous concretions, with the intervening pulmonary substance condensed, hard, and fibrous. A few chronic miliary tubercles were also scattered through the upper lobe ; but the rest of the lung was spongy, crepitant, and healthy. The pleurae on the left side were everywhere firmly adherent, and over the superior half of the lung, which was much atrophied, they were converted into a dense white fibrous mass, three-fourths of an inch thick, which gradually diminished in thickness inferiorly. The left lung was not the volume of the closed fist; it was non-crepitant, felt indurated, but at the same time flaccid, evidently from internal cavities. On sec- tion, the entire mass was riddled with cavities more or less communicating with each other, containing purulent matter, and having a smooth lining membrane. Many of them presented a pouch-like form, and were identical with what have been described as dilatations of the bronchi. At the apex were two encysted calcareous concretions, ofthe size of millet seeds, but there were no other traces of tubercular deposits. The fibrous structure between the cavities consisted of a close dense fibrous texture, of blu- ish colour, from pigmentary deposits, in which no remains of pulmonary structure could be found. The bronchi contained a considerable quantity of viscid, muco-puru- lent matter. Heart, larynx, and trachea healthy. Abdomen.—The large intestines, especially the ccecum, were congested, exhibiting here and there patches of slate-coloured pigment, with traces of cicatrised ulcerations, together with one superficial chronic erosion about half an inch in diameter, of irregu- lar form. The kidneys were of natural size, and on section displayed dilatation of the pelves, with pouch-like enlargements, the result of scrofulous abscesses, filled with pus. The secreting substance was everywhere atrophied, and the tubular substance in many places obliterated. Mesenteric glands and other organs healthy. Microscopic Examination.—A careful microscopic examination of the lining membrane of the pulmonary abscesses exhibited nothing but fibrous tissue, destitute of epithelium. There was nowhere any trace of a mucous surface. Commentary.—The treatment of this case was conducted on the prin- ciples, and according to the rules afterwards to be detailed. It was directed principally to improve the appetite, diminish the nausea, vomit- ing, and diarrhoea, and support the strength by means of cod-liver oil and generous diet. Externally, repeated blisters were applied. During the attack of febricula and variola, antimonials were given in small doses. Latterly numerous remedies were administered to lessen the pains dur- ing micturition, such as anodynes; uva ursas; bals. copaibae; diuretics, etc.; but an enema of starch and solution of morphia succeeded better than anything else. It was always observed that in proportion as the dyspeptic symptoms were relieved, and the assimilation of cod-liver oil and food took place, so his health improved ; and by great care he was not only kept alive for two years, but I had sanguine expectation of an ultimate recovery, when he met wTith the accident which, by exciting acute disease in the kidneys, caused his death. This case presented many points of resemblance to that of Barclay (Case CXLIV.), especially in the scrofulous diathesis and scrofulous caries of the bones, aud the cavity under one clavicle on admission. The diseased lung was more extensively affected, however, and the derange- 668 DISEASES OF THE RESPIRATORY SYSTEM. ment of the stomach more violent and persistent. Indeed, throughout the progress of his case, the chief difficulty in the treatment was the management of the stomach and bowels The cod-liver oil aud diet did not produce the same marked effect as in the case of Barclay, but their operation, though slow, was -still very decided; and for a long time I considered that the pulmonary lesion in this lad was in progress of cure, exactly in the same manner as took place in Case CXLIV. The dissec- tion after deafb. demonstrated that in fact the lung was undergoing con- traction, and that the tubercular disease was being arrested. It pre- sented a remarkable specimen of one of the modes in which this is occa- sionally accomplished, namely, by the formation of pouches or cavities, the lining membranes of which become smooth, and cease to exude tubercle. This condition of the lung has been described by morbid ana- tomists under the name of dilated bronchi, and by Dr. Corrigan, as cir- rhosis of the lung.* In the first case it has been imagined to result from chronic bronchitis, whereby the bronchi are dilated from within; f and in the second, from the formation of fibrous matters, the contraction of which causes this enlargement from without. A consideration of the details of this case, however, must convince every physician that we had here to do with large tubercular excavations, which, by compressing the lung, had obliterated the whole of its texture, and converted it into a con- tracted fibrous envelope of these excavations. All trace of tubercular matter had disappeared, with the exception of two small cretaceous con- cretions, and the respiratory function wras entirely carried on by means of the opposite lung, in which chronic tubercle to a limited extent, and very latent, was found. Whether, under such circumstances, the pulmonary lesion would ultimately have healed, it is difficult to say; but there can be no doubt he might have lived a long time in this condition had he not met with the accident which caused his death. But that many such lesions may be arrested, and life continue, is proved by the observations of lley- naud, who has given figures of what he calls dilatations of the bronchi, many of which were evidently the result of tubercular ulceration.^: Cru- veilhier § has also figured a lung presenting similar appearances. In the case of another man, called Joseph Einnie, which closely re- sembled that of Finlay, I diagnosed, during life, the same contraction of the lung from tubercular excavations, and the same chronic dilatations in connection with the bronchi. This man died of Bright's disease in the Royal Infirmary, January, 1853 ; and on dissection a similar state of the pulmonary texture was discovered, with the exception that the atrophy of the organ was not so great, whilst traces of tubercular infil- tration were more evident. Case CXLVII.||— Phthisis Pulmonalis—Vomica on Right Side—Death from Haemoptysis. History.—Walter Cairns, set. 35, stone-cutter—admitted into the clinical ward * Dublin Medical Journal, vol. xiii. 1838. f Laennec, vol. i. p. 201. t Memoires de l'Academie Royale de Medicine, tome 4me, Plate 4, Fig. 1; Plate 5, Fig. 1; Plate 7, Fig. 2. § Anatomie Pathologique, Livraison 32, Plate 5, Fig. 3. || Reported by Messrs. Cunningham and Calder, Clinical Clerks. PHTHISIS PULMONALIS. 669 February 10, 1851. On the 25th of last July he was discharged from the corps of Sapper* and Miners at Gibraltar, in consequence of chest complaint. Shortly after, he was admitted into the hospital at Woolwich for a fistula in ano. He was discharged in March, and commenced work as a stone-cutter. In September, cough and expecto- ration came on—symptoms which have been gradually increasing until now. Symptoms on Admission.—On percussion, there is complete dulness under the right clavicle extending three inches downwards. On auscultation a loud mucous rale is heard in this situation, with bronchophony. On the left side, inspiration under clavicle harsh, and expiration prolonged. Frequent and severe cough, with purulent expectoration; constant pain in right side of chest; pulse 120, small and weak ; tongue slightly furred; appetite greatly impaired; vomiting during severe fits of coughing; diarrhoea; profuse sweating at night. He is thin, but not emaciated. Fistula in ano still present. Progress of the Case.—Towards the latter part of February the mucous rale under right clavicle was changed into loud gurgling, and the bronchophony into loud pectoriloquy. All the other symptoms continued. During March, the diarrhoea con- siderably diminished, but the cough and expectoration increased so as to destroy rest at ni^ht. Durino1 April and May the symptoms were stationary; towards the end of the latter month, it was observed that the cough was not so severe, but that the breathing was more difficult. The dulness on percussion had extended inferiorly, and moist rales could be heard over the whole right side, increasing in coarseness from below upwards. Increased vocal resonance also was more diffused, with strong fremitus. On the 5th of June, diarrhoea returned, and the sputa were streaked with blood. On the 17th, the diarrhoea had abated, but he experienced great pain and annoyance from the fistula in ano, which poured forth a profuse discharge. Ou the 25th three or four ounces of pure blood were expectorated. Cracked-pot sound is distinctly elicited on percussion below the right clavicle. Fine crepitation may also be heard during in- spiration, under left clavicle, with increased dulness on percussion. Choking sensation in the throat; pain in epigastrium; no diarrhoea. June 28th.—The sputa have con- tinued to be mingled with blood, and occasionally mouthfuls of this fluid, quite pure, have been expectorated. At four o'clock this morning, he brought up 10 oz. of blood, mingled with a matter resembling coffee grounds, apparently from the stomach. Shortly after, about 16 oz. of florid blood gushed from his mouth, when he sank back in the bed and expired. Cod-liver oil and nutritious diet were given during the first few days, hut the stomach was intolerant of it. Afterwards, the diarrhoea was combated by various astringents, such as opium, acetate of lead, tannin, and gallic acid. He also took, at in- tervals, quinine, sulphuric and nitric acids, and bitter infusions. In May, the suffocative cough was much relieved by an emetic of ipecacuanha and sulphate of zinc. The local pains in the chest were greatly relieved by the occasional application of a few leeches and blisters. During the two first attacks of haemoptysis, gallic acid was given in two grain doses every hour, with cold affusion on the chest. Latterly, the vomiting was checked by a mixture of naphtha, Tr. of Cardamoms, and Inf. Calumbae. Sectio Cadaveris.—Thirty-two hours after death. The body, though thin, was not greatly emaciated, there being three-eighths of an inch of fat between the abdominal integuments. Lips and nostrils stained with blood whicii had issued from the nose. Thorax.—Right pleural cavity contained about six oz. of fluid, and its serous walls were united by strong and close adhesions over the upper lobe of the lung. The left pleura; are adherent by a few easily torn adhesions. Both lungs present anteriorly 670 DISEASES OF THE RESPIRATORY SYSTEM. extensive emphysema, with considerable but uniform dilatation of the air vesicles. The bronchi of both sides contained bloody frothy fluid, the blood predominating on the right side. Right Lung.—The upper and a considerable part of middle lobe much diminished in volume posteriorly by compression. There are several irregular cavities in the summit, the largest not exceeding the size of a walnut, with indurated walls. The lower lobe consists of emphysematous and condensed tissue, the latter containing more or less miliary and encysted tubercles, some of the latter as large as a pea. Scattered throughout the inferior lobe, were numerous extravasated patches of blood varying in size from a pin's head to that of a coffee-bean, but not interfering with the crepitation of the lung. Left Lung.—Below the pleura-costalis were numerous miliary tubercles, scattered over the whole surface, but aggregated more densely towards the apex. Here and there were some yellow tubercular masses the size of a pea, with puckerings corresponding to them on the pleural surface. On section, the summit of the organ contained small miliary tubercles. The substance of the inferior lobe contained very few tubercles, but was dense, less crepitant than usual, and con- tained some of the sanguineous patches observed in the opposite lung. Other organs healthy. Commentary.—This was a case of chronic phthisis, which on dissec- tion presented old ulceration on one side, and recent tubercular deposits on the other. It proved fatal by extensive hemorrhage, which caused sinking in a previously debilitated person. The fistula in ano may have contributed to the weakness, for the surgeons who were consulted refused to interfere, on the ground that the operation was not likely to be suc- cessful in a phthisical individual. Death from haemoptysis is on the whole a rare termination of phthisis. Dr. Walshe only met with two in 131 cases, and I believe the proportion to be even much smaller than this. He observes, that " a first hemorrhage having been severe, it is un- likely that a subsequent one will kill directly." But Cairns had three distinct attacks of hemorrhage, the last of which iv as directly fatal. The treatment of this case was conducted by my colleagues for four months before I saw him, on the palliative plan; and I may appeal to the facts it presents, in proof that such treatment produced no effect in any way checking the progress of the disease. In this respect it offers a marked contrast to the preceding cases, in which the treatment was directed by the pathological principles to be afterwards detailed, and had for its object increasing the nutritive powers through the prima via. Case CXLVIII.*—Phthisis Pulmonalis—Two Vomica; on Right Side—Small Cavi- ties on Left Side—Death from Exhaustion. History.—Margaret Moffat, set. 40, a washerwoman—was admitted into the clinical ward, April 5th, 1851. For upwards of three years she has been subject to cough, expectoration, and dyspneea. Three weeks ago, after exposure to wet and cold, she was attacked with severe pain in the right side, and the other symptoms became aggravated. In this state she has continued until admission. Symptoms on Admission.—The report says, there was " httle or no alteration on percussion." Over the part complained of in the infra-mammary region there were loud friction noises, which were also diffused posteriorly over the inferior third of * Reported by Messrs. Pearse and Hoile, Clinical Clerks. PHTHISIS PULMONALIS. 671 right lung. Over the upper portion of the lung, anteriorly, were dry blowing sounds, with harsh inspiration; but posteriorly, crepitation was heard over the apex. Over the left back, fine moist rattles were heard. Sharp acute pain, increased on inspiration, below right mamma; cough troublesome, with copious expectoration of muco-purulent matter, here and there streaked with blood; considerable dyspneea. Pulse frequent and soft: tongue covered with a brown fur; loss of appetite; thirst; skin moist. Progkkss of the Case.—The pain in the side subsided on the following dav, after the application of six leeches; but she complained, during April and May, of occasional return of the pain, and was particularly distressed, in addition to her other symptoms, by attacks of dyspneea. I took charge of this case in the middle of June, when marked dulness was ascertained to exist over the upper third of the right lung, both anteriorly and posteriorly, with mucous rale and increased vocal resonance; and on the left side posteriorly, there was still crepitation. Sputum continued abundant, consisting of purulent matter of gelatinous consistence. Appetite bad. Profuse sweating at night. These signs and symptoms underwent very little variation until her death, on the 30th of.Jdy. The treatment consisted at first of leeches to the side, expectorant and anodyne mixtures, with an aether draught at night. In May she was ordered \ vj. of wine daily, decoction of senega, with 3 ss. doses of Tr. lobel. inflat. Towards the end of the month, blisters were applied externally, and dilute sulphuric acid given internally, in doses of ten drops. In the middle of June, chalybeate and tonic mixtures were ordered, with cod-liver oil, without any effect in restoring the appetite or renovating the nutritive process. Sectio Cadaveris.—Forty hours after death. Body greatly emaciated. Thorax.—There were three or four ounces of fluid in the left pleura. Everywhere firm adhesions between the pleurae on the right side. At the apex of the right lung, the pleurae were thickened to the extent of an inch, by the formation of a dense, white, fibrous structure. Right Lung.—There were two cavities at the apex, of irregular shape, and the size of hens' eggs. Numerous smaller ones existed, scattered through- out the lung. The pulmonary tissue was almost entirely non-erepitant, dark coloured, atrophied, and indurated. Inferiorly there were nodules of a pink fleshy material, which, on microscopic examination, were found to consist of fatty degeneration, and were composed of a multitude of fatty molecules and granules, with compound granular corpuscles. The bronchial glands were much enlarged, several of them indurated, and the size of a walnut. Left Lung was mostly crepitant, but contained some indurated tissue, surrounding small cavities at the apex, the largest the size of a hazel-nut. In the lower lobe posteriorly, there was some cedematous and non-crepitant tissue. Bronchial glands also enlarged, hut less than on the other side. All the other organs healthy. Commentary.—This must have been a very chronic case of phthisis probably of much longer standing than she stated on coming into the house. The right lung was universally condensed, contracted, and nodules of the tubercular matter itself, mingled, perhaps, with pneu- monic exudations, had passed into fatty degeneration, and presented a yellow pinkish colour. There were none of the more violent symptoms of deranged digestive action in this case, such as vomiting or diarrhoea; and I would again point to the fact, that the palliative treatment en- tirely failed to make any impression on the malady. 672 DISEASES OF THE RESPIRATORY SYSTEM. Case CXLIX.*—Phthisis Pulmonalis—Large Vomica with Pneumo-Thorax (f) on Left Side—Softened Tubercle on Right Side—Bright's Disease. History.—James Hutchison, aet. 26, a stone mason—admitted into the clinical ward June 16th, 1851. Last September, after unusual exposure to wet and stormy weather while prosecuting his occupation, was seized with distinct rigors, followed by severe pain in the chest, dyspneea, and cough. The cough and pain left him in Jan- uary, but the dyspneea has continued. About the end of last March, he observed oedema of the legs, and that the urine was diminished in quantity, and was occasionally high coloured. These symptoms have continued since. Symptoms on Admission.—There is marked dulness on percussion over the left side of chest anteriorly and posteriorly, most complete inferiorly. On auscultation the respiratory murmurs are absent at the lower two-thirds of left lung; but over the su- perior third there is loud gurgling, both anteriorly and posteriorly. Vocal resonance is everywhere increased, hut over the apex there is a harsh, brazen, almost metallic sound, on coughing. Posteriorly and inferiorly, there is cegophony. On the ris loaded with and surrounded by carbonaceous deposit. Many air vesicles are enlarged, constituting incipient emphysema. The preparation now in my posses- sion exhibits a characteristic specimen of the mode in which a considerable amount of tubercular exudation is arrested by calcareous degeneration. Natural size. PHTHISIS PULMONALIS. 681 2. These concretions are found exactly in the same situations as tubercle. Thus they are most common in the apex, and in both lungs. They frequently occur in the bronchial, mesenteric, and other lymphatic glands, and in the psoas muscles, or other textures which have been the seat of tubercular depositions, or scrofulous abscesses. 3. When a lung is the seat of tubercular infiltration throughout, whilst recent tubercle occupies the inferior portion, and older tubercle, and perhaps caverns, the superior, the cretaceous and calcareous concre- tions will be found at the apex. 4. A comparison of the opposite lungs will frequently show, that whilst on one side there is firm encysted tubercle, partly transformed into cretaceous matter, on the other the transformation is perfect, and has occasionally even passed into a calcareous substance of stony hard- ness. 5. The seat of cicatrices admits of the same exceptions as the seat of tubercles. In one case, I found the puckering and cicatrix in the inferior lobe only; and have met with three cases where the inferior lobe was throughout densely infiltrated with tubercle, whilst the superior was only slightly affected. It has indeed been argued, that occasionally these cretaceous masses may be the result of a simple exudation. When they are found isolated in the middle or base of the organ, such certainly may be the case, aud consequently the fifth argument may be affected. But this is rare, and can scarcely make any alteration in the vast proportion of those concre- tions and puckerings which are undoubtedly the result of abortive tubercles. With these facts before us, and with the knowledge that there is nothing in the nature of tubercle itself which is opposed to the evidence of these anatomical facts, the frequent spontaneous cure of tu- bercle may now be considered established. Since these observations, however, have become known, it has been stated that after all, practically speaking, phthisis pulmonalis does not mean the existence of a few isolated tubercles scattered through the lung, and that what is really meant, is that advanced stage in which the lung is affected with ulceration, and in which the bodily powers are so lowered that perfect recovery seldom or never takes place. But here again a careful examination of the records of medicine will show that many even of these advanced cases have recovered. Laennec, Andral, Cruveilhier, Kingston, Pressat, Rogee, Boudet, and others have pub- lished cases where all the functional symptoms and physical signs of the disease, even in its most advanced stage, were present, and yet where the individual survived many years, ultimately died of some other disorder, and on dissection cicatrices aud concretions were found in the lungs. I here show you a preparation, exhibiting a remarkable cicatrix in the lung, which I described and figured in tlie " Monthly Journal " for March 1850. As it is short, I may quote it:— 682 DISEASES OF THE RESPIRATORY SYSTEM. Case CLI.—Advanced Phthisis—Restoration to Health—Death many years aftmi-ards from Delirium Tremtns—On Dissection, a Cicatrix, three inches long, in Apex of Right Lung, and Cretaceous Concretions, with puckering at the Summit of Left Lung. "John Keith, set. 50, a teacher of languages, was admitted into the Roval Infir- mary, February 8, 1844, in a state of coma, and died an hour afterwards. On exa- mination, the membranes of tlie brain, at the base, were unusually congested and covered with a considerable exudation of recently coagulated lymph, here and there mingled with bloody extravasation. The apex of the right lung presented a remarkable cicatrix, consisting of dense white fibrous tissue, varying in breadth Fig. 437. The section of the upper portion of lung in Keith's case seen from within, the apex having been left entire to show the deep puckerings which covered its sur- face. The line of the healed cavity is densely loaded with black carbonaceous^ depo- sit, in which are seen five cretaceous concretions, three of them encysted. Tins pre- paration, now in my possession, is perhaps a unique specimen, proving the healing, by cicatrization, of an enormous tubercular excavation in the lung. Natural sir.<-. PHTHISIS PULMONALIS. 683 from one-fourth to three-fourths of an inch, and measuring about three inches in 1 th -pj]e p]eural surface in its neighbourhood was considerably puckered. On making a section through the lung, parallel with the external cicatrix, the substance immediately below presented linear indurations, of a black colour, together -with five cretaceous concretions, varying in size from a pin's head to that of a large pen. The surrounding pulmonary substance was healthy (Fig. 437). The apex of the left lung was also strongly puckered, and contained six or seven cretaceous concretions each surrounded by a black, dense, fibrous cyst. " A very respectable-looking and intelligent man, who attended the post-mortem examination, informed me that Keith, in early life, was in very indifferent circum- stances and bad supported himself as a writer's clerk. At the age of two and-twenty or three-and-twenty, be laboured under all the symptoms of a deep decline, and his life was despaired of. About this time, however, he was lost sight of by his friends; but it was afterwards ascertained that he had become a parish schoolmaster in the west of Scotland, and that his health had been re-established. He returned to Edinburgh six years before his death, and endeavoured to gain a livelihood by teaching Latin and French. He succeeded but very imperfectly, and fell into dissipated habits. Latterly be had become subject to attacks of mania, apparently the result of drink. It was after an unusally severe attack of this kind that he was brought into the Infirmary, where he died in the manner previously described." This case points out the following important facts,—1st, That, at the age of twenty-two or twenty-three, the patient had had a tubercular ulcer in the right lung, the size of which must have been very consider- able when the contracted cicatrix alone was three inches long. 2d, That tubercular exudations existed in the apex of the left lung. It is, therefore, very probable that the statement made by his friend at the examination was correct—namely, that, when young, he laboured under all the symptoms of advanced phthisis pulmonalis. It is shown, 3dly, That after receiving the appointment of a parish schoolmaster, after changing his residence and occupation, while his social condition was greatly improved, these symptoms disappeared. We may consequently infer, that it was about this period that the excavation on the right side healed and cicatrized, while the tubercular exudations on the left side were converted into cretaceous masses, and so rendered abortive. It demonstrates, 4thly. That when, at a more advanced age, he again iell into bad circumstances, and even became a drunkard, tubercular exuda- tions did not return, but that delirium tremens was induced, with simple exudation on the membranes of the brain, of which he died. Although the curability of phthisis pulmonalis, even in its most advanced stage, can now no longer be denied, it has been argued that this is entirely owing to the operations of nature, and that the physician can lay little claim to the result, Andral, who early admitted the occa- sional citatrization of caverns, states this in the following words :— " No fact," he says, " demonstrates that phthisis has been ever cured for it is not art which operates in the cicatrization of caverns; it can at most only favour this, by not opposing the operations of nature, k or ages remedies have been sought either to combat the disposition to tubercles, or to destroy them when formed, and thus innumerable spe- cifics have been employed and abandoned in turn, and chosen from 684 DISEASES OF THE RESPIRATORY SYSTEM. every class of medicaments."* But if it be true, according to Hoffman, that <: Jfedicus natural minister non magister est," it follows that by care- fully observing the operations of nature, learning her method of cure imitating it as closely as possible, avoiding what she points out to be injurious, and furnishing what she evidently requires, we may at leiifth arrive at rational indications of treatment., The cases both of Keith and Barclay, in my opinion, furnish evidence that we have in a great measure attained this end; and this leads me speak, in the second place, of II.—Tlie Pathology and General Treatment of Phthisis Pulmonalis. Many observant physicians have not failed to notice, that phthisis pulmonalis is ushered in with a bad and capricious appetite, a furred or morbidly clean tongue, unusual acidity of the stomach and alimentary canal, anorexia, constipation alternating with diarrhoea, and a variety of symptoms denominated dyspeptic, or referable to a deranged state ofthe prinife viae. Moreover, it can scarcely be denied that, in the great major- ity of cases, these are the symptoms which accompany phthisis through- out its progress, becoming more and more violent towards its termination. Now, as the nutritive properties of the blood are entirely dependent on a proper assimilation of food, and as this assimilation must be interfered with in the morbid conditions of the alimentary canal, the continuance of such conditions necessarily induces an impoverished state of that fluid, and imperfect growth of the tissues. Moreover, when, under such cir- cumstances, exudations occur, it has been shown by the histologist that they do not exhibit any tendency to perfect cell formations, but that corpuscles are produced, which form slowly, and, slowly breaking down, cause softening and ulceration, which becomes more and more extensive as the amount of the exudation increases. An observation of the circumstances which precede the disease, or its so-called causes, clearly indicates imperfect digestion and assimilation as its true origin. Thus phthisis is essentially a disorder of childhood and youth—that is, the period of life when nutrition is directed to building up the tissues of the body. Diminish the proper quantity of food taken by a healthy adult, and tubercular diseases are not induced; but if this be attempted with children or young persons, they are a most common result. It has been supposed that hereditary predisposition, a vitiated atmosphere, changeable temperature, certain unhealthy occupations, humidity, particular localities, absence of light, and so on, predispose to phthisis. Very frequently several of these are found united, so that it is difficult to ascertain the influence of each. When they so operate, how- ever, they invariably produce, in the first place, more or less disorder of the nutritive functions, and are associated with dyspepsia, or other signs of mal-assimilation of food. From a study of the symptoms, causes, morbid anatomy, and histology of phthisis pulmonalis, we are therefore led to the conclusion, that it is a disease of the primary digestion, causing,—1st, Impoverishment of the blood ; 2d, Local exudations into the lung, which present the characters of * Diet, de Med. 1st Edit. Phthisic PHTHISIS PULMONALIS. 685 tubercular exudation; and 3d, Owing to the successive formation and softening of these, and the ulcerations which follow in the pulmonary or other tissues, the destructive results which distinguish the disease. Fur- ther observation shows, that circumstances which remove the mal-assimi- lation of food frequently check further tubercular exudations, while those which previously existed become abortive, and that occasionally very extensive excavations in the pulmonary tissue may, owing to like circum- stances, heal up and cicatrize. The curative treatment of this disease must therefore be directed,—1st, To restoring the healthy nutrition of the economy ; 2d, To subduing local irritation ; and 3d, To the avoidance of those circumstances which are likely to deteriorate the constitution on the one hand, or induce pulmonary symptoms on the other. 1. A healthy condition of the body cannot proceed without a proper admixture of mineral, albuminous, and oleaginous elements. This may be inferred from the physiological experiments of Tiedemannand Gmelin, Leuret and Lassaigne, Magendie, and others ; from an observation of the constituents of milk, the natural food of young mammiferous animals ; from a knowledge of the contents of the egg, wbich constitute the source from which the tissues of oviparous animals are formed before the shell is broken; and from all that we know of the principles contained in the food of adult animals. The researches of chemists, as of Prout, Liebig, and others, point to the same generalization, while they assert that car- bouised and nitrogenised, or, as they have been called, respiratory and sanguigenous food, are necessary to carry on nutrition, inasmuch as oil is a type of the one, and albumen of the other. The chemical theory is imperfect, however, because it does not point out how these elements form the tissues; for is not every form of carbonised or of albuminous food that is nutritious, but only such kinds of them as are convertible into oil and albumen. The reason of this was first pointed out by Br. Ascherson of Berlin, in 1S40, and made known by me to the profession in this country iu 1*41. I have since endeavoured to show, that the elementary molecules formed of a particle of oil, surrounded by a layer of albumen, which are produced, as he described, by rubbing oil and albumen together, are not developed directly into' blood-globules and other tissues, as he supposed^ but must first pass through a series of transformations—a knowledge of which is highly important, not only to a comprehension of nutrition generally, but especially to that abnormal condition of it which occurs in phthisis. Thus the successive changes which occur for the purposes of assimilation in the healthy economy may be shortly enumerated as follows:—1st, Introduction into the stomach and alimentary canal of organic matter. 2d, Its transformation by the process of digestion into albuminous and oily compounds : this process is chemical. 3d, The imbi- bition of these through the mucous membrane in a fluid state, and their union in the termini of the villi and lacteals to form elementary granules and nuclei: this process is physical. 4th, The transformation ot these, first, into chyle corpuscles, and, secondly, into those of blood : which is a vital process. It is from this fluid, still further elaborated in numerous ways, that the nutritive materials of the tissues are derived, so that it must be evident, if the first steps of the process are improperly performed, 686 DISEASES OF THE RESPIRATORY SYSTEM. the subsequent ones must also be interfered with. Hence we can readily comprehend how an improper quantity or quality of food, by diminishing the number of the elementary nutritive molecules, raibt impede nutrition. When we examine with a magnifying power of 2">0 diameters a drop of chyle taken from the thoracic duct of an animal, three hours after it has eaten a meal, we observe that it contains, first, a molecular basis (Gulliver) of incalculably minute particles ; and secondly, numerous cor- puscles in different stages of development into blood-"lobules. This molecular Basis has been proved by numerous chemical analyses to con- sist principally of fat, emulsionised by its admixture with albumen. In short, these two important principles, fat and albumen, constitute essen- b tial elements of the nutritive chyme; and the former divided into exceedingly minute the Fig. 433. glands and the lungs. No one can doubt that the oil and albumen so derived from the food, and so altered chemically and mechanically in the body, con- stitute the material from which blood is formed; neither can there be any question that the presence and emulsionising of these elements in proper proportions, are absolutely necessary to supply and keep up the vital properties of the blood. The peculiarity of phthisis, however, is, that an excess of acidity exists in the alimentary canal, whereby the albuminous constituents of the food are rendered easily soluble, whilst the alkaline secretions of the saliva and of the pancreatic juice are more than neutralized, and rendered incapable either of transforming the carbonaceous constituents of vegeta- ble food into oil, or of so preparing fatty matters introduced into the system, as will render them easily assimilable. Hence an increased amount of albumen enters the blood, and has been found 11 exist there by all chemical analysis, while fat is largely supplied by the absorption of the adipose tissues of the body, causing the emaciation which charac- terises the disease. In the meanwhile the lungs become especially liable to local congestions, leadino; to exudation of an albuminous kind: which is tubercle. This, in its turn, being deficient in the necessary proportion of fatty matter, elementary molecules are not formed so as to constitute nuclei capable of further development in cells; they there- fore remain abortive, and constitute tubercle corpuscles. Thus-a local disease is added to the constitutional disorder, and that compound affec- tion is induced which we call phthisis pulmonalis, consisting of symptoms Fig. 438. Chyle from the thoracic duct of a dog, three hours after eating a meal. a, Fluid chyle showing its molecular basis and corpuscles in various stage-; of deve- lopment into those of blood. 6, Corpuscles of chyle embedded in fibrillated fibrin. They are round in the centre, but more or less compressed and elongated towards the margin. 2j<) diam. PHTHISIS PULMOXALIS. 687 attributable partly to the alimentary canal, and partly to the pulmonary organs. To improve the faulty nutrition whicii originates and keeps up the disease, it is of all things important, therefore, to cause a larger quantity of fatty matter to be assimilated. A mere increase in the amount, or even quality, of the food, will often accomplish this, as in the case of Keith. The treatment practised some years ago by Dr. Stewart of Erskine, which consisted in freely administering beef-steaks and porter, and causing exercise to be taken in the open air, excited considerable attention from its success. I have been informed, that in some parts of America the cure consists in living on the bone marrow of the buffalo, and that the consumptive patient gets so strong, in this way, that he is at length able to hunt down the animal in the prairies. All kinds of food rich in fat, will not unfrequently produce the same effects, and hence the value long attributed to milk, especially ass's milk, the produce of the dairy, as cream and butter, fat bacon, caviar, etc. But in order that such substances should be digested and assimilated, the powers of the stomach and alimentary canal must not have under- gone any great diminution. In most cases it will be found that the patient is unable to tolerate such kind of food, and that it either lies undigested in the stomach, or is sooner or later vomited. Under these circumstances, the animal oils themselves are directly indicated, by giv- ing which we save the digestive apparatus, as it were, the trouble of manufacturing or separating them from the food. By giving consider- able quantities of oil directly, a large proportion of it is at once assimi- lated, and is rendered capable of entering into combination with the albumen, and thereby forming those elementary molecules so necessary for the formation of a healthy chyle. Such, it appears to me, is the rationale of the good effects of cod-liver oil. Since I introduced this substance to the notice of the profession in this country as a remedy for phthisis, in 1841,1 have continually prescrib- ed it in hospital, dispensary, and private practice. I need not perhaps say, that I have given it in a very large number of cases, and have ob- served its effects in all the stages of the disease, and under almost every circumstance of age, sex, and condition. I have had the most extensive opportunities of examining the bodies of those who have died after tak- ing it in considerable quantities, and am still observing the cases of many persons who may be said to have owed their lives to its employment. Further, I have carefully watched tlu progress it has made in the good opinion of the professional public, and perused all that has been publish- ed regarding it in the literature of this and other countries. It were certainly easy for me, therefore, to write at great length on this subject; but I do not see that anything of utility could be added to what I have already published. The following is a summary of my views regarding cod-liver oil as a remedy for phthisis :— 1. Cod-liver oil is, as M.Taufflied pointed out, an analeptic (avaXap.fia.vu>, to repair), and is indicated in all cases of abnormal nutrition dependent on want of assimilation of fatty matter. 2. It is readily digestible under circumstances where no other kind of animal food can be taken in sufficient quantity to furnish the tissues with a proper amount of fatty material. 688 DISEASES OF THE RESPIRATORY SYSTEM. 3. It operates by combining with the excess of albuminous consti- tuents of the chyme, and forming in the villi and terminal lacteals those elementary molecules of which the chyle is originally composed. 4. Its effects in phthisis are to nourish the body, which increases in bulk and iu vigour ; to check fresh exudations of tubercular matter and to diminish the cough, expectoration, and perspiration. 5. The common dose for an adult is a table-spoonful three times a- day, which may often be increased to four, or even six, with advantage. When the' stomach is irritable, however, the dose to commence with should be a tea or dessert spoonful. 6. The kind of oil is of little importance therapeutically. The pure kinds are most agreeable to the palate; but the brown coarser kinds have long been used with advantage, and may still be employed with confidence whenever cheapness is an object. 7. I have never observed its employment to induce pneumonia, or fatty disease of the liver or kidney, however long continued, although such complications of phthisis are also exceedingly frequent. But in some rare cases the oil cannot, even under the best manage- ment, be retained on the stomach, and efforts have been made to intro- duce fat into the economy by some other channel, such as by the skin and rectum. The former plan was first tried by Dr. Baur of Tubingen, who rubbed various kinds of oil into the skin, and even recommended oil baths. Persons occasionally got better under this as they do under every other kind of treatment, but the excessive trouble, aud sense of uncleanliness which greasy frictions occasion, are strong objections to its use. Its costliness also renders it inapplicable to the poor. Oily ene- mata were recommended by Dr. Buist of Aberdeen. But it must be evident that as nature never intended mankind to be permanently nou- rished either by the skin or by the rectum, so, in imitation of her pro- cesses, the object of an analeptic treatment in pulmonary tuberculous must be to cause the elements of the food to be taken by the mouth; to dimiuish the dyspeptic symptoms, aud induce assimilation by the lacteal rather than by the lymphatic vessels. 2. The second indication—namely, to subdue local irritation—is only to be followed out in acute cases by much the same practice as guides us in the treatment of pneumonia, which is the general cause of such irri- tation. From what has been previously said on that subject, it must be evident that, however practitioners may flatter themselves that by bleediog or mercury they have checked inflammation, these remedies in phthisis, so far from arresting the local lesion, have only accele- rated it. In the chronic forms of the disease this indication is only to be met by topical counter-irritation. Hence a seton or issue, a succession of blisters, tartar-emetic ointment, and croton oil, are all beneficial, and may be used according to circumstances. Cold sponging, employed with great precaution, so as not to produce a chill, but rather a glow of heat afterwards, is also beneficial. Such are the only means in our power to meet this important indication, because, combined with this local lower- ing treatment, the general system must be invigorated to the utmost This is the difficult problem to be worked out iu the treatment o' PHTHISIS PULMONALIS. G89 phthisis, and in doing so we shall be much assisted by paying particular attention to the third indication. 3. The avoidance of those circumstances likely to deteriorate the con- stitution on the one hand, or induce pulmonary symptoms on the other, offers a wide field for the judicious practitioner, especially in his charac- ter as a watchful guardian over his patient's health. One of the great difficulties we have to overcome in this climate, is the frequent variations of temperature, and the sudden changes from fervent, heat to chilling cold. Supposing that you have the means of supporting nutrition and keeping down local irritation, it is by no means certain that good will be accom- plished, from the impossibility of securing those hygienic regulations and that equable climate, which are necessary to carry out the third indica- tion. In the first place, nutrition itself is more connected with proper exercise and breathing fresh air than many people imagine. It does not merely consist in stimulating the appetite and giving good things to eat. It requires—1st, Food in proper quantity and quality ; 2d, Proper diges- tion; 3d, Healthy formation of blood ; 4th, A certain exchange between the blood and the external air on the one hand, and between the blood and the tissues on the other ; and 5th, It requires that there should be proper excretion, that is, separation of what has performed its allotted function and become useless. All these processes are necessary for nutrition, and not merely one or two of them, for they are all essentially connected with, and dependent on, one another. Hence the means of prevention consist in carrying out those hygienic regulations which secure the performance of these different nutritive acts, the most important of which are attention to climate, exercise, and diet. Much has been written on climate, but the one which appears to me best is that which will enable the phthisical patient to pass a few hours every day in the open air, without exposure to cold or vicissitudes of temperature on the one hand, or excessive beat on the other. Whenever such a favoured locality may be found during the winter and spring months, its advantage should be considered as dependent on exercise, and on the stimulus given to the nutritive functions, rather than to its influence on the lungs directly. The great mass of those affected with phthisis, however, have not the means of searching out a favourable climate on the Continent, or even of maintaining themselves in a sheltered nook on the western or south-west- ern coasts of this country. It has, therefore, been proposed that such buildings as the Crystal Palace should be converted into winter gardens and public promenades. Not to speak of the intellectual and recreative purposes that such a plan would subserve, it is worthy of our consider- ation how far it would tend to promote health in general, but especially, how it would conduce to the cure of phthisis. Its great advantage would be offering the means of exercise in a pure atmosphere, at an equable temperature. It is easy for us, by confining patients in a suite of rooms in which the heat is regulated, to secure immunity from cold and change of air; but such a contrivance is most intolerable to the patient; the mind becomes peevish, which in itself is a powerful obstacle to the pro- per performance of the digestive functions. But above all, the body is deprived of exercise—that necessary stimulus to the appetite, respiration, 44 690 DISEASES OF THE RESPIRATORY SYSTEM. and other functions. Some years ago, I succeeded in confining a con- sumptive patient to his room for an entire winter. His spirits suffered greatly ; but on the whole he supported the imprisonment with resolution. Next winter, however, nothing could induce him to remain at home, and one day he rushed out of the house, ascended Arthur's Seat, and was much better in consequence. Since then I have been convinced that although by confinement you may gain some advantages, on the whole it is a prejudicial practice if rigorously carried out. What is required in these cases is the means of exercise, whether on foot, on horseback, or in a carriage, where the patient is protected from cold winds, and where the mind can be amused by pleasant sights and cheerful conversation. Such is the case in all those favoured localities considered best for consumptive people, and such would be the advan- tages derived from resorting to the Crystal Palace as a winter garden and promenade. Delicate individuals could be transported thero by means of a close carriage, in the worst seasons, without difficulty, and on entering it could breathe for hours a pure, balmy air, and meet their friends, take exercise in various ways, read, work, or otherwise amuse themselves. Such an out-door means of recreation, combined with care- ful hygienic regulations at home, would go far to remove many of the difficulties which we have to encounter in the ordinary treatment of consumption. With regard to diet, it may be said, in general terms, that one of a nutritious kind, consisting of a good proportion of animal food abound- ing in fat, is best adapted for phthisical cases, whilst everything that induces acidity should be avoided. But, as previously stated, the diffi- culty consists in causing such diet to be taken, on account of the bad appetite and dyspeptic or febrile symptoms which prevail. No effort, therefore, should be spared to overcome the obstacles which prevent food of sufficient quality and quantity from being digested, the appropriate means for doing which must vary according to the circumstances of the case, and will be treated of immediately. The strongest stimulus to the appetite, however, is exercise, and hence the importance of the conside- rations already entered into, with reference to securing what is essential in the treatment of the disease, namely, good digestion and proper assimilation. If the pathology of pulmonary tuberculosis formerly described be cor- rect, it indicates what are the means best adapted for preventing, as well as arresting, the disease when it has already commenced. These are, for the infant, a healthy nurse, cleanliness, and careful attention to all those circumstances which tend to increase the bodily vigour aud to secure good digestion. At the time of weaning and of teething, the most watchful care becomes necessary, so that local irritation and its effects may be prevented as much as possible, and a proper diet, con- taining a sufficient amount of the fatty principles, be taken. During adolescence, indulgence in indigestible articles of food should be avoided, especially pastry, unripe fruit, salted provisions, and acid drinks, while the habit of eating a certain quantity of fat should be encouraged, and, if necessary, rendered imperative. The same precautions, conjoined with proper bodily and mental exercise, avoiding exhausting and too fatiguing occupations, should subsequently be maintained until the predispo- PHTHISIS PULMONALIS. 691 gition to tubercular disease has been completely overcome. In short, everything that can support and invigorate should be adopted, and every- thing that can exhaust and depress should be shunned. As vitiation of the chyle and blood precedes the local deposition of tubercular exuda- tion, it necessarily follows that that numerous class of delicate invalids, whose chief complaint is derangement of the digestive process, with languor and debility, may, by the hygienic means now indicated, and proper treatment of the dyspepsia, be restored to health. Were it possible in all cases for these three indications to be carried out, I feel satisfied the cure of phthisis would be more frequent; but in the treament of this disease, the physician has to struggle not only with the deadly nature of the disorder, but with numerous difficulties over which he has no control, such as, among the poorer classes, the impos- sibility of procuring good diet, and the thousand imprudences not only they, but the majority of invalids, are continually committing. Then another great difficulty is, to convince the patient that, notwithstanding the removal of his urgent symptoms, the disease is not cured, and that these will return, if the causes which originally produced them are again allowed to operate. Sometimes I have found it difficult to keep hospital patients in the house when they are doing well, at other times they are sent out in accordance with certain regulations, which oblige the admis- sion of more acute cases. This was the case with Barclay. (Case CXLIV.) So long as he was under treatment, or rather enjoyed the comforts of good diet of the Infirmary, so long was he well; but sent out, exposed to misery, to insufficient food, and work, he became worse. Lastly, the attempt to relieve distressing symptoms interferes much more than is generally supposed with the curative treatment. This leads me to speak of the III.—Sp>ecial Treatment of Phthisis Pulmonalis. Under the head of General Treatment of Phthisis Pulmonalis, I have pointed out the means of meeting the three indications which should never be lost sight of in this disease. But every case requires a special treament in addition, which will depend on the unusual severity of this or that symptom, or the existence of peculiar complications. It is to the undue importance given to this special, as distinguished from the general treatment, that I attribute much of that want of success ex- perienced by practitioners. Thus it is by no means uncommon to meet with patients who are taking at the same time a mixture containing squills and ipecacuanha to relieve the cough ; an anodyne draught to cause sleep and diminish irritability; a mixture containing catechu, gal- lic acid, tannin, or other astringents, to check diarrhoea ; acetate of lead aud opium pills to diminish haemoptysis; sulphuric acid drops to relieve the sweating; and cod-liver oil in addition. I have seen many persons taking all these medicines and several others at one time, with a mass of bottles and boxes at the bedside sufficient to furnish an apothecary's shop, without its ever suggesting itself apparently to the practitioner, that the stomach drenched with so many nauseating things is thereby 692 DISEASES OF THE RESPIRATORY SYSTEM. prevented from performing its healthy functions. In many cases there can be little doubt that this treatment of symptoms, with a view to their palliation, whilst it destroys all hope of cure, ultimately fails even to relieve the particular functional derangement to which it is directed. Still these symptoms require attention; but their causes, and the means required for their relief, will be best understood by speaking of each in succession. Cough and Expectoration.—At first the cough in phthisis is dry and hacking. When tubercle softens or bronchitis is present, it becomes moist and more prolonged. When excavations exist, it is hollow and reverberating. In every case cough is a spasmodic action, occasioned by exciting the branches of the pneumogastric nerves, and causing simul- taneous reflex movements in the bronchial tubes and muscles of the chest. The expectoration following dry cough is at first scanty and mucopuru- lent, aud afterwards copious and purulent. When it assumes the num- mular form,—that is, occurs in viscid rounded masses, swimming in a fluid clear mucus, it is generally brought up from pulmonary excava- tions. The accumulation of the sputum in the bronchial tubes is an excitor of cough ; and hence the latter symptom is often best combated by those means which diminish the amount of sputum. When, on the other hand, the cough is dry, those remedies should be used which diminish the sensibility of the nerves. In the first case, the amount of mucus and pus formed will materially depend on the weakness of the body, and the onward progress of the tubercle. Hence good nourish- ment and attention to the digestive functions are the best means of check- ing both the cough and expectoration; whereas giving nauseating mix- tures of ipecacuanha and squills is perhaps the worst treatment that can be employed. There is no point which experience has rendered me more certain of than that, however these symptoms may be palliated by cough and anodyne remedies, the stomach is thereby rendered intolerant of food, and the curative tendency of the disease is impeded. Ou the other hand, nothing is more remarkable than the spontaneous cessation of the cough and expectoration on the restoration of the digestive func- tions and improvement in nutrition. When the cough is dry, as may occur in the first stage, with crude tubercle, and in the last stage with dry cavities, counter-irritation is the best remedy, employed in various forms. Opium may relieve, but it never cures. The occasional use of the sponge saturated in a solution of nitrate of silver, is frequently of the greatest service. (See Laryngitis.) Loss of Appetite.—This is the most constant and important symptom of phthisis, inasmuch as it interferes more than any other with the nutri- tive processes. If food, or the analeptic, cod-liver oil, cannot be taken and digested, it is vain to hope for amelioration in any of the essential symptoms of the disease. Here we should avoid a mistake, into which the inexperienced are very liable to fall. Nothing is more common than for phthisical patients to tell their medical attendants that their appetite is good, and that they eat plentifully, when more careful inquiry proves that the consumption of food is altogether inadequate, aud that they loathe every kind of animal diet. In the same manner, they say they are quite well, or better, when they are evidently sinking. We should never be satisfied with general statements, but determine the PHTHISIS PULMONALIS. 693 kind and amount of food taken, when sufficient proof will be discovered, in the vast majority of cases, of the derangement, formerly alluded to, of the appetite and digestive powers. Very commonly also, there will be acid aud other unpleasant tastes in the mouth. In all such cases, especially if too much medicine has been already given, the stomach should be allowed to repose itself before anything be administered, even cod-liver oil. Sweet milk, with toasted bread, and small portions of meat nicely cooked, so as to tempt the capricious appetite, should be tried. Then ten drops of the Sp. Ammon. Aromat., given every four hours in a wine- glassful of some bitter infusion, such as that of Columba or Gentian, with a little Tr. Aurantii, Tr. Cardamomi, or other carminative. In this way the stomach often regains its tone, food is taken better, and then cod- liver oil may be tried, first in tea-spoonful doses, cautiously increased. Should this plan succeed, amelioration in the symptoms will be almost certainly observed. Nausea and Vomiting.—Not unfrequently the stomach is still more deranged; there is a feeling of nausea and even vomiting on taking food. In the latter stages of phthisis, vomiting is also sometimes occasioned by violence of the cough, and the propagation of reflex actions, by means of the par vagum, to the stomach. In the former case, the sickness is to be alleviated by carefully avoiding all those substances whicii are likely to occasion a nauseating effect, by not overloading the stomach, but allowing it to have repose. In cases where too much medicine has been adminis- tered, a suspension of all medicaments for a few days will frequently enable the practitioner to introduce nourishment cautiously with the best effect. I have found the following mixture very effectual in checking the vomiting in phthisis. R Naphtha; Medicinalis, 5 j ; Tr. Cardamomi comp., = j; Mist. Camphorce, 3 vij. M. ft. mist. Of which a sixth part may be taken every four hours. When it depends on the cough, those remedies advised for that symptom should be given. I have tried emetics for the relief of nausea and vomiting, but with no good result. Diarrhoea.—This is a very common symptom throughout the whole progress of phthisis, at first depending on the excess of acidity in the alimentary canal, to which we have alluded, but in advanced cases con- nected with tubercular deposit and ulceration in the intestinal gland. The best method of checking this troublesome symptom, is by improving the quality and amount of the food. The moment the digestive processes are renovated, this, with the other functional derangements of the ali- mentary canal, will disappear. Hence at an early period we should avoid large doses of opium, gallic acid, tannin, and other powerful astringents, and depend upon the mildest remedies of this class, such as chalk with aromatic confection, or an antacid, such as a few grains of carbonate of potash. When, on the other hand, in advanced phthisis, continued diar- rhoea appears, and is obstinate under such treatment, then it may be presumed that tubercular disease of the intestine is present, and the stronger astringents with opium may be given as palliates. Beemoptysis.—This symptom sometimes appears suddenly in individu- als in whom there has been no previous suspicion of phthisis, and in whom, on careful examination, no physical signs of the disease can be detected. On other occasions, the sputum may be more or less streaked 694 DISEASES OF THE RESPIRATORY SYSTEM. with blood ; and lastly, it may occur in the advanced stage of the dis- ease, apparently from ulceration of a tolerably large vessel. In all these cases the best remedy is perfect quietude, and avoidance of every kind of excitement, bodily and mental. Astringents have been recommended especially acetate of lead and opium; but how these remedies can ope- rate, I am at a loss to undefstand; and I have never seen a case in which their administration was unequivocally useful. I have now met with several cases where supposed pulmonary haemorrhage really origi- nated in follicular disease of the pharynx or larynx, and, with the sup- posed phthisical symptoms, was removed by the use of the probang aud nitrate of silver solution. Sweating I regard as a symptom of weakness, and therefore as a common, though by no means a special one in phthisis. Here, again, the truly curative treatment will consist in renovating the nutritive pro- cesses, and adding strength to the economy. It will always be observed that, if cod-liver oil and good diet produce their beneficial effect, the sweating, together with the cough and expectoration, ceases. On the other hand, giving acid drops to relieve this symptom, as is the common practice, by adding to the already acid state of the alimentary canal, is directly opposed to the digestion of the fatty principles, which require assimilation. It should not be forgotten that consumptive patients, and all those suffering from pulmonary diseases, are especially sensitive to cold. The impeded respiration from the lungs in such cases, is counterbalanced by increased action of the skin, which becomes unusually liable to the in- fluence of diminished temperature. Again, cold applied to the surface immediately produces, by reflex action, spasmodic cough and excitation of the lungs. Every observant person must have noticed how cough is induced by crossing a lobby, going out into the open air, a draught of wind entering the room, getting into a cold bed, etc. etc. The mere exposure of the face to the air on a cold day, takes away the breath, in- duces cough, and obliges the patient instinctively to muffle up the mouth. The numerous precautions, therefore, that ought to be taken by the phthisical individual, should be pointed out, especially the necessity of warm clothing, to which large additions should be made on going out into the air. Thus, covering the lower part of the face is important as a means of extra clothing, and not as a means of breathing warm air, as the favourers of respirators imagine. The patient should always sit with his back to the horses or to a steam-engine, and if by accident his shoes or clothes become wet, they should be changed as soon as possible. In the house, ladies should have a shawl near them, to put on in going from one room to another, in descending a stair to dinner, etc. By attention to these minutiae, much suffering and cough may be avoided. Febrile Symptoms.—The quick pulse, general excitement, loss of appetite, and thirst, which are so common in the progress of phthisical cases, are dependent on the same causes as those which induce symp- tomatic fever in general. Vascular distension, resulting in exudation and its absorption, is proceeding with greater or less intensity in the lungs, and frequently in other organs. This leads to nervous irritation and in- crease of fibriu in the blood, accompanied by febrile phenomena. The PHTHISIS PULMONALIS. 695 intensity of these is always in proportion to the activity of local disease, or to the amount of secondary absorption going on from the tissues, or from morbid deposits. Nothing is more common than attacks of so- called local inflammations in phthisis and the careful physician may often determine by physical signs the supervention of pleurisy, pneu- monia, or bronchitis on the previously observed lesion, and not unfre- quently laryngitis, enteritis, or other disorders. In such cases, nature herself dictates that the analeptic treatment, otherwise appropriate, is no longer applicable—food disgusts, and fluids are eagerly demanded. Under these circumstances, it has been common to apply leeches to the inflamed part, and extract blood by cupping, measures which undoubt- edly cause temporary relief, but which are wholly opposed to the plan of general treatment formerly recommended, and to what we know of the pathology of the disease. Every attack of febrile excitement is fol- lowed by a corresponding collapse, and it should never be forgotten that. in a disease which is essentially one of weakness, the patient's strength should be husbanded as much as possible. Hence the treatment I depend on in such circumstances, consists of at first the internal adminis- tration of the neutral salts, especially of tartar emetic in small doses, combined with diuretics, in order to favour crisis by the urine. Sub- sequently quinine is undoubtedly advantageous. I have satisfied myself that such attacks are not to be cut short by leeches or cupping, and although in many cases, as previously stated, temporary relief is pro- duced, the exposure of the person, and unpleasant character of the ap- plications, the trickling of blood, and wet sponges, as often irritate, and give rise to unnecessary risk. Still there are cases where topical blood-letting, if it cannot be shown to have advanced the cure, cannot be proved to have done harm, but these cases, as far as my observation goes, are very few in number. In the rapidly febrile cases, or the so-called instances of acute phthisis, mercury has been recommended; but I have never seen it produce the slightest benefit. Debility.—This is a very common symptom of phthisis from the first, and frequently leads the patient into indolence both of mind and body, a condition very unfavourable for the nutritive functions, upon the successful accomplishment of which its removal depends. It is to remove the weakness that tonics have been administered, but I have never seen quinine, bitter infusions, or even chalybeates, of much service alone, while the continual use of nauseous medicine disgusts the patient, aud interferes with the functions of the stomach. Here again the great indication is to remove the dyspeptic symptoms, give cod-liver oil, an animal diet, and improve the appetite by gentle exercise aud change of scene. Should the practitioner succeed in renovating the nutritive functions, it is often surprising how the strength increases, in itself a sufficient proof as to what ought to be the method of removing the debility. I have frequently seen patients who have been so weak that they could not sit up in bed without assistance, so strengthened by the analeptic treatment, that they have subsequently walked about and taken horse exercise without fatigue, and this after all the vegetable, mineral, and acid tonics have been tried in vain. Despondency and Anxiety.—It is impossible for the careful practitioner to avoid noticing the injurious influence of depressing mental emotions 696 DISEASES OF THE RESPIRATORY SYSTEM. on the progress of phthisis. Indeed the worst cases are those of indivi- duals with mild, placid, and unimpassioned characters who give way to the feelings of languor and debility which oppress them. Such persons are most amiable patients—they give no trouble—anything will do for them—they resign themselves to circumstances, and state that they are eating well and getting better up to the last. These are cases of bad augury, for it is exceedingly difficult to inspire them with sufficient energy to take exercise, or to carry out those regulations which are absolutely essential to renovate the appetite and the nutritive functions. Such persons are benefited by slow travelling, cheerful society, and everything that can elevate the spirits, and, insensibly to themselves, com- municate a stimulant to the mental and bodily powers. Anxiety, on the other hand, though it may sometimes depress aud interfere with the digestive functions, is often a most useful adjunct to the physician. Those who experience it are most careful of their health, sometimes indeed too much so, but, if once satisfied of the benefit of any particular line of treatment, they pursue it with energy. These are cases of good augury, and most of the permanent cures I have witnessed have been in such persons—medical men, aud others acquainted with the nature of their disease, who have exhibited resolution, and a noble fortitude, and have bravely struggled against local pain, general debility, and nervous fear.* CANCER OF THE LUNG. Case CLII.f—Cancer of the Lung, Thyroid Body, and Lymphatic Glands of the Neck—Bronchitis—Leucocythemia. History.—Margaret Stewart, a cook, aet. 60—admitted into the clinical ward July 16, 1851. For some years back she has been subject to a short dry cough, whicii has never been troublesome except after cooking a larger dinner than usual. With the exception of an attack of diarrhcea when the cholera was prevalent, she h:is been more or less constipated. Has never suffered from epistaxis or other form of haemorrhage. Four weeks ago she first perceived a swelling in the neck, which, com- mencing in front, has gradually spread towards the right side. Latterly her breathing has become short and hurried; her strength has decreased, and the cough has been accompanied by considerable expectoration. SYMProMs on Admission.—On admission, the neck presents a prominent indu- rated swelling, anteriorly, measuring about four inches in diameter, evidently owing to enlargement of the thyroid body. A chain of enlarged glands extends from the anterior swelling round the right side of the neck, a little beyond the ear. She com- plains of great weakness, constant sweating at night, and cough with copious frothy expectoration. The chest is everywhere resonant on percussion. There are loud sonorous and moist rales heard over the whole chest, especially posteriorly and inferiorly. The vocal resonance is also unusually loud, but equal on both sides. The tongue is furred, dark brown in the centre ; deglutition is difficult, apparently from pressure of the enlarged cervical glands. The appetite is bad, with an acid taste in the mouth. Other functions properly performed. * For numerous other facts and observations connected with the pathology and treatment of phthisis, see the Author's work on Pulmonary Tuberculosis. 8vo. Edin- burgh, f Reported by II r. D. 0. Hoile, Clinical Clerk. CANCER OF THE LUNG. 697 Progress of the Case.—She continued in this condition for several days, during which iodine and counter-irritants were applied to the neck, and expectorants and anti- spasmodics taken internally to relieve the cough. The dyspnoea, however, gradually increased; deglutition became mare difficult, and her strength diminished. On the 30th of July the urine was ascertained to contain albumen, which had previously not existed. She died without a struggle, August 5th. Sectio Cadaveris.—Forty hours after death. Neck.—On dissecting the integuments from the neck on the right side, a consider- able number of glands, about the size of a barleycorn and small pea, were observed in clusters between the platysma myoides and the sterno-mastoid muscle. A hard tumour existed in front of the neck, stretching along the whole front of the trachea, and over the great vessels on either side beneath the sterno mastoid muscles, and posteriorly on the right side, as far back as the transverse processes of the vertebrae, and down beneath the clavicle to the anterior surface of the first rib, where it was firmly adherent to the periosteum. A prolongation of the tumour, about the size of two walnuts, passed be- neath the sternum at its upper end, being attached to its periosteum. This prolonga- tion on section presented the outline of a congeries of enlarged lymphatic glands, hav- ing a white appearance, in some places soft, and even diffluent, and yielding on pressure a copious milky cancerous juice. Thorax.—There were lax adhesions at various points on the pleurae on both sides. The pleural cavities contained a little fluid on the right side, amounting to about five ounces. At the lower part of the left lung, and also at the back part of right lung, there was a small amount of recent membranous exudation. A multitude of small cancerous nodules were scattered throughout the whole of both lungs. Some were immediately be- low the pleuras, and some in the substance of the organs. For the most part these masses were scattered pretty equally, being as numerous at the base as at the apex, and vary- ing from the size of a millet seed to that of a small walnut. Some were of firm con- sistence, and others soft and friable, presenting various degrees of induration. They all on pressure yielded a copious milky juice. The mucous membrane of the bronchi was of a mahogany colour, and the tubes were more or less filled with muco-purulent matter. Abdomen.—Abdominal organs healthy. Microscopic Examination.—The cancerous juice squeezed from the cervical glands, and the nodules scattered throughout the lungs, contained numerous cancer- cells, which it is unnecessary to describe minutely here. (See p. 0& -=-x- e «• r«.., 12S.) Associated with these -^ \>°;\ £% /0$$ CO were a considerable number of «< p rV „"„ .'' • '"" k->QJ^'' ' ''-^ °/;M i* 3Mcy^o round colourless corpuscles, % W>M .■•^^■r. • " &J' varying in diameter from the p- .' °- V) ** *?£&* * 150thtothel00thofamilli-!t V,, ;.!- ' ' ^\ • metre in diameter. An unusual ,. >. '■<»?;* ..-•, s~*\ m %* 9J number of these cells also exist- V^ " °'y ^- C©//^ ed in the blood, as was deter- °'^^%K^f sW' * " " ■* '"' mined both before and after Fig. 439. Fig 440. death. (See Leucocythemia.) r ig. 439. Corpuscles in cancerous juice squeezed from the thyroid body. Fig. 440. The same, after the addition of acetic acid, showing the cancer cells, and those peculiar to the gland, which were found in large numbers in the blood. 250 diam. 698 DISEASES OF THE RESPIRATORY SYSTEM. Commentary.—In the case before us, the chest was frequently exam- ined with great care, and was ascertained to be everywhere resonant on percussion. Loud sonorous and moist rales were heard on both sides, especially posteriorly and inferiorly. Hemce there were all the signs of bronchitis, which was found'afterwards to exist; but there was associated with them unusually loud vocal resonance, equal on both sides. It occurred to me at the time that this latter sign was merely indicative of dimin- ished volume in the lungs; but, after the dissection, it became manifest that it was owing to increased density of the organs, from the dissemi- nated cancerous nodules. Whether the conjoined signs of augmented or unusual resonance of the lungs, bronchitis and increased vocal resonance, will prove diagnostic in such cases, further experience only can deter- mine. Doubtless, it will be always difficult to separate such signs, depend- ent on nodular cancer, from those connected with collapse of the lung, which is so common a result of chronic bronchitis. In the present case I was in great doubt, notwithstanding my acquaintance with the valuable sign of tumour in the neck, as pointed out by Dr. Kilgour, of Aberdeen.* The treatment, it must be obvious, could only be palliative. Cancer of the lung may occur in two distinct forms,—1st, That of disseminated nodules; 2d, That of infiltrated masses. In the former case there are no physical signs, or functional symptoms, which indicate the presence of cancer; in the latter there are unusual dulness, and resistance on percussion, increased vocal resonance aud tubular breathing, or dimin- ished respiration, according to the density, position, and extent of the cancerous infiltration. If with these signs there be indications of the exist- ence of cancer in other parts of the body, there will be little difficulty in forming the diagnosis; and even should this be absent, the history of the case, advanced period of life, and the non-existence of moist rattles will occasionally be sufficient. It must be confessed, however, that notwith- standing the valuable labours of Stokes, Hughes, M'Donnell, Walshe, and Kilgour, the means of diagnosing this lesion with certainty are very defec- tive. In the present work, eight other cases are recorded in which can- cer of the lung existed (Cases XXIX., XXXVII., XLIX., LXV., LXXL, LXXVI, LXXVIL, and LXXXV.) In one of these the pleu- rae only were affected (Case LXXVII.) With the exception of Case XXX VlL, in which the posterior surface of the lungs could not be exam- ined, the pulmonary organs were carefully percussed and auscultated in all. But in none did any combination or succession of signs exist which could induce any one to pronounce that pulmonary cancer was present. Case LXXVI. alone presented the gelatinous sputum tinged with blood, or the currant jelly expectoration described by Stokes. In Case XLIX. there was ulceration and gangrene of the fungoid mass, with all the signs of pneumonia—and pneumonic condensation was found surrounding the epithelioma of the lung after death. In Case LXXI. there was thoracic aneurism, to which all the physical signs were attributable. When infil- trated cancer exists to any amount in the apex of the lungs, associated with cancer in other organs, or with an evident tumour in the neck or mediastinum, the diagnosis is comparatively easy. * Monthly Journal of Medical Science, June 1850. CARBONACEOUS LUNGS. 699 Nothing can be more variable than the minute structure of cancer in the lung. When recent, it may present delicate round or oval cells (Fig. 119.) When more advanced, it may exhibit large compound cells (Fig. 12(>.) as in Case LXXVI. When in the infiltrated form and softened to any extent, I have seen the whole reduced to a mass of irre- gularly-formed nuclei, as in Fig. 325. On one occasion I found a large mass of brain-like looking cancer of the lung, somewhat fibrous, and principally composed of elongated fusiform corpuscles. CARBONACEOUS LUNGS. Case CLIIL*—Carbonaceous Lungs with Black Expectoration. History.—Thomas Wilson, aet. 38, collier, from the Oakley Mines near Dunferm- line, was admitted into the clinical ward 26th of July 1851. He states that he has been employed about coal mines for the last twenty-four years, during the principal part of which time he has been occupied in blasting rock for the sinking of pits, using large quantities of gunpowder daily. He is much exposed to cold and wet in this occupation, working almost constantly with wet feet, and frequently with the whole of his clothes drenched. During the laying open of a new surface for the working of coal, he has often worked in an atmosphere barely capable of supporting the combus- tion of the miners' lamps; he has observed this particularly when working iron-stone. Notwithstanding, it was only about seven months ago that he began to be troubled with short dry cough, and difficulty of breathing. He continued to work till about four months ago, when the cough became more severe ; he had much dyspnoea, and frequent profuse perspiration, especially at night. Two weeks after this—that is, about fourteen weeks ago—he was laid up from work; and about the same time, while under treat- ment, he began to spit much, and observed that the expectoration was of a deep black colour. The change was so sudden as to alarm him considerably. Symptoms on Admission.—On admission, the thorax is of large dimensions and well formed. On percussion, there is slight comparative dulness on the left side of the chest over the upper half in front; and there is also appreciable dulness over the same extent on the same side posteriorly. There is complete resonance on the right side anteriorly and posteriorly. On auscultation, for some inches below the clavicle on the left side, the inspiration is rough and harsh, and there is prolongation of the expiration. Lower down on the same side, there is also fine moist rale, and the vocal resonance is somewhat increased. On the right side there is loud pealing vocal resonance both anteriorly and posteriorly: it is particularly loud in front immediately below the clavicle, but there is nothing abnormal to be detected in the respiratory sounds. The expansion of the chest is equal on both sides. Breathing is equal and unembarrassed while he is sitting or lying in bed, but on using much exertion, it be- comes short and difficult. There is some cough, but it is not very troublesome. States, that at the commencement of his illness, he could not lie on his left side; but at pres- ent he can lie in any position without uneasiness. The sputum is in considerable quantity, adheres tenaciously to the bottom of the spit-box, and is of an intense black colour. On being placed in water, a small portion of a lighter colour swims on the surface, but the greater part sinks immediately. On being allowed to stand for a * Reported by Mr. "W. Calder, Clinical Clerk. 700 DISEASES OF THE RESPIRATORY SYSTEM. little, the supernatant water becomes nearly clear, the dense black mass remaining at the bottom of the dish. Acetic, sulphuric, and nitric acids and also aq. potass*, though boiled with the sputum, do not in the least affect its colour. The other sys- tems are quite normal. Has good appetite, no sour or unpleasant taste in his mouth. Bowels are regular at present, and are generally so ; has never had diarrhoea. Does not sweat at night, nor unless when employed at his work. Pulse during examina- tion was 88, soft and full; during his stay in the house has averaged about 76. He was ordered an expectorant mixture; and during the last fortnight he was in the house, he had three table-spoonfuls of cod-liver oil daily. He went out by his own desire in August, the symptoms having undergone little change. Microscopic Examination of the Sputum.—On placing a small portion of the sputum below the microscope, many of the epithelial cells are seen loaded with the black carbonaceous matter. In some of them the nuclei are evident, the matter being deposited between them and the cell walls; in others, the nuclei are quite concealed. In other parts of the field, all appearance of cells is lost, and nothing but apparently homogeneous black masses are visible. Some of the cells may also be seen ruptured, and the bla.ck contents poured out. (See Fig. 337.) Commentary.—The physical signs existing in this case leave us in lit- tle doubt that there was considerable condensation at the apex of both lungs. This was indicated on one side by considerable dulness on per- cussion, and on the other by a pealing vocal resonance. It is true, the resonance in this place was unaccompanied by any change in the per- cussion note, a circumstance that may be caused by the existence of slight emphysema counterbalancing the increased density of the pulmo- nary tissue. The history of the man's case, the nature of his employ- ment, and the black sputum, at once indicated to us that this condensa- tion was owing to accumulation of carbonaceous matter in the lungs, a disease which is peculiarly apt to occur in coal-miners, the moulders in iron and copper, and a few other trades. Case CLIV.*—Carbonaceous Lungs with Black Expectoration in a Female. History.—Christina Nasmyth, set. 42, the wife of a coal miner residing near Mus- selburgh—admitted 21st May, 1857. For nine years previous to marriage she worked in a coal pit, being engaged in pushing the trucks along the tratn-ways. She married at sixteen years of age, and has never since worked in the pit. She has had four children, all healthy. Her own health she declares to have been excellent till January, 1857. About this time she noticed a cough accompanied by sputum of inky black colour, and by sense of pain over the breast and between the shoulders. Her appetite failed, and she became very weak. Latterly her voice has become hoarse and broken. Medical treatment before admission had not been effectual. Symptoms on Admission.—No dyspneea; cough is unfrequent, short, and rather dry; sputum scanty, consisting of frothy blood with tenacious masses of bluish- black mucus; painful sense of tightness over the breast; the voice is harsh and broken. There is slight dulness under the right clavicle, with creaking sound during inspiration, prolonged expiration, and some increase of vocal resonance. There is crack-pot sound under left clavicle, bronchial inspiration with a few moist sounds at close of inspiration, and increased vocal resonance ; posteriorly, percussion seems * Reported by S. de Melho Aserappa, Clinical Clerk. CARBONACEOUS LUNGS. 701 unimpaired; no moist sounds are audible, but occasional sibilant and snoring sounds during expiration over middle of both lungs. The cardiac organ is normal in position and size ; the first sound is rough at apex ; the pulse is 80, and of good strength. Ap- petite is defective ; occasional thirst in the mornings; no vomiting; considerable flat- ulence ; bowels are open generally every second day ; menstruation regular; urine 1010 sp. gr., otherwise normal. Progress of the Case.—May 23d.—So trace of blood in the sputum, which con- sists of several tenacious masses of a bluish-black colour, floating in a slightly viscous mucus. On microscopic examination, there are seen numerous molecules of pigment occasionally lying free, but sometimes contained in large cells; there are also visible n few bundles of fibrous and elastic tissue. Ordered milk and steak diet. 26th.__ No moist sounds are now audible under left clavicle ; respiration continues to be loudly bronchial at left apex, and less so, but still unusually loud over the rio-ht • hoarseness of voice has diminished. 27th.— Ordered Emplastrum Picis (6 by 6) to be applied over the chest. 28th.—No change in respiratory murmurs, nor in sputum ; some dyspneea, and considerable debility. Is ordered a mixture of sweet spirits of nitre and aromatic spirits of ammonia. 29th—The black masses are now fewer in number. June 1st.—Hoarseness of voice has ceased; sputum more scanty, with fewer black masses; appetite is improved ; patient walks daily about the ward. June 6th.__Has continued in the same state as at last report; is anxious now to return to her family and is accordingly discharged to-day relieved. Commentary.—It would appear from the account of this woman, that from the age of seven to that of sixteen years she worked in a coal-pit. She then married, ceased to work in the pit, and continued healthy for twenty-six years. Then for the first time cough came on accompanied with black spit and disorganization of the lung. This circumstance proves that the tendency to carbonaceous formation may be formed several years before it becomes manifested in active disease, which may be induced subsequently by any of the ordinary causes which occasion bronchitis or pneumonia. Young girls are not now so much employed in coal-pits as formerly, and such a case as the above must now be con- sidered, in many points of view, as one of great rarity. From the circumstance of this disease being very common among the colliers in the neighbourhood of Edinburgh, it has been thoroughly studied here. In the first case that was recorded by Dr. James Gregory, the black matter was analysed by Dr. Christison, and shown by him to consist of pure carbon or lamp black, a result confirmed by every sub- sequent writer. The papers by Dr. William Thomson, inserted in the XX. and XXI. Vols, of the Transactions of the Medico-Chirurgical So- ciety of London, contain a mass of important information concerning this disease; and in a series of communications by the late Dr. Mackellar, inserted in the " Monthly Journal " for 1845, you will find numerous facts and opinions regarding it, the results of long and extensive prac- tice among the colliers of Haddingtonshire. On examining the lungs of those who die labouring under this dis- ease, they are found to present a deep black colour, which is most intense towards their apices. On section, the pulmonary tissue yields on pressure a copious black inky juice, which stains all surrounding objects, attaches itself to the inequalities of the skin of the hands, and insinuates itself 702 DISEASES OF THE RESPIRATORY SYSTEM. under the nails like fine black paint. At the apices of the lunors, the pulmonary tissue is generally more or less condensed, and the black matter thicker, and often of the consistence of putty. In advanced cases, ulcerations and cavities exist, exactly resembling iu all their characters those of phthisis, with the exception that no tubercle can be discovered, and that the whole is of an intense black colour Occasionally black indurated and gritty masses can be felt and dug out, which in some rare cases present a slight crystallized structure, like coal or crystallized car- bon. The morbid anatomy of the disease will be best understood by carefully examining the preparations which exist in the University Museum.- On placing some of the black fluid squeezed from the lung under a microscope, and examining it with a power of 250 diameters linear, it is seen to consist of a multitude of black molecules of extreme minute- ness floating in a liquid. Here and there may be observed cells, similar to those previously described as existing in the sputum, more or less loaded with similar molecules of black matter, on which the strongest chemical re-agents produce no effect whatever. (See Figs. 56, 57, and 337.) I have frequently examined the disease in all its stages, and never found it to be referable to the changes occurring in blood after hemorrhagic extravasations, as Virchow supposes to be the case. When we endeavour to investigate the pathology of this disorder, we are met with a host of difficulties. Does it originate from the inha- lation of carbonaceous particles floating in the atmosphere, or is it the result of a secretion of carbon in the pulmonary system itself? The principal fact on which the first opinion rests, is the frequency of the disease in colliers,, and in moulders of iron and copper. Yet it is curious, that whilst it is common among the workmen of some coal pits, it is unknown among those employed in others, although the dust and powder is as finely levigated in one place as iu the other. There is another curious fact connected with the disease in coal miners, viz., that those engaged in working at what is called the coal wall, and in sifting or transporting the coal^ are little affected; whilst those who work at the stone wall are peculiarly liable. This working at the stone wall, consists in blasting the rock by means of gunpowder. Hence the prevalence of black deposits in the lungs has been by some not so much attributed to the dust of coal, as to the smoke of the ex- plosions, or of the lamps carried by the miners, confined as it is in nar- row passages, where little ventilation exists. Even this explanation has difficulties; for it has been proved, that in some mines, where blastiug is carried on very extensively, aud where there is much coal dust it does not exist at all; and hence it has been supposed that there are some kinds of stone which disengage gases, or the working among which is much more deleterious than others. Thus Mr. Philip of Aberdour, who has had great experience in this disease, in a communication be made to Dr. Thomson, says, " In working at stone work, that is, in sinking pits and driving mines of communication, the workmen are exposed, in an eminent degree, to the influence of the impure air; for, besides working in a confined space, and in a cul-de-sac, where the ventilation is very imperfect, there is also a considerable exudation of the carbonic acid gas from the fresh cut surfaces of the CARBONACEOUS LUNGS. 703 minerals. In this impure air they continue to work for many hours daily, for some months, their operations being frequently carried on several yards in advance of where their lamps will burn." In another place, he says, " Those pits and mines which have been noted for the impurity of the air, have given origin to the greatest number of cases." Again, Mr. Steele of Craighall says, he considers the disease to be caused by running mines in stone, and working in impure air. He also observes,—" A principal reason is, that the stone contains some poisonous matter, which is probably of a metallic nature, as the workmen complain of it exciting a styptic and metallic taste in the mouth. A mine was carried across the strata in the Niddry estate, the finishing of which required a number of years. Six or eight of the miners employed in it died; several were obliged to leave it, and only one of those who com- menced it was able to work in it throughout, and lived to see it com- pleted. There was a particular stone in this mine, which was repeatedly met with, and to which the miners gave the name of arsenic, which was found highly pestiferous. Its exact nature I am not acquainted with. In a stone mine, run some years ago in the Newbattle field, a great many meu died,—the average length of time each of the miners employed in it lived being about two years. The mortality was ascribed to the nature of the stone." The facts connected with this peculiar black colouring of the lung leave it therefore undecided whether it be owing to the inhalation of coal dust, the smoke of gunpowder and oil lamps, or carbonic acid gas, entering the lung. Is the powder deposited directly and primarily in the minute tissue of the organ, or is the carbon deposited secondarily, and by a process of secretion from the blood ? Before we can answer these questions, there are two other series of cases, which it is necessary to take into consideration. 1st, Persons have been known to have the black spit, and black infiltrated appearance of the lungs, with caverns, without ever having been in a coal mine, or exposed in any way to gunpowder smoke. Several such cases are given in the paper of Dr. W. Thomson. One of these is by Dr. Browne, now Commissioner of Lunacy for Scotland; another by the late Dr. Moir of Musselburgh. The subject of this last case was never exposed to noxious vapours, unless it mignt be carbonic acid,—as he was the proprietor of an extensive brewery, and in the daily habit of inspecting the tun-rooms, the large vats in which overflow with that deleterious gas. Another case was observed by the same gentleman, in the person of a coachman, where, after death, the lungs were found to contain collections of an inky or tarry fluid, which stained the fingers, as if with soot or charcoal. A fourth and similar case, in a woman, is related by Dr. Veitch. In none of these cases were the individuals exposed to the fumes of smoke, or coal dust. I have myself seen several such cases; in one especially, a cyst in the bronchial gland existed, about the size of the human eye- ball, filled with a black inky fluid. -(/, M. Guillot of Paris has brought forward another series of cases in old persons.* He is physician to the hospital for aged people, and says there is scarcely an individual of advanced life who does not present the * Archives Generates de Medecine, vol. 67. 704 DISEASES OF THE RESPIRATORY SYSTEM. carbonaceous deposit in the lung, generally most marked at the apex. The carbon often exists in crude masses, obliterating the vessels and bron- chial tubes. I have also seen many cases of this kind, and there can be no doubt that the longer we live, the more carbon is deposited in the lungs. In infants, as is well known, those organs are of a light pink colour, and they become more gray and of a deep blue or black tint as life advances. What are we to conclude from these cases ? The black matter in all of them, when chemically examined, is undoubtedly free carbon, and is distinguished by the action of chemical agents; hence it is not likely to be an alteration of haematin, resulting from bloody extravasations into the pulmonary tissue, as Virchow supposes. It never presents the brownish colour or structural character we have shown to be present in coal* a circumstance opposed to its being derived from without, in the form of dust. Dr. Pearsonf thought that we are always insensibly breathing an air more or less loaded with smoke, the results of combustion, and other impurities; and this of course accumulates the older we get. If this opinion were true, it should be more common in persons who inhabit densely populated aud manufacturing towns, as London, Liver- pool, Manchester, or Glasgow. Yet we do not find this to be the case. The air in Paris is remarkably pure, the fires of manufactories are few, and yet there, according to Guillot, it is common. On the other hand, should we conclude that it is formed internally by a chemical process in all cases ? If so, must we ascribe it to the inhala- tion of carbonic acid gas, rather tlian to carbon in a minutely divided state, inspired from without ? In the present state of our knowledge, we cannot answer these questions with any exactitude. Another point of great interest is the apparent antagonism of carbona- ceous deposits with tubercle. We frequently find the black lungs of colliers to contain small or large ulcerated cavities, with bands crossing them ; but we rarely find tubercle. In one or two cases chronic tubercle has been found; but it does not appear that the caverns filled with black matter in the miner are owing to tubercle. Such is the analogy, however, existing between these cavi- ties, and the symptoms they occasion, that the disease has been named " black phthisis " by several persons. Some have supposed that tubercu- lar tissue is first set up, and that the carbonaceous deposit is then insinu- ated among the textures and ulcerations. By others, and especially by the late Dr. Mackellar, it is maintained that there is never tubercle in these cases, and that ulceration is entirely owing to the accumulation of masses of carbon which are expectorated. I have carefully examiued several lungs iu various stages of the disease, but have never been able to satisfy myself of the existence of tubercle. The difficulty of the investiga- tion, however, is very great, for it is probable that, did a tubercular exuda- tion exist, it would be so impregnated with the carbonaceous matter, as not to be recognisable even under high powers. On the other hand, the bronchial tubes are frequently loaded with purulent matter of the usual appearance, but which, instead of presenting pus-corpuscles, is loaded with particles closely resembling those found in softened tubercle. * See the Author's paper on the structure of various kinds of coal. Transactions ot the Royal Society of Edinburgh, vol. xxi. part I. f PhilosoDhical Transactions. 1853. CARBONACEOUS LUNGS. 705 Guillot has alluded to the well-known fact, that in old persons who present traces of tubercle, the cretaceous concretions are always sur- rounded by black matter. He thinks that the carbonaceous deposit com- presses tlie capillaries which immediately surround the tubercle, prevents its further exudation, and so induces cure. But this is by no means in- variable. Still it is an undoubted fact, that the black matter, like tuber- cle always exists in greater proportion at the apex of the lung, and the rarity of recent tubercle in combination with it, leads us to suppose that it exerts a peculiar influence on tubercular deposits. I have also seen black matter surrounding tubercle of tha peritoneum, but in this situation it has not been free carbon, for long immersion in spirit has caused the disappearance of all colour. (See Fig. 330.) So far as my observations have yet carried me, no difference is to be determined structurally between the pigment of melanosis and that of the disease under consideration. Some cells spit up by the miner, con- taining black granules, exactly resemble those in melanic cancer. (Com- pare Figs 336 and 337.) On the other hand, there is a marked differ- ence in the chemical constitution; as in the one, the black pigment, whatever be its nature, is fugitive, and removable by mineral acids; in the other, fixed, and unchanged even under the blow-pipe. Hence all black deposits may be divided into two classes ; to distinguish which we may call one class by the name it has so long borne, viz., " melanotic," and the other, from its chemical composition, " carbonaceous.'1'' With regard to the treatment of individual cases of black phthisis, there is little to be said. The disease, once established, does not admit of cure by art; and it is a curious fact, that a man may work in a coal mine for many years without the black spit; but when it comes on, even should he leave the mine immediately, he will continue to expecto- rate carbonaceous matter for a long time afterwards. Of this both the cases before us are corroborative, and the circumstance is one which constitutes a strong argument in favour of those who contend for the disease being dependent upon a secretion rather than a mechanical deposition of carbon. A palliative treatment, guided by the nature of the symptoms and strength of the constitution, is all that is admissible. The only means of preventing the disease seems to consist in ventilating the mines where colliers work, or adopting the means of carrying off the fumes to which the moulders of iron aud copper are exposed. Such prophylactic measures are equally called for, whatever theory of the nature of the disorder shall ultimately be proved to be correct. 45 SECTION Till. DISEASES OF THE GENITO-URINARY SYSTEM. In no department of medicine has our knowledge of the diagnosis and treatment of disease made more rapid progress in recent times than in that relating to disorders of the genito-urinary system. Notwithstand- ing what has been very justly said as to the impropriety and frequent danger of unnecessary mechanical exploration of the uterine passages with instruments, it cannot be denied that, used with judgment and dis- cretion, they have materially contributed to a recognition and successful treatment of lesions that would otherwise have been unknown or misun- derstood. The use of the microscope in the examination of the urine, conjoined with an histological investigation of morbid alterations in the kidney, hitherto grouped together under the name of " Bright's Disease," has also thrown a flood of light upon a class of disorders formerly involved in the greatest obscurity, besides opening up a field to the chemical pathologist in his endeavour to work out the transformations necessary for the excretory processes, which cannot be too highly valued. From these various investigations medicine has already derived great advantage, and will doubtless obtain much more. The diseases of the generative organs of women, however, constitute at present so peculiarly a speciality of the obstetrician, that the only one of them that I shall allude to is OVARIAN DROPSY. Case CLV.*—Ovarian Dropsy—Frequent Paracentesis—Excision of both Ovaries —Strangulation of the Intestine—Phlebitis—Death from Ileus the seventieth day afler the operation. History.—Jessie Fleming, unmarried, set. 20—admitted July 5th, 1S45. She states, that eighteen months ago she first perceived a tumour in the lower part of * Reported by Mr. D. P. Morris, Clinical Clerk. OVARIAN DROPSY. 707 the abdomen, deep seated in the middle of the hypogastrium. She remembers that she could push it aside in various directions without pain, and that at this time it was about the size of an orange. She can assign no cause for its appearance. The tumour rapidly increased in bulk, until at the end often months the abdomen was greatly dis- tended—so much so, that respiration and progression were rendered difficult. Para- centesis was now performed, and forty imperial pints of a viscid yellowish-coloured fluid were removed. The abdomen, however, again rapidly increased in size, and paracentesis was again had recourse to. The operation has now been performed six times, the intervals between each becoming less and less lengthened, and the amount of fluid, though always considerable, varying in amount. She says that immediately after every tapping, a tumour can be felt about the size of a child's head on each side of the abdomen; that these tumours (she thinks there are two) are movable laterally, but seem to grow from below. She thinks the one on the left side is larger and higher up than that on the right. Her general health has been little affected by the disease. Symptoms on Admission.—At present, July 6th, she complains of pain in the head, which is stated to be dull and heavy, and seated principally over the forehead. It comes on occasionally, and lasts for three or four days at a time. She has pain in the loins very frequently, especially when the dropsy is large. Special senses and common sensibility normal. Her sleep is much disturbed by breathlessness, and by the semi-erect posture the dropsy requires. Motion is impeded by the size of the abdo- men, and from its great weight. There is much muscular weakness. The abdomen measures 48A inches at its greatest girth, which is just above the navel. It fluctuates distinctly. Dulness of the liver cannot be defined by percussion. The skin of the abdomen is marked by transverse fissures or marks of a purplish colour ; it often feels very hot and as if it were bursting; tongue clean; appetite a little impaired ; no thirst or sickness; bowels regular; stools somewhat fluid, but of healthy aspect; urine scanty, thick, high coloured, of acid reaction, containing a yellowish brown sediment, but unaffected by heat; skin dry, not warmer than usual. She states that she never perspires. Has no cough or pectoral complaints except dyspneea, which is very severe at night. On auscultation the chest appears to be healthy. Pulse 88, sharp and small; heart's sounds apparently abrupt, but natural. The catamenia have appeared at irregular intervals, sometimes of three weeks, at others five weeks, and when present are profuse. Progress of the Case.—From this time she remained generally in about the Bame condition. The urine passed in the twenty-four hours never exceeded twelve ounces, and on one occasion was as low as six ounces. The abdomen gradually became more tense and the dyspneea more urgent. July 12th.—Mr. Syme performed the operation of paracentesis of the abdomen. The trocar was introduced to the left of the linea alba, about two inches above the pubic bone. Five imperial gallons of a yellow-coloured transparent fluid were removed. The last four ounces which came off were viscid like white of egg, and contained a few yellowish opaque flocculi. The fluid was densely coagulable on application of heat or nitric acid. The flocculi, when examined with the microscope, were found to be composed not of lymph, as was at first supposed, but of numerous cells, varying in size from the 100th to the 40th of a millimetre in diameter. The great majority were about the 50th of a millimetre. They were slightly granular, of round and oval shape, unaffected by water, but becoming more transparent on the addition of acetic acid, and exhibiting a distinct nucleus about the 140th of a millimetre in diameter. (See Fig. 70.) The nucleated cells were imbedded in a granular matter which could easily be broken down. Shortly after the operation, she complained of considerable pain in the abdomen towards the left side, which was not increased on pressure. Fifty minims of tincture 708 DISEASES OF THE GENITO-URINARY SYSTEM. of opium to be taken immediately. July 15th.—Has continued to feel more or les* pain in the abdomen, which is not superficial or peritoneal. The bowels have been freely opened by compound jalap powder, and she has passed from 4S to ">(i oz. of urine daily. The puncture is now healed; the abdomen is still voluminous but soft. On palpation, a tumour with distinct margins, about the size of the adult human head, may be distinctly felt, firmly attached inferiorly within the pelvU, but its upper portion movable to a considerable extent from side to side. She describes the pain as being of a dull, gnawing, and continued character; not lancinating nor increased on movement. Pulse 98, of natural strength ; tongue slightly furred ; has tolerable appetite ; no thirst, but says she vomits everything she takes. The matters vomited are thrown up about ten minutes after each meal, in successive moutbfuls accompanied by'gnawing pains at the stomach. These latter pains are felt under the false ribs on the right side. The stomach is often felt to be distended, followed by considerable eructations of gas; bowels have been open four or five times; urine much increased in amount since the operation; to-day she passed thirty-eight ounces. The compound jalap powder was directed to be given again. July 18th.—To-day she was carefully examined by Professor Simpson, who employed his uterine bougie. By this means the fundus of the uterus was raised above the brim of the pelvis, where it was distinctly felt presenting its obtuse, rounded, natural form. The Professor stated his opinion that the tumour was connected to the left ovary by a narrow pedicle. Urine ten ounces. July 19th.—The examination of yesterday was followed by great pain. She described this as being " tremendous," and seated in the back. The nurse said she cried out as a woman in labour. About two and a half hours afterwards a draught containing one drachm of solution of morphia was given. It relieved the pain, but it continued until 11 p.m. An anodyne and ether draught was then given, which was immediately rejected by vomiting. August 7th.—Since last report the vomiting has gradually abated, under the influence of opium and creosote pills. The urine, however, has again diminished in amount, and for the last ten days has only been from ten to twelve ounces, while the size of the abdomen has slowly increased to its former volume. To-day, paracentesis was performed by Dr. James Duncan, and five arid a half gallons of fluid removed, presenting the same characters as that described July 12th. Soon after the operation, she experienced considerable pain in the back and upper parts of the abdomen, which ceased at midnight after taking a draught with half a drachm of the solution of morphia. Aug. 16th.—Since last report has been in the Surgical Hospital. Dr. Bennett proposed to the acting sur- geons severally the operation of ovariotomy, which they declined to perform. To- day, accordingly, she returned to the medical ward. During the interval her general health has been good. The fluid in the abdomen is again accumulating. By a care- ful examination the tumour can be ascertained to be quite free from-adhesions to the anterior walls of the abdomen. These latter can be pulled forwards and held steady, while the tumour is made to roll free beneath. Passed during the last 24 hour9 eighteen ounces of urine. The liver was carefully percussed. Its extreme dulness in the right hypochondrium is three inches; it is pushed considerably upwards, the upper line of dulness being on a level with the nipple. She denies ever having suffered from dyspeptic symptoms, or so-called attacks of bile; and her general health is in every respect good, and the amount of urine discharged diminishing. Her gene- ral health is not so robust as when she first entered the house. Dismissed from the Infirmary August 24th. September 3d.—After leaving the Infirmary, she went into lodgings, having been placed by Dr. Bennett under the care of Dr. Handyside. On the 2d that gentleman performed paracentesis, and removed four gallons of fluid, and to-day, having satis- fied himself that it was a case urgently calling for the performance of ovariotomy, OVARIAN DROPSY. 709 he consented to perform it according to the request previously made to him by Dr. Bennett. Sept. 5th.—Bowels have been opened four times during the night, the last time at 8 this morning, from the purgative of Ext. Colocynth, gr. x., administered yesterday evening, and a domestic enema given this morning. She is in good health and spirits. Tongue clean. Operation of Ovariotomy.—The operation was performed, September 5th, at half past 12 by Dr. Handyside, in the presence of Drs. Beilby, Simpson, W. Campbell, A. D. Campbell, Baillie, Bennett, and Struthers, and Professor Goodsir. The temperature of the room was raised to 72°. The patient was placed on a table before a good light, her feet resting on a stool, and her shoulders raised and supported by pillows. Dr. Handyside, now standing to the right side of the patient, made, with a strong scalpei, an incision of about three inches in length through the skin nnd subcutaneous cellular tissue, midway between the umbilicus and pubes and over the linea alba. This incision was deepened carefully, the tinea alba divided, and the peritoneum reached. A fold of this membrane was pinched up with the forceps, and a small opening made into it. Through this opening some glairy fluid escaped, indicating that the cavity of the abdomen had been opened. With a probe- pointed bistoury the peritoneum was now slit open to the extent of an inch less than the external wound. A large quantity of the glairy fluid then escaped, which occasioned some delay. Through this opening Dr. Handyside now introduced two of his fingers, in order to ascertain that no adhesions existed on the exterior surface of the tumour. None being felt, the wound was dilated upwards for other three inches, with a probe-pointed bistoury, which was guided by two fingers introduced into the abdomen. Through this opening Dr.. Handyside introduced his whole hand, and finding the tumour nowhere adherent, the wound was extended upwards to rather more than midway between the umbilicus and the ensiform cartilage, and downwards to within two inches of the symphysis pubis. In cutting upwards, the umbilicus was avoided, the incision passing to the left side of it. Through the large opening the fundus of the tumour now presented, and the charge of it was committed to Professor Simpson, who drew it gently outwards. At this time, as well as before and after, care was taken to prevent protrusion of the intestines. This was done by Mr. Goodsir, who, with both hands, pressed the edges ofthe wound downwards and backwards against the intestines and from the tumour. • On the anterior aspect and fundus of the tumour were now observed several round smooth-edged apertures, through which some of the glairy fluid was seen to escape, being of the same character as that which had flowed from the peritoneal cavity, but rather more viscid in consistence. One of these openings was dilated with a bistoury, which allowed of the escape of a large quantity of the glairy fluid. This had the desired effect of diminishing considerably the size of the tumour. The pedicle of the tumour was next examined, and it was found to consist of the left broad ligament of the uterus, somewhat elongated and enlarged, but not altered in texture. The uterus was seen to be of normal size, though of a rose-red colour, and to be unconnected with the tumour, except through the medium of the ligament. The pedicle of the tumour being now put on the stretch by exerting slight traction on the latter, a strong curved needle, in a fixed handle, and carrying a strong double ligature, was passed through its middle. The double end of the ligature being divided, each half was tied separately, so that each included one-half of the pedicle. Some delay was occasioned by the difficulty experienced in tying the ligatures, as the elasticity ofthe part included caused the first half of the knot to slacken before the other half could be thrown. The tumour now required to be removed. This was done by cutting carefully with a scalpel at about an inch beyond the part sur- rounded by the ligatures. In doing so, a cyst, which had extended down to the 710 DISEASES OF THE GENITO-URINARY SYSTEM. pedicle, was necessarily opened, and some more of the glairy fluid escaped. During the division of the pedicle, venous blood escaped freely from the tumour, but after the removal of that latter, no bleeding occurred from the divided surface of the pedicle although the mouth of at least one large artery was visible. The right ovary was now examined, and it was found to be enlarged to the size of a walnut, and to con- tain several small cysts. Accordingly, Dr. Handyside proceeded to remove it also. A needle carrying a double ligature was passed through the middle of the ligament of the ovary, and the ends tied separately in the same manner as on the other side. No bleeding followed the division of the ligament beyond the ligature. The portions of the broad ligaments which were left were unaltered in structure. The four ends of ligature attached to each broad ligament were now tied together around the latter, and then three of the ends cut off, so as to leave only one from each side hanging at the lower angle of the wound. The blood mixed with the remainder of the glairy fluid was now sponged carefully out of the lower part of the abdomen and the pelvis, which were exposed. The peritoneum lining the abdominal wall, as well as that covering part of the intestines, was now examined, and seen to be of a red colour; but on no part was there any mark of the effusion of lymph. Such of the intestines as were seen were quite natural in their appearance. All oozing of blood from the incisions in the abdominal wall having ceased, no vessel having required ligature, the edges of the wound, with the careful exclusion of the peritoneum only, were approximated and retained in accurate apposition by means of ten twisted sutures. Corresponding parts of the edges of the incision were indicated by the dark points and cross lines which were previously marked with the nitrate of silver, and which, on the now flaccid skin, were found to be of great use. A long pad of lint was now laid, as a compress, along each side of the wound, and a lighter one over it, and these were retained by broad strips of adhesive plaster. Lastly, over these pressure was made, and support given, by the ends of a double many-tailed bandage, which had been placed under the patient before the operation began, and which were crossed and pinned alternately at opposite sides of the abdomen. The patient was then placed in bed, a dry blanket having been previously wrapped round the thighs and pelvis. The patient bore the operation well. At one time she felt faint, but syncope never occurred, so that no stimuli were given. The pulse never sunk below 80, but remained most of the time between 90 and 100. The operation occupied in all about forty minutes. Fifteen of these were taken up in the preliminary incision, examination, and removal of the large tumour,—five in the removal of the small one, and twenty in sponging out the pelvis, introducing the sutures, and applying the compresses, straps, and the many- tailed roller. Subsequent Progress of the Case.—Immediately after the operation, one drachm of the Solution of Morphia was administered. At 4 p.m. she complained of acute pain in the abdomen, and two grains of solid Opium were given in the form of pUL At 8 p.m. another grain of Opium was taken. At 9 p.m. the pain ceased on her being turned in bed. The pulse was 100, soft, and eight oz. of urine were drawn off by the catheter. September 6th.—Has taken during the night a drachm and a half ofthe solution of Morphia, wbich occasioned drowsiness but no sleep. At 2 p.m. there was slight difficulty of breathing. At 9 p.m. the pulse was 148, full and strong, and difficulty of breathing was increased ; 20 oz. of blood were taken from the arm. Sept. 7/h.—At 2 p.m. was allowed to have a little warm gruel, followed by fifteen minims of the " black drop," as she was very irritable and restless. Sept 8th.— List night had some beef-tea and toast, and slept several hours. The wound was dressed at 2 p.m. for the first time. Union by first intention had taken place every- where, except where the ligatures interpose. Sept. 10th.—Wound discharging. OVARIAN DROPSY. 711 freely around the ligatures. Complains of tormina and restlessness. Bowels open. At 9 p.m. there was considerable tenderness of the abdomen, and twenty-four leeches mere applied. Sept. 11th.—Passed a tolerable night. Abdominal tenderness dimi- nished, but still pain in left iliac region. Pulse 130, soft. Respirations 35, but easy. Twenty leec/ies to be applied over seat of pain, and three grains of dames'1 powder, with half a grain of Opium, every three hours. Soda water with Raspberry Vinegar for drink. Sept. 22d.—Since last report has gone on well—occasional symptoms having been carefully treated. For the last few days has complained of cough, but on aus- cultation and percussion the lungs appear to be healthy. The nourishment has been gradually increased, and she has taken eggs and beef-tea, and to-day allowed two oz. of steak for dinner. Between three and four oz. of laudable pus escape daily from the wound round the ligatures. Sept. 28th.—Is so well that she sat up in a chair for some time. Appetite much improved, and has been eating meat daily. October 3d.—Has had slight diarrhcea. The discharge from the wound is copious and fcetid. In the evening, on pulling one of the ligatures, it came away, with a slouch about three inches long, and the diameter of a crow quill. To have a grain of Opium- Oct. 10th.—Looseners of bowels returns occasionally notwithstanding the use of Lead and Opium Pills. Cough has been troublesome, with to-day tenacious sputa, slightly tinged here and there of a rusty colour. On examining the chest, a crepitating rale is heard for the first time about the middle third of left back, and inferiorly there is sonorous rale, both with inspiration and expiration. Over the right back the respiratory murmurs are generally harsh, with increased vocal reso- nance, but no rale. On tightening the ligature, which is still firmly attached, about three ounces of thick greenish offensive pus flowed from the opening. To lie on the face as much as possible. R^ Mucilag. ?j; Syr. Simp.; Vin. Ipecac, aa ? ss ; Sol. Mur. Morph. 3 ij ; Aq. Font. ~ iv; M. Sumat 3 ss quartd qudque hord. At 9 p.m. the ligatures, on being firmly pulled, suddenly came away, producing a sensation as if she had received a blow in the abdomen. There was no slough attached, and the separation was not followed by blood, although flakes of dead tissue were observed in the pus. Pressure was made by pads over the iliac fossa and umbilical region, so as to direct the pus externally. Oct. 20th.—Since last report there has been much cough, with all the signs and symptoms of limited pneumonia of both lungs, poste- riorly and inferiorly. The pulse has varied from 120 to 140, and been soft, and the- treatment has consisted of rest in bed, anadoynes at night, with wine and nutrients. Yesterday a blister was applied to the left thorax, inferiorly, and to-day she is much better. All crepitation has disappeared; the cough has ceased. Over left back inferiorly, near spinal column, there is a space the size of a hand, dull on percussion. In the last few days she has been eating food with appetite, and sitting up an hour daily. November 1st.—Since last report, although the physical signs of chest have undergone little change, general health has been so good that she ha<» been up daily, and walks freely about her room. About half an ounce of healthy pus is discharged daily from the wound. At half-past 4 p.m., during the temporary absence of the nurse, feeling very hungry, she went to the press, where the provisions were kept, and ate half a teacupful of arrowroot, half a pint of strong soup, a small piece of roast beef, and a piece of bread, being all the food she could get at. Immediately afterwards, she experienced severe griping pains over the whole fibdomen, followed by vomiting of the matters taken. The abdomen became distended and tympanitic above the umbilicus, and a curve of intestine was very prominent in this situation, and clear on percussion. A few drops of 01. Menth. Pip. afforded slight relief, and wann fomentations were applied to the abdomen. Frequent vomiting of a greenish fluid, however, continued, aud in the evening five grains of Opium were given in the form of suppository. Nov. 2d.—An enema was given at 10 a.m., and another four 712 DISEASES OF THE GENITO-URINARY SYSTEM. hours afterwards, without causing any evacuation from the bowels, which have not been opened since 6 p.m. on the 31st of October. 8 p.m.—There has been frequent retching during the day, with discharge of mouthfuls of mucus. Marked difference between tympanitic fulness and distension above the umbilicus, and the flatness nnd collapse of the abdomen below it. Had nothing to eat, and drank only a little cof- fee. 5 Calomel gr. viij; Gum. Opii, gr. ij ; Conserv. Rosar. q. s. Ft. pil. ij. One to be taken immediately. Four pounds of warm water to be injected slowly. If no motion by 12 o'clock, to have an enema, composed of an infusion of six ounces of boiling water added to 15 grains of tobacco. Nov. 3d.—The warm water injection returned imme- diately with much flatus and some small pieces of fceculent matter. ' The tobacco injection was not given. This morning the countenance is anxious ; pulse 120, small' tongue furred; great thirst; no appetite ; considerable distension of the upper part of the abdomen, and a distended knuckle of intestine prominent and strongly marked out below the integument, pressure on which causes tenderness. Twelve leeches to be applied to the abdomen. To have the tobacco injection. 8 p.m.—This morning the tobacco injection (not quite the whole of it) was given. It was retained ten minutes, and caused considerable collapse, with tremors and vomiting. Two large warm- water injections have been subsequently given, which have returned without foeces. No tenderness of abdomen, to which a turpentine embrocation is ordered to be applied. Nov. 4th.—Complained last night of a throbbing pain in the calf of left leg, and swelling of foot and ankle. To-day the whole limb is swollen as high as the groin, and an induration is felt in the course of the femoral vein. The vomited mat- ters were clearly fceculent. From this time she gradually sank. She vomited from time to time matter sometimes fceculent, at others bilious, and occasionally felt colic pains. She became greatly emaciated, which permitted the swollen and tympanitic intestines to be strongly marked out above the umbilicus. The pulse varied from 130 to 150, and was not absolutely weak until the day she died. Calomel and opium pills were continued, with occasional injections per anum, and small quantities of nourishment. The mind remained unclouded to the last, and latterly the tympanitic distension of abdomen and swelling of right inferior extremity somewhat diminished- On Nor. 12lh, at midnight, she requested the nurse to raise her up. This was done, when she fell back and expired—the 70th day after the operation. Sectio Cadaveris.—Forty hours after death. The body was greatly emaciated. The head was not opened. Thorax.—The cavity of the pleura on the left side contained about one ounce, and on the right about two ounces of serum. On the left side the pleura were adhe- rent so strongly, that the lung was lacerated in removing it; this more especially between the inferior surface of the lung and upper surface of the diaphragm. On the right side the pleura were adherent at the apex, and over inferior lobe, but the adhesions were easily torn through. The anterior margin of the upper lobe of the left lung was emphysematous ; its posterior portion slightly engorged. On section it crepitated readily, aud was healthy in structure. The inferior lobe felt den?e exter- nally, and on section the parenchyma was of a brownish red colour; splenifiedi easily breaking down under the finger, and portions of it placed in water sunk nearly to the bottom of the vessel. The two upper lobes of the right lung very emphyse. matous anteriorly, engorged posteriorly and inferiorly, but otherwise healthy. The anterior half of the inferior lobe also emphysematous, with here and there indurated patches of chronic lobular pneumonia. The posterior half of this lobe was splenified throughout, as in the opposite lung. The lining membrane of the bronchi was healthy, here and there covered with mucus. Both lungs were small in volume. OVARIAN DROPSY. 713 The heart was small and pale. Its right cavities contained a firm dark coagulum. Tl e valves and structure of the organ healthy. In the aorta there was a small but firm coagulum, partly decolorized. \isi»OMEN.__On reflecting the walls of the abdomen, a few chronic bands of lvmph were torn through, uniting the opposite portions of peritoneum. The line of incision was firmly united except at its lower end, where a round opening existed about the size of a pea. On the peritoneal surface the union was marked by a dark blackish line, which was perfectly smooth and free from lymph. The omentum was thin and transparent, destitute of fat, and stretched tightly over the intestines. Its inferior margin adhered strongly to the visceral and parietal peritoneum, about an inch above the pubic bones. The omentum was cut through transversely about its middle, and the intestines below exposed, which were greatly distended with gas. These were found to be portions of the ileum, the coils of which were more or less adherent to each other, to the mesentery, omentum, and to the neighbouring organs, by bands of chronic lymph. The adhesions were now carefully torn through, the gut liberated and traced downwards. Exactly five feet and a half from the ccecum, above and to the left of the umbilicus, the intestine was constricted by a band of lymph, as if a ligature had been tied around it. Above the constriction the gut was distended to about the size of the wrist; below it was collapsed to the size of the little finder. Air could be pressed from the superior portion into the inferior, but the passage of water poured from above was completely checked at the seat of stricture. All the intestines above the stricture were greatly distended with gas; those below it, including the ccecum, colon, and rectum, were small and collapsed. The cavity of the pelvis was blocked up, and separated from the general cavity of die abdomen bv firm adhesions between the surfaces of the abdominal walls, the omentum, and knuckles of intestine. The peritoneum in this place, and especially in the left iliac hollow, was covered with a dense layer of chronic lymph. This lymph was about one-eighth of an inch in thickness, of a dirty greenish colour, mixed with black pigmentary matter, of great hardness to the feel, and cut under the knife like cartilage. With some trouble, the united knuckles of intestine and portions of omentum involved were separated and drawn out. A cavity was thus exposed, about the size of an orange, situated between the uterus and rectum, lined throughout by the same dense, chronic lymph spoken of above. The anterior sur- face of the uterus was firmly united to the bladder by chronic adhesions. On the right side about one inch of the Fallopian tube and broad ligament remained, the extremities of which were closely united to the anterior wall of the cavity. On the left side the margins of the uterus and short pedicle of the broad ligament were so united to the walls of the cavity that they could not be separated. This cavity or pouch between the uterus and rectum communicated with the external opening, and was evidently the place where the pus during fife had accumulated. A sinus opened into it superiorly, which on being traced upwards was seen to extend, above the descending colon, between the peritoneum and intestines as high as the diaphragm on the left side, where it terminated in a cul-de-sac, the size of a hen's egg. The sinus was about the si'ze of the little finger, and lined throughout by the same dense, greenish lymph formerly noticed. The cul-de sac was full of dirty-yellow offensive pus, and bounded by a portion of the stomach and left lobe of the liver internally; the diaphragm above and posteriorly; and the colon and spleen externally and inferiorlv. It also was lined with dense chronic lymph. The mucous membrane of the stomach and small intestines was healthy. The latter contained a clayey coloured soft fceculent matter. The large intestines were empty. No appearance of inflammation existed at the constricted part. The internal surface of the rectum, extending seven inches from the anus, was intensely vascular, thickened, and 714 DISEASES OF THE GENITO-URINARY SYSTEM. inflamed. Six ulcers, varying in siz.3 from a sixpence to that of a shilling, were scattered over the diseased part of the gut, one of the largest being only an inch from its extremity. They were round in shape, and covered with a raised dirty greenish slough. The liver, kidneys, and spleen were anaemic, but healthy in struc- ture. The femoral and saphena veins could be felt hard and distended below the integuments. On dissection, these, as well as the external iliac vein, up to the point where it passed under the layer of lymph, in the left iliac hollow formerly described, were found to be obstructed by a coagulum of blood. This coagulum was adherent to the internal wall of the vessel, was partially decolorized, and of the consistence of soft cheese. This obstruction of the vessels ceased about three inches below Poupart's ligament. Description of the Tumours removed.—The tumour which involved the left ovary, on being removed, weighed nine pounds and a half. It was of an oval form, measured thirteen inches in its longest, and nine inches and a half in its shortest diameter. Its envelope was composed of white, dense, and glistening fibrous tissue, having upon its external surface patches of various sizes, resembling chronic lymph, On its anterior surface might be seen openings, or ulcerations, varying in size. The edges of these ulcerations were smooth and rounded, and of the same thickness as the fibrous envelope. The cut surface, which had been near the ligature, now presented a large opening into the tumour, through which numerous cysts, varying in size from a pea to that of a billiard ball, protruded. The incision into it, made during the operation, had opened up one of these cysts about the size of a cocoa-nut. The tumour was sent to the University Museum, minutely injected by Mr. Goodsir, and afterwards cut up, in order to show its internal structure. In dividing it, some of the internal cysts were found to be full of pus, whilst others contained the usual glairy fluid, common to these tunours. Three preparations were made from this tumour, which may be seen in the museum, and which demonstrate the following facts :— 1st. A portion of the fibrous sac, showing the attachment of numerous cysts vary- ing in size and shape. A minute injection has been thrown into the arteries (?) and exhibits how richly the walls of the internal cysts are supplied with blood-vessels. One of these cysts, about the size of a small hen's egg, has its upper half fully injected, whilst the lower half is pale. The margin between the two is uneven but abrupt, and from the creamy and distended appearance ofthe cyst, there can be no doubt that it is full of pus. 2d. A portion of the fibrous sac, showing the incision which separated the tumour from its attachments. The opening is of an irregular form, about three inches in'its longest diameter. 3d. A portion of the fibrous sac, showing the ulcerated openings formerly described. The right ovary was about the size of a walnut. It was formed externally of a dense fibrous capsule, and internally of several small cysts. The natural stroma of the organ had entirely disappeared. Commentary.—The life of this young woman was rendered miser- able by the enormous size of her abdomen, and the'difficulty it caused to the functions of respiration, micturition, locomotion, etc. She earnestly desired that any operation should be performed which held out a prospect of relief, and bore the excision of both ovaries, which was most skilfully performed, with the greatest courage. From this she may be said to have recovered, for, notwithstanding the chest com- plication which arose, she was from the forty-eighth to the fifty-eighth OVARIAN DROPSY. 715 day after the operation so well, that she sat up and walked about with- out inconvenience. On this last day, feeling the intense hunger of a convalescent, she took advantage of the nurse's abscence, and ate largely. The stomach thereby was distended, the intestines displaced, so that a filament of chronic lymph, attached to the abdominal walls, became twisted round a portion of bowel, causing complete mechanical strangulation of it, and death twelve days later, with all the symptoms of ileus. To this accidental circumstance, and not to any direct influence • of the operation, must the fatal result be attributed. The question I have frequently asked myself is, Was I warranted in proposing and urging others to perform the operation ? The reasons that induced me to do so were the following :—1st, The youth and good constitution of the patient; Idly, The disease was rendering her life miserable, and she earnestly wished the operation to be performed. Zdly, Death seemed unavoidable at no distant period. At least it could not be anticipated that five gallons of fluid could be removed from the abdomen every three weeks for any length of time, without injury to the vital powers. 4thly, Extirpation of the tumour appeared to be the only possible means of cure. Wily, The care I.had taken informing the diagnosis, and my conviction of its accuracy, which was afterwards fully confirmed. Again, on looking at the statistics of the operation, previously pub- lished by Dr. Atlee * I found that abdominal section had been performed for ovarian tumours, real or supposed, 101 times. If we extract from this list cases where the operation was not completed, and those on the point of death before the operation was begun, we shall have ninety remaining, in all of which the tumour was excised. Of these, sixty-two recovered and twenty-eight died. Thus, whatever might be thought of the correctness of the statistics, the broad fact still remained, that an ovarian tumour had been extracted from living women in sixty-two cases with perfect success. An acquaintance with the structure and mode of development of these growths must convince us that the only other pos- sible mode of cure is by rupture of the cyst, and then only under parti- cular circumstances. This is an occurrence of extreme rarity, and yet, were we to be guided by the opinions of those surgeons who refuse to perform ovariotomy in any case, no other termination is to be expected, ami the disease, notwithstanding the facts previously stated, is to be con- sidered as irremediable by art. But every case must stand upon its own merits, and when all the circumstances of the one detailed are taken into consideration, the perfect diagnosis that was established,, and the probability of a speedily fatal termination (a probability afterwards ren- dered certain by the suppuration discovered to exist within the cysts), it must be granted that the operation, if admissible at all, was so in this instance. An important practical question presents itself in regard to the treat- ment after the operation, on which there was a difference of opinion among the practitioners who witnessed the case and dissection, viz , How the cavity or pouch containing pus, between the uterus and rectum, and the sinus leading from it up to the diaphragm, were connected with the pressure made on the abdomen by the many-tailed bandages and coni- * American Journal of the Med. Sciences, April, 1845. 716 DISEASES OF THE GENITO-URINARY SYSTEM. presses, in order to direct the matter towards the external opening. Some have thought, that the pressure employed, instead of directing matter downwards, may have forced a portion of it upwards; while others are inclined to believe, that if the pressure, which latterly was much relaxed, had been more steadily continued, the formation of that cavity and sinus might have been prevented. The question is important however, in reference rather to the proper treatment of future cases, than 'to the fatal event of this case; for the symptoms of ileus and the death of the patient were obviously dependent on the constriction of the por- tion of ileum above noticed by a band of lymph which was at the dis- tance of some inches from any part of the wound, and had no connection either with the cavity or the sinus. Although various lesions were found after death, their origin and con- nection with each other will easily be understood from a perusal of the case, and of the post mortem examination. Notwithstanding the unsuccessful termination of this case, I am .still of opinion that ovariotomy is warrantable ivhen the diaynosis of the tumour is certain, and other circumstances favourable. The more fre- quently it is performed, the more readily will experience dictate the avoidance of many errors that even now encumber the practice of it. When once recognised as a legitimate mode of treatment, and only per- formed in appropriate cases, there is every reason to hope, from the experience of the past, that the degree of mortality which has hitherto accompanied it will gradually diminish. Before such a result can be hoped for, however, it is necessary that our notions of the pathology and diagnosis of the disease should be improved. To these points I shall refer afterwards. Case CLVI.*—Ovarian Dropsy—Spontaneous Ulcerative Opening of the Cyst into the Bladder, and Evacuation of its Contents—Recovery. History.—Anne Pyper, a servant, set. 25, was admitted Nov. 8, 1848. She had been delivered fourteen days previously of a male child in the Maternity Hospital, the labour being a natural one, and presenting nothing unusual. On the birth of the child, however, the abdomen still continued enlarged, and at first led to the suspicion that another foetus remained in the uterus. After a time, the true nature of the case vas rendered manifest, and a large swelling was detected, which was movable to a certain extent, and presented all the characters of an encysted tumour of the left ovary. Symptoms ox Admission.—The abdomen was swollen to about the size usual during the sixth or seventh month of pregnancy. The tumour extended from the epigastrium to the pubes, but bulged considerably towards the left side. Its surface was irregular; and two large nodules, each the size of a cocoa-nut, existed about its centre. It was tense and firm to the feel, somewhat elastic, but no fluctuation could be detected. The tumour was firmly fixed, and the" seat of constant pain, especially in the left lumbar region, which was increased by pressure, by lying on the right side, or on assuming the erect posture. The urine was of a slightly yellow colour, and presented its normal characters. The digestive, respiratory, circulatory, nervous, and integumentary organs appeared to be healthy. She had observed the * Reported by Mr. James Struthers, Clinical Clerk. OVARIAN DROPSY. 717 tumour seven months before her delivery ; and it has gone on gradually increasing, and been somewhat painful from the first. Eight leeches were ordered to the most ■painful part ofthe abdomen. Progrkss of the Case.—For four days the patient remained in the same con- dition, the local pain, however, having been relieved by the leeches. On Nov. 12, my attention was directed to the urine, which now presented a copious white deposit, occupying two-fifths of the jar, while the supernatant portion was of a light amber colour,, and unusually viscid. The deposit was determined by the microscope to consist of pus, mingled with a few granule corpuscles. The clear portion was strongly coagulable by heat and nitric acid. At first it was imagined that the cyst had burst into the vagina, but the patient and nurse concurred in saying that there was no discharge between the intervals of micturition, and that all the fluid came from the bladder. The urine presented the same characters for the next three days; the amount discharged during the twenty-four hours being about three pints. On the 15th, the tumour had somewhat diminished in size, its hardness and tensity had disappeared, and distinct fluctuation was perceptible in it. A broad flannel roller was ordered to be applied firmly round the abdomen, and com- pression made by means of pasteboard, previously soaked and modelled to the abdominal surface. From this time, the abdomen rapidly diminished in volume, while the amount of purulent viscous fluid discharged from the bladder varied from three to five pints in the twenty-four hours. The appetite and general health continued good; and she was ordered nutritious diet, with four ounces of wine daily. On the 23d, the amount of pus contained in the urine was greatly lessened, and the clear portion presented only a slight haziness on the addition of nitric acid. On the 27th the abdomen had regained its natural size, although a dense mass, evidently the collapsed ovarian sac, could readily be distinguished, occupying the left iliac and hypochondriac regions. The urine now also was natural in quantity, and presented only a slight sediment, consisting, as shown by the microscope, of some crystals of oxalate of lime, and a few pus globules. From this period she may be said to have recovered. She suffered occasionally from uneasy feelings on the left side, some- times amounting to pain, which were relieved by the application of four leeches, followed by a small blister. One of the leech bites ulcerated superficially, but soon healed up. She was dismissed on the 18th of December, expressing herself as being well in every respect, having been sitting up and running about the ward for the fort- night previous. The indurated mass in the left iliac region was greatly diminished in size, but still very perceptible to the feel, though not to the eye. Commentary.—The history of this case can, I think, only lead to one conclusion, namely, that an ovarian encysted tumour was present on the left side; that the individual cysts had, if not altogether, at all events for the most part, broken down to form one large cavity; that the contents of this cavity had suppurated, and a fistulous opening formed either into the ureter or the bladder (most probably the latter), through which the contained fluid was evacuated, permitting collapse of tlie sac and cure of the disease. The permanency of this cure would depend upon, whether all the secondary cysts had been ruptured and were brokeu down before the fistulous opening took place. This is a point which it was impossible to ascertain with certainty ; but a careful examination of the woman before she left the Infirmary, convinced me that no rounded nodules or cysts could anywhere be felt. The only instance I am aware of, in which an opportunity presented itself of dissecting an ovarian encysted tumour sjnie time after its 718 DISEASES OF THE GENITO-URINARY SYSTEM. spontaneous rupture, was in an individual I saw examined by the late Dr. Makellar.—(Monthly Journal, Jan. 1847, p. 558.) In that ca-h or pulmonary symptoms. Below the acromial extremity of the left clavicle, a loud blowing murmur can be heard over the subclavian artery, which is inaudible on the right side. Circulatory, digestive, urinary, and integumentary systems otherwise normal. Progress of the Case.—The patient complained of tympanitis and pain, for which she was treated by occasional purgatives, enemata, carminatives, and anti- spasmodics. On the 6th of October, I requested Dr. Simpson to examine her per vaginam. He found the cervix uteri about three quarters of an inch in length, increased in thickness and density. The os uteri was patulous, and admitted easily the first phalanx of the index finger. The edges were rough. The body of the uterus was mobile, but its volume was increased. The left ovary was enlarged, and the rectum distended posteriorly. At this time the patient expressed her opinion that a discharge of fluid was about to take place. Nothing occurred, however, until the 5th of November, when, a little before five o'clock p.m., rising to micturate, she felt something give way in the lower part of abdomen, and about 50 oz. of fluid escaped on the floor. A small quantity was carefully collected, and was found to consist of slightly opalescent serum, of sp. gr. 1005, slightly coagulable by means of heat and nitric acid. On introducing the uterine probe, the cavity of the uterus measured three inches and a half in length, and contained nothing abnormal. Nothing unusual followed the discharge of fluid. On the 28th of December, there was also a consider- able watery discharge. During all this time she continued to complain of vague abdominal pains, which were evidently feigned. She was carefully watched, and no cysts had come away. On the 1th of January she expressed herself so well that she was desirous of going out. Feeling satisfied that this request on her part was to procure the means of im- position, permission to go out was granted, and Mr. William Calder, one of the clini- cal clerks, agreed to follow her. She went straight to the market, and was seen, after making inquiries of one or two butchers, to purchase a pig's bladder. Three days afterwards, January 7th, I was shown at the visit, a macerated piece of this bladder, which she affirmed had been passed during the night, and was a portion of a ruptured cyst. According to her own account there had been violent bearing-down pains for three nights previously. I proceeded to inspect the substance, and on informing her that it was a piece of pig's bladder, her astonishment and alarm may easily be con- ceived. She subsequently confessed this imposture, but nothing could induce her to communicate anything with regard to her former ones. Commentary.—In June, 1^52, I received from a highly respectable practitioner in the north of Scotland, a bottle containing several cysts, with a letter informing me that they had been passed per vaginam by this woman then labouring under ovario-uterine disease. He wrote that " The patient, about eighteen years ago, had a mature child. Her labour was followed by an attack of peritonitis, and she dates her pre- sent ailments from this period. Before the case came under my care, she had been long in hospital for ovarian dropsy, and was there repeatedly tapped. During the last few years she has passed per vaginam from time to time, one of the membranous productions of which 720 DISEASES OF THE GENITO-URINARY SYSTEM. I herewith send you specimens. You will perceive that in some instances they were perfect casts ofthe interior of the uterus; in others they have been broken in the removal. When she first applied to me, the paracentesis had been destroyed beyond the usual time. The drop- sical accumulation was great, and her general health in a very uns iti>- factory state for surgical interference; and before I could make up my mind to operate, nature kindly came to the relief of doctor and patient, and managed the thing so well that I have allowed the good dame to have everything her own way since. She did it thus: a membranous cyst was thrown off, and this was immediately followed by the dis- charge per vaginam, of the dropsical fluid, to the amount of several pints. That this also came from the uterus, I satisfied myself by tactile examination whilst the fluid was passing. Since then this pro- cess, the discharge first of the membrane (distended with serum), and immediately after of the effusion, has been repeated every few months, the patient in the interval enjoying an astonishing measure of health." Without entering into a minute description of these cysts, it will suffice to say, that after carefully examining them, I came to the con- clusion that they were the urinary bladders of some animal—and from the size (between two and three inches in their long diameter), per- haps of lambs or small pigs. They had evidently been macerated, and the external and half of the muscular coat removed, and the smooth mucous surface turned inside out. In some of them, however, there could be seen the two openings of the ureters, whilst in others fragments of one or both tubes were still attached. On communicating my opinion as to the nature of these cysts to her medical attendant, and hinting that so far the woman was an impostor, he replied as follows:— " I removed two or three of the membranes, on as many different occasions, from the vagina, and tin.' state of the os uteri, as ascertained on their removal, was always such as to leave no doubt in my mind as to their having been ejected from the uterine cavity. On each occasion the woman suffered severely, having had regular and painful uterine contractions, till the diseased product was expelled, and profuse haemorrhage afterwards generally inducing syncope. I mentioned in my former note that I have more than once felt the dropsical fluid (which, as I also stated, is generally discharged shortly after the sac) passing from the os uteri. Add to this that the woman's circumstances are such that it would be next to impossible for her to procure the means of per- petrating the trick you suspect her of. The membranes were kept hy me for years immersed in spirits. May not this circumstance have rendered your examination of them less satisfactory ? " In this letter my correspondent announced his intention of sending the woman to Edinburgh, if I could take her into the Clinical Ward of the infirmary. This I promised to do, and having passed another " cyst'' in the interval, she came to Edinburgh. On reviewing the facts of this case, it appears probable that cysts formed in the left ovary had burst at successive times into some portion of the left Fallopian tube, and so been gradually emptied ; and that with a view of exciting further sympathy, she had introduced the macerated urinary bladders of lambs, sheep, or pigs into the vagina, and pretended that they had been formed in the uterus. OVARIAN DROPSY. 721 Pathologg of Ovarian Dropsy. The subject of encysted tumours of the ovary has been consider- ably elucidated by numerous writers, but more especially by Hodgkin, Seymour, Bright, Cruveilhier, and Miiller. From these it would ap- pear that the ovary'^iay be the seat, 1st, of a simple cyst; 2d, of a com- pound cyst, formed of a capsule containing a number of secondary cysts; and 3d, of similar cysts more or less combined with a sarcomatous struc- ture, generally considered of a malignant nature. The first of these seldom becomes larger than an orange, and is for the most part only detected after death. The two latter frequently reach a large size, and contain several gallons of fluid, constituting what has been called ova- rian dropsy. In these cases, the accumulation of fluid sooner or later interferes with the process of respiration, so as to render paracentesis necessary. This operation is repeated again and again at snorter inter- vals, until the patient sinks. On dissection, death is found to have been occasioned by peritonitis, by suppurative inflammation within the sac, or by exhaustion. The source of the fluid, removed by tapping in ovarian dropsy, was pointed out by me in 1846.* On some occasions the serum exists within the cavity of the abdomen, and the tumour can be felt to move or float in it. At other times it is confined within the cystic tumour. Thus some have supposed the fluid to be ascitic, caused by pressure on the large abdominal veins, whilst others have supposed that the growth irritates the peritoneum, and occasions an increased effusion of serum. In the case of Fleming (Case CLV.), it was also argued by some of the objectors to ovariotomy, that excision of the tumour would not remove the ascites, as that was probably dependent on causes unconnected with it. Now, in that and similar cases, where four or five gallons have frequently been removed from the abdominarcavity, it must be evident that the amount of fluid could not be contained in the cysts of a tumour only the size of the human head. Neither could it have been the result of peritonitis, as the fluid was clear and of a brownish amber colour. Again, the liver aud other abdominal viscera were healthy, and they could not have caused venous obstruction ; nor was it likely that such an ovarian tumour, floating as it did mostly in fluid, could, by its pressure, have occasioned effusion of that fluid from the veins. It must be concluded, therefore, that in such cases the fluid is secreted within the tumour, and passes through one or more openings in its walls into the peritoneal cavity. The mode of growth and the structure of encysted tumours of the ovary.— In all the specimens of the disease I have examined, whether the growth is only the size of a walnut, or is so large that it has entirely filled the abdomen, the original form and structure of the ovary has disap- peared. Whether a new growth is produced, or, as has been supposed by some, the Graafian vesicles are enlarged, and thus originate the tu- mour, is not yet determined. I am inclined to adopt the latter opinion, and to think also that the external capsule is formed by the thickening and extension of the serous membrane which covers the organ. Sooner * Pathological and Clinical Observations on Encysted Tumours of the Ovary. Edinburgh Medical and Surgical Journal. Vol. lxv. 46 722 DISEASES OF THE GENITO-URINARY SYSTEM. or later the enlarged ovary is found to consist of a dense fibrous envelope or sac, containing internally numerous secondary cysts attached to its walls. As the tumour developes itself these cysts become larger, more numerous, and crowded together. Each individual secondary cvst con- tains a clear glairy gelatinous fluid, and is composed of a firm fibrous capsule, lined by a smooth membrane. On making a thin section com- pletely through one of these cysts, its greatest thickness will be found, on a microscopic examination, to be composed of fibrous tissue, lined in- ternally by a delicate membrane covered with epithelial cells. (See Figs. 1S1>, 183.) The whole are richly supplied with blood-vessels. As the tumour enlarges, it ascends from the pelvis, where it is origi- nally confined, and occupies more and more of the abdominal cavity. The Fallopian tube and broad ligament become elongated. The fim- briated extremity of the former is sometimes obliterated, at others it stands out from the morbid mass. Sometimes the tumour forms ad- hesions externally, more or less extensive, to the peritoneum, omentum, colon, or neighbouring viscera. At others it floats loose in a fluid within the abdominal cavity. Meanwhile the internal cysts press upon each other, they become dis- tended with fluid, the blood-vessels are compressed, and iu such places farther growth is checked. In consequence of this, absorption of their structure occurs; and one or more open into each other, as was pointed out by Hodgkin, constituting a multilocular cyst. Occasionally the pres- sure acting upon the external sac causes it to become thinner and thin- ner, until at length perforations are produced in it also, through which the fluid contents of the cyst escape into the abdominal cavity. Thus relieved from pressure, the margins of these perforations become once more vascular, and of considerable thickness, often resembling the round perforating ulcer of the stomach so well described by Cruveilhier. Under such circumstances, the internal membrane of the cyst continues to se- crete, and pour its fluid into the peritoneum, rendering paracentesis neces- sary. At other times no opening iu the sac takes place, the secondary cysts burst or open into each other internally, so that, after a certain period, three, two, or only one cavity may remain, with bands stretching across and forming imperfect septa, or with a few small cysts attached to the internal wall, and clearly indicating its original structure. In either case, sooner or later, suppuration is in most instances established within one or more of the cysts, or within the external sac itself. This suppura- tion seems to occur in some cases by the formation of pus corpuscles in the gelatinous matter; in others by inflammation taking place in the walls of the cyst or sac,- leading to exudation, which is afterwards converted into pus. The patient does not long survive this occurrence. If perforation have taken place in the external wall of the tumour, peritonitis is gene- rally induced; if not, the patient sinks exhausted, whether the pus he evacuated or not. Occasionally more or less blood is extravasated into the inflamed cysts, which, with the various stages of suppuration, cause the sanguiuolent, coffee-like, greenish, or purulent fluids so often observed. The gelatinous contents of the cysts vary greatly in different cases: in some being diffluent, in others glairy like white of egg, whilst in many it is semi-solid, resembling coagulated calf's-foot jelly, or strong size. When fluid, it frequently contains flocculi, which are patches of epithelial OVARIAN DROPSY. 723 membrane, more or less united together by granular matter. When gelatiniform, it often contains faint oval corpuscles, or a few primitive corpuscles. (See Figs. 179,180.) Occasionally an opalescent or opaque creamy appearance is communicated to the jelly by the formation of pus corpuscles or minute granules (Fig. 298,) and sometimes it is wholly fila- mentous, mixed with granule cells and other products of inflammation. This jelly like matter, when consistent, presents all the characters of coagulated liquor sanguinis, which has not yet passed into organization. Acetic acid developes in it, or causes to be precipitated, a white mem- brane, having all the characters of fibrous tissue. Frequently, granules, cells, and filaments may be observed in its various stages, as is the case with recent exudation from the serous membranes, or in other simple forms of hyaline blastema. Not unfrequently the ovary contains hairy and other growths, teeth (p. 167), and calcareous deposits, and may be the seat of cancer. In this last case I also pointed out and figured in the memoir referred to, that the so-called cancer often consists of an epithelioma of a remarkable kind, columnar epithelial cells forming and separating in great abundance.* I have now examined several such diseased ovaries; one especially, for- warded to me by the late Mr. Russell, Of Birmingham, exhibited to the naked eye all the characters of cystic encephaloma, and yielded an abun- dant milky juice. On examining this with a microscope, it was seen to contain, 1st, numerous columnar epithelial cells, with fatty granules accu- mulated within their broad extremities ; 2d, a multitude of diaphanous celloid bodies; and, 3d, numerous free nuclei, as in Figs. 441, 442, 443. See also Fig. 184. Fig. 441. Fig. 442. Fig. 443. The diagnosis of ovarium tumours was formerly very defective; so much so, indeed, as in some cases to have led to the opening of the abdo- men to excise a tumour which had no existence, and in many others to the performance of an operation when, from adhesions or other causes, * Ibid. Case II. Fig. 1. Fig. 411. Groups of columnar epithelium in the juice of an encephalomatous cystic growth of the ovary, with fatty granules accumulated at their extremities. Fig. 412. Diaphanous celloid bodies, naked nuclei, and granule cells. Fig. 443. a, The nuclei after the addition of acetic acid; b, the columnar epithelium acted on by the same re-agent. 25u diam. 724 DISEASES OF THE GENITO-URINARY SYSTEM. the growth could not be removed. In all cases of abdominal tumour there are two rjuestions which every practitioner desires to answer with certainty, namely, 1st, What is the seat ? and, 2d, What is the nature of the tumour? With regard to the first point, 1 must refer to obstetri- cal works, in which all the circumstances, local and general, are pointed out, which distinguish such ovarian growths from pregnancy, with which they have often been confounded. Therein also will be found the means of exploring the cavity of the uretus with the uterine sound, an instru- ment, which, by enabling the practitioner to elevate, depress, or brino- forward, the fundus of the organ, so as to permit of its being felt through the integuments, in various positions above the pubes, affords most valu- able information. In cases of ovarian dropsy, the information thus arrived at is nega- tive, but this becomes of immense importance when the i|iK-tinn arises (as it always does). Is the tumour uterine or ovarian ? in the case of Fleming, this point was anxiously debated, but when on the introduction of the sound the fundus of the uterus could be distinctly felt above the pubes presenting its usual rounded character, there could no longer be any suspicion that the tumour originated in that organ. Again, by push- ing the uterus from side to side, we are enabled to act upon the ovaries, and to determine, by the impulses communicated to the hand, whether the tumour be on the right or left side, and to form a tolerable idea, in certain cases, whether it be free or attached. By means of this instru- ment, then, we are materially assisted in resolving the first important question regarding the seat of the tumour. A microscopic examination of the fluid removed by paracentesis may also sometimes give important indications as to the nature of the tumour. If, for instance, the fluid be clear, with polygonal or rounded and swollen epithelial cells (see Figs. 86 and 175), they are highly characteristic of cystic ovarian growths. If columnar epithelial cells are found in cpian- tity, there" is probably an epitheliomatous cancroid of the ovary (see Figs. 184, 441, and 442). If, on the other hand, there be pus or blood cor- puscles, areolar texture, or calcareous salts and deposits, the amount of purulent formation, haemorrhage, disintegration, or mineral degeneration, may be judged of thereby. Treatment of Ovarian Dropsg. The anatomical examination of encysted tumours of the ovary must convince every one that they are not curable by internal medicines. The idea that a dense fibrous envelope, containing numerous secondary cysts, all richly furnished with blood-vessels, can be absorbed through the agency of mercury, iodine, or any other drug, is purely imaginary. There is not one positive fact to support such an opinion. Neither can it be supposed, from what has been described of the mode in which these tumours are developed, that so long as any of the secondary cysts remain intact, a cure can be hoped for. But we have seen that the natural course of these secondary cysts is to open into each other, until at length only one large cyst remains. Under such circumstances it may be conceived that a rupture might, by exciting inflammation, and thus destroying the OVARIAN DROPSY. ^9^ secreting surfaces, or inducing adhesions between them, cause a radical cure of the disease. Such is probably the explanation of those rare cases of cysts, well established in science, which have apparently burst, and rapidly disappeared. A case of this kind has been recorded by Lebert,* in which the tumour burst into the peritoneum and subsequently disap- peared. In other cases the tumour may unite with neighbouring hollow viscera, and by ulceration empty its contents into them, so that they are discharged (Cases CLVI. and CLVIL), or it may open on the external surface. When a perfect cure has been brought about in this way, it will generally be observed that the progress of the morbid growth has been chronic, that consequently time has been allowed for all the secondary cysts to open into each other, and that the inflammation which follows the rupture may then be supposed to act by obliterating or causing adhesions between the walls of the cyst, as in the case of hydrocele. When, on the other hand, sudden rupture of the external sac takes place, whilst some of the cysts remain entire, the termination in cure is impossible, and the peritonitis occasioned more frequently causes death. The occasional occurrence of such spontaneous recoveries has led to the proposition of producing permanent artificial openings, with a view of imitating a natural cure. Mr. Bainbridge of Liverpool suggested making an incision into the sac, and uniting its edges with the external wound; and Dr. Tilt of London has proposed making a minute aperture by means of Vienna paste, so as to cause a permanent opening. Such practice can only be useful at a particular period in the growth of ovarian tumours—that is, when all the internal cysts have broken down into one. But such cases are exceedingly rare, and such practice can be of no real advantage until we learn to distinguish in the living subject unilocular from multilocular cysts. Numerous cases and dissections of ovarian tumours have convinced me, that, in the present state of the art, this knowledge is not to be arrived at with any degree of certainty; and that consequently any proposal, however valuable in itself, which is founded upon the assumption of our possessing that knowledge, is not likely to be practically beneficial. The same remark applies to injections of the tincture of iodine or any other fluid, which can only operate on indivi- dual cysts, and not on the entire growth. It is astonishing how some individuals accommodate themselves to very large abdominal swellings. I have known several cases where the patient has laboured under an enormous encysted tumour of the ovary for ten or even fifteen years. On the other hand, many facts demon- strate that when once paracentesis is had recourse to as a palliative measure, suppuration within the cysts, and a cachectic state of the con- stitution, is more likely to supervene. One important practical rule, therefore, to be followed in the treatment of these cases is, not hastily to have recourse to tapping, but rather, by all possible means of delay, to further the natural disposition, which the internal cysts exhibit under pressure, of forming one large sac. This once accomplished, there is nothing inconsistent in supposing that inflammation produced artificially is as capable of producing a permanent cure as is a spontaneous rupture. There is every reason to believe that artificial pressure is capable of * Physiologie Pathologique, tome ii. p. 71. 726 DISEASES OF THE GENITO-URINARY SYSTEM. facilitating the absorption of the walls of the secondary cysts, and their opening into each other; but we possess no means of ascertaining when only one sac is produced. That it has succeeded in obliteratiii" and ultimately curing the disease, however, has been proved by Mr. Isaac Brown,* who by binding a book on the tumour firmly, has caused inflam- mation and disintegration of the internal cysts, and then letting out the pus, has actually cured some cases. The practice, however, is by no means safe. Case CLVI. seems to me illustrative of the effects of pressure. It must be acknowledged that the seven months which had elapsed between the time the tumour was first perceptible, and the period when it sponta- neously burst into the bladder and collapsed, was a remarkably short one. In the most favourable cases this result takes about two years to accom- plish by itself; but in the instance of Pyper, the tumour was subjected to the gradually increasing and equable pressure of the pregnant uterus, and to its influence must, I think, be attributed the fortunate result and rapid breaking down of the secondary cysts. The ulceration into the bladder was probably determined by the direction the pressure had as- sumed in this case, and, of course, could not be imitated artificially, There still only remain two methods of curing an ovarian dropsy by art—viz., 1st, by excision ; and 2d, by pressure followed by puncture. Cases CLVI. and CLVII. confirm the views suggested by pathology with regard to the modus operandi of the latter treatment; and if, in cases which do not admit of extirpation, pressure be so gradually and equably applied as to obliterate the internal or secondary cysts, an artificial opening then made would cure the disease. The difficulty is to ascer- tain when the moment for making the puncture has arrived—in other words, when a multilocular is converted into a unilocular cyst. In the present state of the art, this, as I have said, is impossible; but, as an exact indication of the difficulty is often the best preliminary to its removal, I do not despair of one day seeing it completely conquered by the cultivators of medicine. As regards excision, the practice of late years has tended to confirm its propriety in such cases as that of Fleming (Case CLV.), in which the tumour has no adhesions of any extent to the abdominal walls, where its presence is the cause of great deformity and much suffering, and where the youth and general health of the patient, and freedom from other dis- eases, hold out hopes of a favourable result. Dr. Clay of Manchester has recently stated that he has operated in 79 cases of ovarian tumour, 55 of which have been successful, and that he is confident that, operating de novo, from his increased experience he would not have more than '25 per cent, of fatal cases. NEPHRITIS AND PYELITIS. Case CLVIII.f—Acute Nephro-Pyelitis—Recovery. History.—Helen Kessick, set. G5, a nurse—admitted November 25, 1852. States that, for the last twenty years, she has been subject at intervals to occasional pains in * See cases recorded in the Lancet. f Reported by Mr. F. B. de Chaumont, Clinical Clerk. NEPHRITIS AND PYELITIS. 727 the lumbar region. ?he had never experienced any difficulty or uneasiness in micturi- tion, till about five years ago, when she noticed that the urine was tinged with blood; this was accompanied with pain in the right lumbar region, preceded by shivering, and followed by febrile symptoms. She was admitted into the Royal Infirmary, where she remained for seven weeks, and was dismissed cured. She had no return of the symptoms till about twelve months ago, when she was again seized with shivering, and a return of the lumbar pain. During the summer the urine was tinged with blood for two days, but afterwards again became normal, and she continued better till about four weeks ago, when she once more experienced pain on passing water, which, with increased uneasiness in the lumbar region, has continued up to the present date. Symptoms on Admission.—On admission, tongue much furred; appetite bad; great thirst; no nausea; complains of pain in the epigastric region, but no tumour or hardness can be detected ; bowels have not been opened for two days. She has con- siderable pain in right lumbar and both hypochondriac regions, also in the hypogas- trium, after making water, which is passed in less quantity than usual. Urine sp. gr. 1016, coagulable by heat and nitric acid, and deposits, on standing, a copious ropy mucus-like sediment, showing, under the microscope, large quanties of pus globules, and a few crystals of triple phosphate ; pulse 76, soft; no palpitation of heart; com- plains of occasional headache with frequent giddiness, and muscae volitantes ; sleeps ill at night, and complains much of cold feet; other functions normal. R^ Liquor. Potass.; Sp. AVth. Nit. aa 3 'j ; Sol. Mur. Morph. 3 iii; Mist. Camph. z v- M. Stanat § ss quartd qudque hord. R 01. Ricini §j. Sumat statim. To use barley water as a drink. Progress of this Cask.—December 4th.—Feels very weak ; continues otherwise in much the same state ; urine still albuminous, with copious deposits, containing pus and triple phosphates. To have 3 oz. of wine. Dec. 11th.—Continued to improve till last night, when she was seized with shivering and pain in lumbar and epigastric regions ; great nausea and vomiting; tongue moist, but much furred ; great headache ; urine as before. Omitt. mist, et vinum. R Sol. Antimon. 3 iij; Sp. A5th. 2xit. 3j; Aqme Acet. Amman, et Aquae aa ; iiss. M. Sumat 3 ss ter in die. Warm fomenta- tions to be applied to the loins. Dec. 13th.—Was rather better yesterday, but has still pain in right lumbar region. To-day she is still sick, the pain in right lumbar region somewhat increased ; there is great dysuria; the urine is of high colour ; still albuminous, sp. gr. 1018, with copious sediment, showing, under the microscope, numerous blood globules, and a quantity of debris of cells mixed with the pus and triple phosphates, which are still as abundant as formerly. Dec. 15th.—Was no better yes- terday, and began to complain of severe pain in the hypogastrium. Omitt. mist. If Tinct. Hyoscyam. I ss; Sol. Mar. Morph. 3 iss; Muci/aginis r ij; Aqua; I'm. M. Sumat ? j ter in die. To-day she still complains of the pain in hypogastric and lumbar regions. The urine is diminished in quantity, and deposits, on standing, a viscid tenacious sediment, which, in addition to the blood corpuscles, pus, and triple phosphates, now shows casts of the urinary tubes, crowded with granules. To be cup- ped on the lumbar region to 8 oz. Dec. 16th.—Only six oz. were obtained by the cupping. The pain in back is much relieved, and she is able to sit up in bed without uneasiness, but there is still pain in the hypogastrium ; pulse 72, soft; tongue still furred; no nausea or vomiting, but some pain in the bowels ; headache nearly gone ; urine of a dirty red colour, still coagulable; showing blood, pus, and phosphates under the microscope as before. Habeat enema domesticum et sumat Sol. Mur. Morph. 3 ss, et Mudlaginis ; j ex aqua hord somni. Dec. 18th.—Symptoms much the same as at last report. Urine sp. gr. 101."), and again shows casts of the urinary tubes. The bladder was sounded to-day, but nothing abnormal could be detected. Dec. 20th.— 728 DISEASES OF THE GENITO-URINARY SYSTEM. Urine contains a large quantity of gelatinous mucus, in which a few broken-down granular casts can be detected. IJ Sol. Mur. Morph. 3 "s; Tinct. Hyosnnim. - i ■ Mveilaginis zi'i Fiat haust. omni node sumendus. R; Decoct. Uvw Ursi zx; Tinct. Hyoscyam. 3J; Sp. Ab'th. Nit. ?j; Mueilaginis 5 ij- M. Sumat |i ter in die. Dec. 26th.—Continues in much the same state, but the pain in the hypogastrium has considerably increased. She had some sweating last night, and the pulse is now 8(i and soft; the tongue is still furred ; no appetite ; great thirst; bowels not open for some days; great dysuria ; urine presents the same characters as before. Applic. hirudines quatuor hypogastrio et postea bene foveatur. I£. Pulv. Jalapm et Pulv. Scammon. aa. gr. vi. M. Sumat hord somni. IJ Sol. Mur. Morph. 3ss; Mucila- ginis 3J. M. Sumat eras mane. Dec. 2^th.—The pain in the hypogastrium hav- ing greatly abated, the leeches were omitted at the patient's request; the bowels were well opened by the medicine. To-day she feels much better, and slept well without the draught. Tongue more clean and moist, but the urine contains rather more blood. January 1st, 1853.—She still continues improving, but pain in the hypo- gastrium is not quite gone. The urine is more natural in colour, the deposit greatly decreased, and the blood has now disappeared. March Oth.—Since last report has ex- perienced occasional lumbar pain, but on the whole has been slowly getting well. The urine, which has gradually been getting clearer, is reported to-day as quite normal, and free from albumen. A slight hernial protrusion has been discovered in the right iliac region, to which a truss was applied. March 28th.—Dismissed relieved of all her symptoms. Commentary.—This was a case of acute nephritis, with tendency to recurrence, exhibiting local pain, inflammation of the mucous membrane (pyelitis), as shown by the excessive discharge of mucus and pus, and inflammation of the secreting substance of the organs, as proved by the frequent appearance of blood, casts of the tubes and the persistent albu- men. During a period of four months, however, during which a variety of treatment was had recourse to, as recounted in the report, all the urinary symptoms disappeared, although there was still a tendency to the return of pain in the lumbar region. This case indicates the mode in which acute diseases of the kidney frequently pass into chronic ones; but from the circumstance that the right kidney only was attacked, and that the left one could still secrete a sufficient quantity of urine, no oedema or dropsy occurred. Case CLIX.*—Subacute Nephritis, with great Anasarca—Recovery—Acute Nephri- tis of Left Kidney—Recovery. History.—Anne Hewison, aet. 18, a seiwant—admitted Dec. 14th, 1856. She has been in the Surgical Hospital on three occasions during the last four months, on account of abscesses in and about the axillae, from which she is now free. For six weeks she has experiened pain in the lumbar regions, most severe when the weather was coin, and increased by coughing and' hard breathing. A fortnight ago she observed that the feet and abdomen were swollen. Since then she has become gradually anasarcous. * Reported by Mr. M'Leod Pemberton, Clinical Clerk. NEPHRITIS AND PYELITIS. 729 Symptoms on Admission.—The integument all over the body is cedematous, and the face especially is considerably swollen. All the depending parts of the trunk, together with the extremities, are pale, pitting readily on pressure. The catamenia have appeared on three occasions at the interval of a fortnight, and been very copious. The urine is highly albuminous, sp. gr. 1010, diminished greatly in quantity, but the exact amount cannot be ascertained. Numerous waxy casts are visible in it under the microscope. The chest is resonant everywhere on percussion. Sibilant sounds are audible at the apex of right lung, both with inspiration and expiration, the remains, she says, of a cold that has troubled her for five weeks. She suffers occasion- ally from palpitation ; but the circulatory system on examination is normal. Pulse 80, of good strength. The abdomen very tumid, with distinct fluctuation, and painful on pressure over the whole anterior surface, but most so on the right side opposite the lumbar region. The digestive system otherwise, and the nervous functions are normal. Habeat Potass. Bitart. 3 j ter in die. Progrkss ofthe Cask.—December 16th.—The amount of urine passed is greatly increased, and has amounted to 51 oz. during the last 24 hours. Dec. 20th.—The whole body is now much less cedematous. Pulse 75. Passed 150 oz. of urine during the last 24 hours. Dec. 25th.—Has passed about 100 oz. of urine daily, which is pale, sp. gr. 1010, and now only faintly albuminous. GEdema of extremities has now disappeared ; but still some swelling of face and abdomen. There are slight febrile symptoms. Pulse 100, weak. Complains to-day of sore throat. The tonsils are enlarged, and the mucous membrane of fauces congested. An astringent gurgle was ordered, and warm poultices to be applied to the throat. Dec. 26lh —Yesterday after- noon and to-day she passed urine of a dark brown colour. It is highly albuminous, with a sediment composed of urates and blood discs, as seen under the microscope. There is pain in the left loin. Throat not so painful. Face anxious. Pulse 90, of good strength. To omit the bitartrate of potass. IJ Sp. ASther. Nit. 3 ij ; Mueila- ginis ^ ij ; Aq. Font. § vj. M. Two table-spoonfuls to be taken every four hours ; warm fomentations to the left lumbar region. Dec. 28th.—Has continued to feel pain in the left loin, which is increased on pressure. Has passed 24 oz. of urine during the last 24 hours, highly albuminous, less dark, and now of a light chocolate colour, turbid, with no layer of fat perceptible on repose, but numerous tube casts and some urates and blood corpuscles seen in it with the microscope. All sore throat, fever and (edema of the integuments have now disappeared. Pulse 84, firm. Dec. 31st.—Has passed from 50 to 60 oz. of urine daily. Has still dull pain in the loins, but otherwise better. From this time she began to sit up and walk about the ward. The lumbar pains returned at intervals, but finally left her Jan. 26th. The urine also retained a trace of albumen for some time ; occasionally, however, disappearing for a day. On the l§th of Jan. she took Potass. Bitart. gr. x. ter in die. The urine was examined daily, and on Jan. 27th up to the 30th, not a trace of albumen could be discovered. She was then dismissed quite well. Commentary.—In this case, a somewhat chronic form of nephritis or Bright's disease appeared before her admission, which occasioned intense general anasarca of the body, and was characterised by albuminous urine containing numerous waxy casts. The cedematous face and general appearance were in this girl highly distinctive of renal dropsy. The strong diuretic effects of the bitartrate of potash, in scruple doses, caused this to disappear. She was then seized with acute nephritis of the left kidney, as indicated by the febrile symptoms, pain in the left loin, in- creased on pressure, bloody and turbid urine, etc. From this also she gradually recovered under the employment of gentle diuretics, demul- 730 DISEASES OF THE GENITO-URINARY SYSTEM. cents, and warm fomentations locally. All trace of tendency to perma- nent albuminuria—so common a sequela of nephritis—was also got rid of by the action of small doses of cream of tartar. The occurrence of sore throat and febrile symptoms with this last attack, induced ine to inquire carefully as to whether there was any proof of scarlatina, hut I could not discover any. Case CLX.*—Acute Desquamative Nephritis, proving rapidly fatal from Diminished Flow of Urine, General Anasarca, and QZdema of the Lungs. History.—William Lawson, set. 34, married, was admitted to the Skin Ward Nov. 28, 1856, for an attack of scabies, which has lasted four months. He has been drinking freely lately—is ancemic aud emaciated. On examination, innume- rable minute isolated vesicles are to be seen scattered over the whole body, with the exception of the head and neck ; most abundant on the flexor surfaces. On the legs there are few patches of eczema. Dec. 2d.—He was ordered to rub himself all over twice a day with simple lard, which, on the 6th, was exchanged for sulphur ointment. Commencement of the Disease.—Dec. 11th.—Especial attention was directed to him to-day in consequence of cough and evident dyspneea. He thinks he must have caught cold from being so long naked when employed rubbing himself. Since the 7th he has observed slight oedema of his feet, which was followed by cough. He has paid little attention to these symptoms. The urine is found to be highly albuminous and of brownish colour. On microscopic examination of the sediment, it was seen to contain numerous desquamative tube casts. His cough troubles lnm chiefly at night, when he finds there is difficulty of breathing or lying in the hori- zontal posture. On percussion there is slight impairment of resonance over right chest anteriorly, below level of third rib. There is no increase of vocal resonance. The respiratory murmurs are more feeble than on the left side, and inspiration is occasionally sibilant. Posteriorly, percussion over lower half of both sides gives resonance of a somewhat flat tone. Fine moist sounds attend the close of inspiration, and expiration, feeble below, is exaggerated superiorly. I£ Sp. Aether. Xit. ; 8s i Tr. Digitalis, Tr. Scilla, aa 3 iss ; Aqiue ad § vj. M. A table-spoonful to be taken every four hours. Progress of the Case.—December 12th.—Over dull region anteriorly moist sounds, clicking in character and few in number, attend the extreme close of inspiration. Vocal resonance also slightly increased in the. area of dulness, and posteriorly there is slight comparative dulness over middle third of right side. Urine of brown smokey colour, with blood corpuscles visible under the microscope. Sputum scanty, purulent, not streaked with blood. Extract % iv of blood from the loins by cupping. Omit the mixture. To have 3 ss of Bitartrate of Potash three times a day. % ij of Gin daily. Dec. 15th.—Since last report the dyspnoea has been gradually increasing, and the pulse becoming weaker. It is now 100, and soft. The sputum is scanty, purulent, not tinged with blood. Percussion over both lungs inferiorly and posteriorly is impaired, especially on the right side. On auscultation, a fine moist rattle accompanies the inspiration, and there is an in- crease of the vocal resonance. Urine presents the same characters as formerly, * Reported by Mr. Wm. Guy, Clinical Clerk. NEPHRITIS AND PYELITIS. 731 and contains chlorides in abundance, but does not amount to ^ xx daily. The "in is increased to 3 iij daily. To have 3 iv of port wine in addition, fy Amman. Carb. gij; Tr. Card. Comp. §j; Aqiue ad 3 vj ; Ft. mist. A table-spoonful to betaken retry second hour. Dec. 17th.—Has been steadily getting worse. The respirations are now 40 in the minute, and he is obliged to retain the sitting posture. Takes no nourishment. Pulse 126, very feeble. Crepitation and increased vocal resonance now heard posteriorly as high as spine of scapula. No pain. Pulse 80, of good strength. To be dry cupped over chest and back ; warm bottles to feet. Towards evening the face more pallid, hands and forearms cold and slightly cedematous. At 1) r.M. the breathing was 48 per minute, and so laboured that he was bled to about : xiij. Toward close of venesection the pulse at left wrist, previously imperceptible, could be detected small and exceedingly weak ; and patient (on inquiry) admitted himself to be slightly relieved, although to others this was not perceptible. Fiftien minims of Sol. Mur. Morph. ordered. Dec. 18th.—His wife states that he slept from three to six o'clock this morning. The dyspnoea is as great as before the venesection ; respirations catching in character. Has passed very little urine, and that at stool; on examination it was found to contain pus corpuscles in considerable quantity, beside the casts before mentioned. He is obliged to sit up and lean forward in bed ; his intellects are somewhat impaired. During the night delirious. Dec. 20th.— Evidently sinking, but conscious. Dec. 2lst.—Died this morning at half-past three o'clock. Sectio Cadaveris.—Tldrtg-three hours after death. The body is generally anasarcous, with great oedema of the scrotum ; surface pale ; no trace of scabies, with the exception of a few small circular cicatrices about the hands and fingers. Thorax.—All the cavities of the heart and large vessels were distended with blood, for the most part coagulated and decolorized. The cavities of the heart itself in con- sequence were dilated. This was especially observed in the left ventricle, the walls of which were rather thinner than natural. The pericardium and all the valves were healthy. The heart weighed 16 oz. The right pleura was everywhere strongly ad- herent. The right lung was moderately voluminous, and felt heavy. Ou section, it was seen to be highly cedematous, yielding on pressure a copious frothy fluid. No solid exudation anywhere. The left lung was unadherent, and rather less voluminous than the right one, and though cedematous was not so in the same degree. Abdomen.—On stripping off the capsule from the surface of the kidneys, they both appeared of their normal size and of a pale fawn colour. When cut into, the cones were found somewhat congested, the cortical tissue pale. The latter contained nume- rous white lines or streaks, generally directed at right angles to the circumference of the organ. There was no trace of granulation, and the density of the kidneys was much diminished, the organs being more soft than usual. The liver was congested, but otherwise normal; it weighed 4 lbs. The other abdominal viscera were healthy. Micuosconc Examination.—On scraping a fresh cut surface of the kidney, a pulpy matter was readily obtained, which, on examination under a power of 250 diameters, were seen to be composed of large fragments of the tubes, crowded with epithelial cells, which were agglutinated together by a fine molecular matter. Groups of these cells surrounded by, or imbedded in this molecular substance, could also be seen isolated. On the addition of acetic acid, the molecular matter and the walls of the cells were rendered more transparent, whilst the nuclei were uuafiected. The 732 DISEASES OF THE GENITO-URINARY SYSTEM. urine in the bladder contained a few desquamative casts of the tubes, spermatozoa, and a number of isolated epithelial cells from the kidney. Commentary.—The acute disease of which this man died, came on in the ward during the inunctions he practised over the body in order to remove a chronic scabies, which extended itself to a great extent over the integument. The first approach was so slow as not to excite atten- tion—he himself considering it as an ordinary cold. On the 10th of December, when cough and some dyspnoea attracted my notice, the feet and legs were already cedematous, and the urine diminished in quantity, as well as highly albuminous. It was observable, however, that there were no symptoms of fever, no local pain, and the question arose, whether, in conjunction with diminished urinary excretion, there was or was not pneumonia. My diagnosis in the negative was assisted not only by the absence of febrile symptoms, and by the loud and superficial character of the crepitating rale in both lungs spreading upwards, but by the con- stant presence of chlorides in the urine (see p. 613.) On the other band, the chemical and microscopical examination of the urine soon left us in no doubt that we had to do with an acute attack of desquamative nephri- tis, producing general anasarca, and more especially rapid oedema of the lungs. This diagnosis was fully confirmed by the dissection after death, the cortical portion of the kidneys being pale and comparatively free from blood, whilst the tubes were gorged with exudative granular matter, mingled with a mass of epithelial cells. Both lungs, especially the right one, were infiltrated with serum. The rapid progress of this case, evi- dently dependent on obstruction of the renal tubes, seemed to demand active remedies. But the state of the pulse and tendency to prostration from the commencement forbade antiphlogistic remedies, even bad other considerations not pointed out their inutility (see p. 264.) For the same reasons, diaphoretics were too slow and uncertain in their action to be depended on, although morphia and local warmth were tried. Diu- retics, therefore, were given, and subsequently stimulants to counteract exhaustion, a practice which, though condemned by some on the principle that we stimulate an organ already in a state of irritation, we have too frequently seen succeed when all other remedies have failed, to have any doubt as to its value. The real danger, however, in this case, was early to be traced to the consecutive effect on the lungs, and the difficulty the heart experienced in propelling the blood through those organs, so that at length as a palliative I determined on venesection. The man's arm was so cedematous, and the vein so small, that I was obliged to perform the operation myself, and it is remarkable, as illustrative of the infrequency of phlebotomy now-a-days, that of three advanced students present only one had ever seen an individual bled, and that the nurse who held the basin fainted away. At this time the man's pulse was imperceptible at the wrist, although the heart's action was strong. He stated that he felt somewhat better, but I regretted to observe that little or no relief was afforded to him. NEPHRITIS AND PYELITIS. 733 Case CLXI.*—Acute Desquamative and Hemorrhagic Nephritis—Hydrothorax—Col- lapse ofthe Right Lung—Pulmonary CEdema and Bronchitis, with Symptoms of Pneumonia. History.—Andrew Craig. set. 45, a waiter, stout and fat—admitted July 1st, 1851. He has had delirium tremens several times, and been of very dissipated habits. Six days ago, after unusual exertion, during which he was exposed to wet, he was seized with rigors, fever, and vomiting. Next day he observed bis feet to be cedema- tous, and his urine to be highly coloured; cough and expectoration subsequently made their appearance, and yesterday the breathing became very difficult, symptoms which continued to increase. Symptoms on Admission.—On admission the body generally is anasarcons, and the face puffy and bloated. He labours under great dyspneea, has a troublesome cough accompanied with a viscid sputum, in some places of a rusty colour, and in others mingled with clots of blood the size of a pea. On percussion there is marked comparative dulness at the base of right lung anteriorly, extending two inches above the hepatic dulness. Inspiratory murmur over this dull portion is accompanied by barsh and tubular breathing, with increase of the vocal resonance. Posteriorly, also, marked dulness on right side, over lower half of lung, with loud crepitation on inspiration, and bronchophony. The heart sounds are quick, healthy in character, impulse strong. Pulse 100, feeble. The urine is of a dark brown colour, turbid, and much diminished in quantity ; sp. gr. 1014; highly coagulable on the addition of heat and nitric acid, and exhibiting under the microscope numerous desquamative casts, mingled with blood corpuscles. Other functions normal. Re Vin. Antim. j 'j ; Sp. jEther. Nit. Zi'y, A quce 3 vss. M. A table-spoonful to be taken every four hours. To have § iij of wine daily. Progress of the Case.—July 2d.—The dulness and crepitation posteriorly is now as high as the middle of scapula on the right side, and there is commencing dulness, with crepitation audible low down, posteriorly over left lung. Dyspneea increased. Other symptoms the same. To be cupped over chest, and 3 v of blood extracted. Hab. Pulv. Jalap, comp. 3 j July 3d.—Dulness now extends over two- thirds of both lungs posteriorly and inferiorly, with loud bubbling rattles on inspira- tion, and bronchophony. Anasarca has greatly increased, the lower extremities and the scrotum being enlarged and distended. Only 8 oz. of urine passed since yesterday, of dirty brown colour, and turbid ; otherwise the same. Bowels well open. Dyspneea now urgent. Cough frequent and troublesome. Sputum pneumonic. Pulse 120, weak. To have Pot. Bitart. 3 ss three times a day, and 3 iij of gin instead of ihe wine; nutrients. July 4th.—Has passed 16 oz. of urine, and is somewhat better. Prostration continues great. Otherwise the same. July 5th.—Comatose, and evidently sinking. He expired on the morning ofthe 6th. Sectio Cadaveris.—Fifty hours after death. Anasarca ofthe whole body. Head.—The subarachnoid cavity contained a considerable quantity of fluid, ele- vating the surface above the convolutions. The lateral ventricles contained little serum. Otherwise normal. Thorax.—Each pleural cavity contained about a pint of sero-sanguinolent fluid. Both lungs condensed from collapse posteriorly, but crepitant anteriorly. On section they presented a smooth surface of purple colour, and yielded on pressure a copious * Reported by Mr. W. M. Calder, Clinical Clerk. 734 DISEASES OF THE GENITO-URINARY SYSTEM. frothy fluid. The large bronchi were filled with muco-purulent matter, and their lining membrane was staiued of a dark mahogany colour, and highly congested. Heart weighed 19 oz. Hypertrophy, with dilatation of right ventricle. Valves healthy. Abdomen.—Kidneys of large size, the two weighing 18 oz. They were externally of a brownish purple colour, the vessels everywliere congested, with hemorrhagic spots the size of pins' heads, scattered numerously over their surface. On section, the cortical substance was mottled; the dark congested patches being mingled with white opaque, and fawn-coloured substance. The malpighian bodies here and there were tinged with blood. The tubular cones were of a deep purple colour, especially towards their base. The mucous membrane of the pelvis moderately congested. Liver con- gested and somewhat enlarged. Other organs normal. Microscopic Examination.—The fawn-coloured portion of the cortical substance of the kidneys was soft, and the tubes crowded with desquamated epithelial cells mingled with molecular exudation. The vessels in the congested parts were tinged with blood. The hemorrhagic spots depended on the extravasation of blood into one or more convolutions of the tubes. Commentary.—This case was in many respects like the last, but its progress was even more rapid. The pulmonary oppression and oedema came on more quickly, and having been at first confined to the right side, accompanied with tenacious sputum of a rusty colour, and ushered in by rigors and febrile symptoms, presented all the symptoms and physical signs of a pneumonia. Thus the febrile attack corresponded with the commencing period of the supposed pneumonia. Then the man was a waiter, and an habitual tippler, and we were called upon to decide whether the acute symptoms were connected with the lung or with the kidney. Now it is rare to see a case of acute nephritis producing general anasarca, and running its course so rapidly, and in consequence we considered the renal disease to have been chronic—in short, an ordinary case of Bright's disease, with supervening pneumonia. It turned out, however, to be an acute attack of nephritis, accompanied by rigors, fever, vomiting, etc., followed by rapid anasarca, and death by coma. The rusty sputum was also calculated to mislead; for although the air tubes were filled with tenacious purulent mucus, there was no appearance after death of bloody extravasation into the parenchyma of the lung. It must, therefore, have been altogether bronchitic. Such a case of acute nephritis, so complicated, must be considered of extreme rarity. It occurred before the value of testing the urine for chlorides was known, as a diagnostic sign of pneumonia, or I might have assisted in attributing the acute symptoms to the kidneys rather than to the lungs. On dissection there was found the same desquamative nephritis as in the last case, associated with hemorrhage into the tubes and malpighian bodies, and intense congestion of the capillaries, especially ou the surface. This, of course, added to the obstructive character of the lesion, and increased the fatality of the case. I cannot help thinking that many such cases as the two just recorded must have been mistaken by physi- cians for pneumonia, before the advantages of auscultation were known. If complicated with aortic disease, there would have been a hard vibrat- ing pulse, and large bleedings, and antiphlogistic remedies used, which would have hastened the fatal result. Modern medicine, by pointing out that such cases depend on obstruction of the uriniferous tubes by NEPHRITIS AND PYELITIS. 735 desquamated epithelium or extravasated blood, surely demonstrates that blood-letting can have little to do with their relief. Even as a palliative it often fails, as Case CLX. sufficiently shows. The hemorrhage into the tubes and great vascular congestion in this case occasioned greater obstruction to the renal excretion than occurred in the former one. Hence the uraemia and head symptoms which existed for twenty-four hours before death, a symptom from which Lawson was comparatively free. Case CLXII.*—Acute Nephritis—Chronic Pneumonia—CEdema of the Lung and Anasarca proving fatal—Perforating Ulcer ofthe Duodenum, without symptoms. History.—James Abernethy, set. 41, a cooper—admitted July 21, 1855. States that he always enjoyed good health until swelling and suppuration occurred in his left hand, for which he entered the surgical hospital last April. Six weeks ago he observed his urine become as dark as porter, and his feet and legs to be swollen. These symptoms were preceded by rigors, but no pain in the loins or anywhere else. The oedema continued to extend, and three weeks ago dyspneea came on, which has gradually increased till now. He has had no cough nor expectoration. Symptoms on Admission.—The urine is of a muddy brown colour, deficient in quantity, no pain or difficulty in voiding it. It contains a considerable amount of albumen, with the normal amount of chlorides; sp. gr. 1020. With the microscope there can be seen numerous waxy casts of various sizes, some stretching completely across the field, and branched, others convoluted. Many are filled with epithelium, several only half filled, and not a few are composed of a pale diaphanous membrane. They also present a few pus and blood corpuscles, and a good many granules and granule cells, with an abundance of phosphates. On percussing the chest the resonance is equal and good on both sides anteriorly. On the mouth being opened, a loud cracked-pot sound can be elicited over the whole anterior surface of right lung. Posteriorly there is dulness over the inferior half of this lung, with panting resonance of the voice, and crepitation on inspiration. There is also slight crepitation, with sibilation over the lower half of the left lung posteriorly, but no dulness or increase of vocal resonance. Heart sounds are normal; pulse 94, regular but weak. No appetite, great thirst; abdomen somewhat distended and fluctuating. Skin generally anasarcous; that over the back pitting deeply on pressure. The left arm, from the elbow down, is one mass of ulceration, with purulent infiltration in the cellular tissue. He is very weak and exhausted. IJ Sp. AJth. Nit. 3 ij ; Sp. AEth. Chloric. 3 iss. So'. Mur. Morph. 3 j ; Aqua ad % viij ; Ft. mist. One ounce to be taken every night, or when the breathing is urgent. Habeat Potass. Bitart. 3j ter in die. Progress of the Case.—July 25th.—There has been little change until to-day, when he has become somnolent. Cannot take nutrients. Pulse continues very weak. Dry cupping, diaphoretics, and diuretics have failed to increase the amount of urine. Continue nutrients and wine at intervals. July 26th.—Loud crepitations now heard over both lungs posteriorly. Dyspneea urgent. Surface covered with sweat, but no alleviation in the symptoms. Died on the 27th. Sectio Cadaveris.—Twenty hours after death. Body generally anasarcous ; left forearm the seat of erysipelatous ulceration. Thorax.—Both lungs cedematous, with coherent pleurse. On separating these on * Reported by Mr. Robert Byers, Clinical Clerk. 736 DISEASES OF THE GENITO-URINARY SYSTEM. the right side posteriorly, the pulmonary texture broke up, being rendered soft by chronic pneumonia, and being everywhere iufiltrat sd with serum. At the apex of right lung, a few cretaceous masses. Abdomen.—On the under surface of the right lobe of the liver, below the peritoneal coat, were several calcareous concretions the size of millet seeds, adherent in two places to the coats of veins, and projecting slightly into their canal (phlebolites). The gall-bladder was slightly thickened ; the cystic duct obstructed in its centre; but the hepatic duct pervious. Both kidneys were of a pale yellow colour externally, slightly mottled with vascular patches. On section the cortical substance was slightly dimi- nished in thickness, and the cones unusually congested. An inch beyond the pylorus, the duodenum was perforated by a round ulcer, the size of a fourpenny-piece, the edges of which were adherent by soft lymph to the pancreas and neighbouring coil of intestine. Internally the edge of the ulcer was black, and around it were several patches varying in size from a threepenny-piece to that of a shilling, quite black. The peritoneum contained about half a gallon of serum. (tther organs normal. Microscopic Examination.—The cortical substance of the kidneys showed the convoluted tubes to be filled with desquamated epithelium, a considerable proportion of whicii had undergone the fatty degeneration. Commentary.—Following on a prolonged ulceration in the arm, which had confined this patient to the surgical hospital, there supervened de- squamative nephritis, general anasarca, and oedema of the lungs, similar to what occurred in the two preceding cases. There was also present universal adhesion of both pleurae, and disorganization of the posterior and interior half of the right lung, as I conceive, from a limited exuda- tion into its texture. What, however, constitutes a remarkable feature in this case, is the presence of a chronic ulcer in the duodenum, which had not been manifested by any symptom whatever; which was attended by limited hemorrhage into the mucous coat of the intestine internally, and externally by exudation, or so-called effusion of lymph (peritouitis), without any local pain or uneasiness. The term Desquamative Nephritis was introduced by Dr. Johnson, to denominate a lesion in which the tubes of the kidney are blocked up, not only by exudation, but by the separation and accumulation of their epithelial cells. Such desquamation, I believe, occurs occasionally in all epithelial and epidermic structures. I have occasionally seen it in the lung, forming what may be called a desquamative or vesicular pneumonia. If it occurs generally throughout both kidneys, as in the three last cases narrated, it is usually fatal; but if partial, and a sufficient number of tubes are left unobstructed, so as to admit of increased action under the stimulus of diuretics, a cure may be anticipated. Under such circumstances, also, a spontaneous recovery may be hoped for, which may be assisted by diaphoretics. So far from considering diuretics injurious, I believe that in such cases they hold out the only chance of successful treatment. Cupping and diaphoretics in such violent and rapid cases are wholly insufficient to overcome the tubular obstruction, however they may occasionally relieve. On the other hand, the good effects of diuretics were well ^observed in Cases CLVIII. and CLIX. NEPHRITIS AND PYELITIS. 737 Case CLXIII *—Nephritis followed by the formation of a large Abscess in the Right Kidney, opening into the lumbar cellular tissue—Ulceration of Ureter and Blad- der—Thickening of Mitral and Tricuspid Valves—Partial Atrophy of Lungs, with and without Induration—Partial CEdema. History.—Margaret Martin, set. 47, servant—admitted 18th October, 1852! She always enjoyed good health till about twelve months ago, when she was exposed to cold and got her feet wet. Shortly after, she was attacked with dysuria, and observed that the urine was of a very dark red colour, and much diminished in quantity. A week afterwards, she experienced sharp cutting pains in the hypo- gastrium, stretching down the thighs. She was still able, however, to follow her usual occupation, till the beginning of September last, when she suffered from pain in region of right kidney, in the larger joints, and from oedema of the legs, especially the right. The bowels have been very costive, and the abdomen has become much distended. Four weeks ago she passed some very dark, bloody-looking matter in the urine, which continued of a red colour for five days. Her habits appear to have been rather intemperate. Symptoms on Admission.—On admission, the tongue is loaded in the centre with a dark fur; great thirst, but appetite good ; bowels open. There is distinct fulness and dulness on percussion in the right lumbar region, extending as far forward as the umbilicus, and filling up the space between the false ribs and crest of the ilium ; and there is great tenderness on pressure over the same extent. Has some pain in micturition, shooting down the thighs, especially on right side, which is also some- what cedematous. Urine passed in very small quantity, sp. gr. 1015. It is albumi- nous, and deposits on standing a copious sediment, showing under the microscope numerous pus and blood corpuscles. Pulse 90, of good strength, but occasionally intermitting. She has occasional palpitation. The cardiac dulness is somewhat in- creased transversely; impulse very strong, and an indistinct hollow murmur accom- panies the first sound, and is heard loudest at the apex. The thorax is considerably deformed, and the sternum highly arched; but the chest is otherwise normal. Habeat enema c. 01. Terebinth. 3 i. Progress of the Case.—Nov. 20th.—The bowels not having been fully acted on by the enema, she was ordered last night, half a drachm of Compound powder of Jalap, which caused copious stools. 5 Infus. Papav. § v; Tinct. Hyoscyam. 3 'j; Syrupi. 3 i. M. Sumat § j ter in die. Nov. 21.—Has been complaining much of pain in loins and right leg. She was ordered an enema with half a drachm of the Sol. of Morphia on the evening of the 20th ; and last night, the pain having again re- turned, and prevented her from sleeping, she had the following draught: 5 Sol. Mar. Morph. 3 ss; Tinct. Hyoscyam. 3 j ; Mucilaginis et Aq. Menth. aa 3 ss. M. Nov. 22. —Feels much better to-day. There is less swelling of abdomen, little or no pain in the hypogastrium, but a feeling of soreness in right lumbar region. Bowels con- fined ; urine passed in small quantity, albuminous, and contains a large deposit, con- sisting chiefly of pus. Nov. 24.—Continues in the same state, but complains much of pain in bowels, which are still confined. Urine passed in small quantity. She was ordered yesterday the following:—5 Bitart. Potass. 3 ii; Gambog. gr. ij. M. ft. pulv. hora somni sumend. et habeat mane Pulv. Dover! gr. xv. The bowels were freely opened, with considerable relief to painful distension of abdomen, but no diminution of the swelling and hardness. Appl. Tinct. Iodin. abdomini. Nov. 28.— Is complaining much of pain in abdomen and right leg, for which she had 10 grains * Reported by Mr. Francis M. Russell, Clinical Clerk. 47 738 DISEASES OF THE GENITO-URINARY SYSTEM. of Dover s powder last night, with partial relief. The cough is now troubling her more, and she seems much weaker. B- AEth. Chlor. 3 ij; Sol. Mur. Morph. 3 j; Sp. Ammon. Aromat. 3 iij ; Mist. Camph. 3 vss. M. Sumat § ss ter in die. Nov. 30.__ On auscultation of chest, occasional moist rales are to be heard, with prolonged expiration; but no increase of vocal resonance. The sounds of the heart very dis- tinct over the whole chest. The apex beats in epigastrium ; its action is irregular, and a blowing murmur accompanies the first sound. There is still tenderness in right lumbar region, with great pain in right iliac ; the swelling of abdomen has not diminished, and upon deep pressure, a distinct fulness and hardness can be felt in right iliac fossa, to which four leeches were ordered to be applied, followed by warm fomentations. H Sp. ASther. Nit. 3 ss ; Liquor. Potass. 3 ij ; Mucilag. § ij ; Sol. Mur. Morph. 3 iij ; Aqua; 3 iij. M. Sumat § ss omni hord. Intermitt. alia medicamenta. Habeat Sp. Juniper! Co. § iii per diem. December 3.—Feels rather better, but bowels very costive, unaffected by a powder of calomel and jalap administered last ni Ursi Ibj. One ounce to be taken four times a dan. August 8th.—During last week he has been suffering from nausea, vomiting, and looseness of bowels. Aug. 12th.—These few days past he has had rigors, followed bv heat of skin and sweating. The attacks last only for a couple of hours, and come on regularly at two o'clock. He lias been ordered the following pills:— R Sulph. Quina 3 ss; Conf. Rosar. quant, suff. ft. massa in pilul. xx. dividenda. Two to be taken every sixth hour during the intermissions. Diarrhoea has continued, and for it he has been using the following mixture:—PJ Tinct. Catechu 3vi; Sol. Mur. Morph. 3 ij; Conf. Aromat. 3 i; Mist. Cretce § v. M. One table-spoonful to betaken three times a day. Aug. 14th.—Diarrhoea relieved; urine less turbid; sp. rrr 1009- not coagulable by heat and nitric acid. Aug. 21st.—Since last report has been gradually growing weaker. Mucous rale has been occasionally audible under the- ri"ht clavicle ; expectoration insignificant. He has been unable to retain any food on his stomach for several days, scarcely even wine and water. Diarrhoea has also returned. Latterly his strength has become very much exhausted, and during the last two days, he has lain in a state of great prostration ; his pulse often scarcely to be felt at the wrist; his intellect, however, never became impaired. This morning he died at four o'clock. Sectio Cadaveris —Forty-eight hours after death. Body much emaciated; rigor mortis considerable. Thorax.—Pericardium normal; contained about three drachms of clear straw- coloured serum. Heart small and soft; valves healthy; muscular substance pale; nnder the microscope, the muscular fibres appear deficient in striae, and loaded with small tatty granules. Left pleura normal. Right pleura presents dense adhesions over the whole of the lung, more marked, however, at the apex and base. The right lung itself was small, collapsed, and excessively emphysematous, along its anterior free margin. The apex presented numerous hard cicatrices, and on being cut into, showed numerous tubercular masses in all stages, some of them commencing to break down and disintegrate, others undergoing the process of hardening and repair. In cne spot about an inch below the apex, a small vomica, about the size of a hazel nut, existed. Left lung voluminous; highly emphysematous; cicatrized around the apex, the cica- trices, as in the other lung, being very firm and dense. On being cut into, masses of tubercular matter were found, but in a more latent state than in right lung.^ Abdomen.—Liver normal in size, undergoing the fatty degeneration; pale- coloured and friable; under the microscope, the hepatic cells appeared loaded with fat. Spleen normal. Small intestines healthy, slightly congested towards the lower part. Large intestines. The mucous membrane, throughout the whole extent, but particularly in the descending colon, sigmoid flexure and rectum, appeared thickened, congested, and in many places ulcerated; the ulcers were small, their edg^s very slightly elevated, and their surface undergoing the process of separation. Right kidney was much enlarged; quite smooth; the capsule densely adherent. On dividing the ureter, pus escaped in considerable quantity from the pelvis of the kidnev; and on cutting into the substance of the gland itself, several ulcers, varying in size from a horse-bean to that of a small walnut, were found; thofr contents varied in consistence ; in some the pus was thin and diffluent; in others, it had the consistence and appearance of white paint. The ureter on this side was greatly thickened, of the size of an ordinary little finger; the thickening extended beyond the orifice of the ureter along the trigone of the bladder; the ureter was quite per- vious, and contained a quantity of pus. Left kidney was small and lobulated; the substance of the gland was found to have disappeared, leaving a large cavity, which 742 DISEASES OF THE GENITO-URINARY SYSTEM. was enclosed by a covering of the proper substance of the kidney, not exceeding four lines in thickness, and filled with cheesy matter of the consistence of putty; the ureter was closed, except for two inches above the bladder; externally, it was of normal size; muscular wall of bladder somewhat thickened, especially around the orifice of the right ureter; mucous coat congested and much softened; the bladder contained about 6 oz. of thick, turbid, and semi-purulent matter. Commentary.—In this case, the renal abscesses formed in a young man of scrofulous constitution, and exhibited a more lingering tendency than in the former one. Indeed, notwithstanding the great disorganiza- tion found in the kidneys after death, the fatal result was chiefly brought about by the intestinal disease, and the exhaustion caused by colliquative diarrhoea. The left kidney evidently presented the incipient changes which commonly precede the spontaneous cure of scrofulous abscesses in this, as in other internal organs. The purulent matter was of the con- sistence of putty, the animal portion having for the most part been broken down and absorbed, while the mineral portion was comparatively increased. In this manner, not unfrequently encysted cretaceous masses form in the kidney and remain latent, the rest of the renal substance performing its normal function. Sometimes an entire kidney may, in this manner, be completely destroyed, and the .whole converted into a calcareous mass, of which I possess a remarkable example, from an indi- vidual who had quite recovered from the disease, and whose remaining kidney, though enlarged, was in its texture healthy. Indeed, the spon- taneous cure of tubercular depositions in the kidney, presents the same pathological history as that we have described of similar lesions occur- ring in the lungs, p. 680, and the puckerings, cicatrices, cretaceous and calcareous concretions resulting from them, have a similar significance. It follows that our general principles of treatment should also be the same, namely, supporting the constitution by analeptics and especially by cod-liver oil, so as to enable nature to bring about a cure. This should always be the primary object of treatment; whilst remedies directed to the renal symptoms should, although by no means neglected, be subordinate to that great end. In the present case this indication could not be fulfilled on account of the great irritability of the alimen- tary canal, especially of the stomach. For another example of this disease, see Case CXLVI. Case CLXV.*—Calculous Niphritis and Gangrenous Abscess of Right Kidney- Waxy Liver—Recto- Vesical Fistula. History.—James Allen, aet. 25, a tin and copper smith—admitted August 18, 1848. At three years of age was cut for stone by Mr. Liston. Thereafter he enjoyed good health until three years ago, when after straining himself at a trial of strength, he was suddenly seized with a sharp pain in the right flank, just below the ribs. At the same time the urine became turbid, and was of a high colour. The pain left him at the end of three months, but the turbidity of the urine con- tinued. After six months' interval he had a similar attack—this time, he says, induced by drinking a glass of spirits—which also lasted three months. After * Reported by Mr. Frederick Hunter, Clinical Clerk. NEPHRITIS AND PYELITIS. 743 another interval of about six months, the pain and urinary symptoms again returned, and have continued more or less severe ever since. He was in the surgical hospital for three months, where he was frequently examined for stone, but none was found. At this time he was observed on several occasions to pass air by the urethra, the urine being of a gangrenous odour. He left the surgical hospital last May, and has been somewhat better since, the urine for some time having been clear and healthy. But having bathed in the sea a fortnight ago, he was seized with rigors, followed by fever, together with the former local symptoms, which have continued ever since. Symptoms on Admission.—The countenance is pale and sallow, expression de- jected; body not emaciated, but with a general look of chronic disease. He complains of great pain and tenderness in the right lumbar region, which on examination presents a fulness, without great deformity, but well marked when compared with the opposite side. The hepatic dulness on percussion measures five inches vertically, the lower margin anteriorly being on a line with the umbilicus, and stretching across the abdo- men into the left hypochondrium. He has never suffered from pains shooting down to the bladder, nor in the bladder itself. But there is occasional pain after micturition, and always frequent desire to pass urine—indeed every hour—although little is voided. The urine is turbid, of dirty yellow colour; acid, of sp. gr. 1017, very fcetid, highly coagulable, and contains a considerable sediment of pus and mucus. The pulse is 108, soft. Tongue covered with a whitish fur. Appetite good. Other functions well per- formed. IJ Tart. Antim. gr. ij; Aqua; § viij; Solve. Sumat 3 ss tertid qudque hord. Applicent. hirudines viii later! dolenti, et postea foveatur. Progress of the Case.—September 26th.—The local pain has been relieved by the treatment, but it returns with severity at intervals. For some time the urine has been clear. He has had a slight diarrhoea, which has been checked by a chalk and aromatic mixture ; and has occasionally taken at night Pulv. Dover! gr. viij. October 3d.—Two days ago was again seized with rigors, fever, and acute pains in the right flank. The urine is again loaded with pus and mucus, and of foetid odour. The ap- petite is gone; there is thirst and frequent vomiting. Pulse 120, soft. A saline an- timonial mixture. Oct. 6th.—Anxious countenance ; pain continues, preventing sleep. Can take no nourishment. Much exhausted. Vomiting diminished. R Pu1v. Dover! gr. x. hora somni. Nutrients. Wine four ounces daily. Warm fomentations to the side. Oct.lOth.—Local pain somewhat diminished. Complains of diarrhoea. IJ Acid. Gallic. 3 ss; Opii, gr. xij; Conf. Rosar. q. s. ; ft. pil. xij. Sumat unam sextd qudque hord. Oct. 15th.—Since last report has gradually sunk, and died this morning. Sectio Cadaveris.—Forty-eight hours after death. Thorax.—Pericardium contained about a drachm of turbid serum, with a few floating flakes of lymph. Lungs and heart healthy. Abdomen.—The liver was considerably enlarged, and had undergone the waxy degeneration; its substance being pale and dense, with a smooth surface on section. On attempting to remove it, the right lobe was found to be adherent to the colon; and on separating this adhesion with the fingers, a quantity of pus escaped. This originated from a large abscess in the right kidney, containing about half a pint of pus, mixed with curdy matter. The superior wall was composed of the substance of the liver, a, portion of the lower and posterior border of which organ was absorbed. The posterior wall rested on the quadratus lumborum muscle, and anteriorly it was in contact with the transverse colon and the pyloric end of the stomach. When opened from behind, the walls of the abscess were found to be covered with shreds of gangrenous tissue, of 744 DISEASES OF THE GENITO-URINARY SYSTEM. a dark greenish colour, of gangrenous odour. Renal substance could only be detected at the lower part; the rest ofthe kidney was converted into a fibro-cystic structure, in some places of great density. Two of the cysts contained uric acid calculi; one re- sembling in size and form two walnuts united together by a neck, the other of a some- what angular form, with rounded edges, the size of a hazel nut. These calculi were imbedded in pus, and partly projected into what might have been the pelvis of the kidney, but which was converted into a fibrous sac communicating with the ureter. The bladder presented at its neck the cicatrix of an incision made in the usual situation for lithotomy. About two inches above this were three mucous excrescences the size of peas. In the centre of these was a depressed spot, through which a director readilv passed backwards and upwards through the cellular tissue into the rectum. The mucous surface of the rectum at this point was highly vascular, and covered with lymph in patches to the extent of four inches in depth round the gut. Left kidney weighed 13h oz., and appeared healthy in structure: Other organs normal. Microscopic Examination.—The structure of the left kidney was quite natural. The liver presented the usual atrophied and translucent appearance in the cells, charac- teristic of the waxy degeneration, a few only containing a small number of fat granules. Commentary.—The local and general symptoms in this case were so clear as to leave me in no doubt from the first, that this man had a cal- culus imbedded in his right kidney, causing an abscess in that organ. The recurring rigors and fever, with pains shooting down the right groin to the bladder, and occasional vomiting; the turbid, bloody, purulent, and gangrenous urine; the remarkable fulness in the right lumbar region, with tenderness on pressure; and the past history of the case, constituted an unmistakeable group of phenomena diagnostic of calculous nephritis. Indeed, so certain was the fact, that more than once nephrotomy was spoken of as a possible means of relieving him, every other organ with the exception of the liver being at one time apparently healthy. It was with great interest, therefore, that the dissection after death was watched, which fully confirmed the diagnosis. It also pointed out that the other kidney was enlarged and healthy, performing double duty without diffi- culty ; that the liver was enlarged and waxy, and that a recto-vesical fistula existed, causing disease of the intestinal mucous membrane to which the diarrhoea latterly might be attributed. In reference to an operation, it appeared to me at the time that it might easily have been effected after the method of Marchetti,* as the two calculi were loose within cysts, and surrounded by pus. The enlargement of the liver prevented the performance of such an operation being seriously enter- tained in this case. But here, as in ovariotomy, the great difficulty is to establish in the living subject an exact diagnosis, and this I had no diffi- culty in doing six weeks before his death, and when his general health was tolerably good. For such a disease nothing but palliatives are to be thought of. As the size of the stone cannot be known, diluents are indicated with the possibility of favouring its descent along the ureters to the bladder, a practice which, should it fail in that respect, is also useful in carrying off the pus which may accumulate in the pelvis of the kidney, should perchance any healthy secreting texture still remain in it. * An account of a gentleman being cut for the stone in the kidney, with a brief inquiry into the antiquity and practice of nephrotomy, by C. Bernard.—Phil. Trans. October, 169G. NEPHRITIS AND PYELITIS. 745 Case CLXVL*—Chronic Pyelitis, and Cystic Kidneys—Dilatation of Ureters— Fungoid Ulceration of Urinary Bladder. History.—Jane Watson, set. 74, widow—admitted November 15th, 1852. As far as can be ascertained from the patient, whose mental faculties are very much impaired, she has been labouring under her present complaint for the last eight months. About that time, she was exposed to cold from sleeping on damp straw, and was seized with rigors, pain in the back, and in the larger joints. The urine at the same time decreased considerably in .quantity, with frequent micturition, accompanied by pain. These symptoms lasted for about a month, after wbich the amount of water passed became greatly increased in quantity, and dysuria disappeared. For the last three months, the urine has been occasionally mixed with blood, continuing for a few days and then becoming natural. Since the date of her first attack, she has com- plained of p'ain in the region of the right kidney, much increased at those periods when blood was observed in the urine. Symptoms on Admission.—On admission, she has a peculiar cachectic appearance. and is much emaciated. Tongue moist, cracked in the centre, great thirst, appetite impaired, bowels costive. She has considerable pain and tenderness on pressure in the right lumbar region, where there is also some fulness. The urine is passed in con- siderable quantity, specific gravity 1010, alkaline, highly coagulable on the addition of heat and nitric acid. It is quite turbid when passed, and deposits on standing a copious yellowish gelatinous-like sediment, which, under the microscope, is seen to contain numerous pus corpuscles, granule cells, and casts of the tubes, crowded with granules. When the bladder is about half empty, there is frequently a sudden stop- page of the flow of urine, when she suffers from severe pain in the hypogastrium. stretching down the thighs, especially on the right side. Pulse 90, of moderate strength. Heart's sounds feeble, otherwise normal. Other functions natural. The bladder was examined by Mr. Syme, and a large ulcer was detected, occupying the base and neck of the bladder, ty Tinct. Hyoscyam! 3 vi; Tinct. Opii 3 ij ; Mucila- ginis et Aqua aa ? vi. M. Sumat § j ter indies. Progress of the CasE.—November 18th.—Continues much in the same state. Urine presents the same characters as before. Omittatur mistura Hyoscyami. IJ Potassce Acetatis I ss; Sp. AStheris Nitrici 3 iij; Mucilaginis et Aqua; aa 1 iij. M. Sumat I j quartd qudque hord. IJ Sol. Mur. Morphia 3 j; Mist. Camphorce 3 j, M. Sumat dimidium hora somni et alterum post horas tres si opus sit. Warm fomentations to be applied to the loins. Nov. 21st.—The warm fomentations were ap- plied as ordered, and afforded considerable relief; she sleeps well at night-after taking the draught; the casts have now disappeared from the urine, but a few granule cells are still viable, mixed with pus corpuscles, blood globules, and some crystals of triple phosphate. Urine still of specific gravity 1010, highly albuminous, and of a very putrid smell immediately after being passed. Nov. 24th.—The quantity of urine is now greatly diminished; presents the same characters as on the 21st. There is still pam and tenderness in right lumbar region ; frequent desire to pass water, the first half of which flows with comparative facility, but the remainder comes very slowly, requiring external pressure to empty the bladder, at the same time there are sharp shooting pains in the vulva, and the inner side of the thighs, extending down to the knees. She appears much exhausted ; pulse weak, 96. To have four ounces of wine. Nov. 28rA.—Is much in the same state ; the urine is still highly coagulable ; the sediment examined by the microscope presents a large number, 1st, of finely molecular exuda- tion casts ; 2dly, groups of broken down pus cells ; 3dly, crystals of triple phosphate ; • Reported by Mr. Robert Francis M. Russell, Clinical Clerk, 746 DISEASES OF THE GENITO-URINARY SYSTEM. 4thly, granular cells; 5thly, blood corpuscles. December 4th.—Is now passing her fceces and urine involuntarily; appetite rather improved; pulse 85, weak. The warm fomentations have been continued since the 18th ult. To have six ounces of wine. Dec. Sth.—Still passes everything in bed; complains of great pain and tenderness in right lumbar region ; still takes food well; pulse 90, of better strength. Dec. 15th.__ Appetite very much impaired within the last two or three days; still complains of pain over right kidney, and passes dejections involuntarily. Only an ounce of urine could be obtained for examination. It is still coagulable ; the sediment presenting under the microscope, the same characters as on the 28th ult., with an increase in the number of blood corpuscles; pulse 100, very weak. Dec. 23d.—Since last report the patient has been gradually sinking, and she died this morning. Sectio Cadaveris.—Fifty hours after death. Body emaciated. Thorax.—Pericardium contains about two ounces of serum. Heart small, presents a large amount of fat on its surface ; valves and endocardium perfectly normal. Left lung slightly adherent at apex; middle and lower lobes of right lung strongly adherent posteriorly; both lungs were crepitant throughout with the exception of some hardened deposits at apex of the left, which look like old tubercle. Bronchi contain much frothy mucus. The aorta through the whole of its course (and both iliac arteries) contained a large amount of calcareous deposit, principally seated in the arch of the aorta, and the thoracic portion of that vessel. Abdomen.—Stomach and intestinal canal normal; pancreas pale; spleen very small; liver small, congested, firm, and dense. Lumbar glands considerably enlarged, and contain a very great amount of yellowish opaque juice, evidently purulent, but no distinct abscesses. Both kidneys of normal size when viewed externally; the ureters dilated to the size of a swan quill; pelvis of both kidneys dilated to three or four times the normal size; cortical and tubular substance correspondingly small in volume ; several of the pyramids distorted and crooked in direction, but their basic line always distinct; cortical substance pale ; malpighian bodies and striae destitute of blood ; surface smooth, but more adherent to capsule than usual. On careful examin- tion with the naked eye, a considerable number of cysts from the smallest visible size up to i inch diameter are observed in the cortical substance, especially near the surface. The bladder of normal size ; all its walls much thickened ; the mucous membrane presents a soft fungoid-looking ulcerated mass, in which no peculiar or characteristic structure could be observed. All parts of the mucous membrane were equally diseased. Microscopic Examination.—The cysts in the kidney can be traced down to very minute sizes (the smallest observed was about the GOOth of an inch in diameter), having the usual appearance of such cyst formations. The malpighian bodies shrunk, blood- less and opaque, without apparent morbid deposit, but with thickening of their mem- brane and nuclei. In some of the tubes similar thickening and epithelial engorgement, producing an appearance of opacity in the tubuli without any recognisable granular deposit. When the tubules are washed out and examined separately, they appear (most of them) smooth. Epithelium small and compressed, but, generally, regularly disposed and normally developed. In a few places, traces of granular and molecular exudation, but to an insignificant extent. Commentary.—The complication of renal and vesical disease here met with, is by no means an uncommon one in aged persons Ita existence leads to obstruction of the ureter, at its entrance into the bladder, distension of the ureter above, accumulation of urine in the NEPHRITIS AND PYELITIS. 747 pelvis of the kidney, and, as a consequence, inflammation and distension of its mucous lining walls, pressure on the secreting portion, and atrophy of its substance. Such a lesion, if it exist in both kidneys, must neces- sarily at last so interfere with their functions, as to be incompatible with life. The chronic disease of the bladder, on which the renal disease for the most part depends, only admits of palliative measures for its relief. Cystic disease of the kidney may originate in various ways,—1st, From creator or less obstruction in the tubuli uriniferi, and consequent accumu- lation of the fluid above, forming cystic collections. 2d, It may originate in the sacs surrounding the malpighian bodies, the fluid accumulating in them producing distension, and so causing cysts. 3d, In the enlarge- ment of the secreting cells of the organ, which here, as in the ovary, become distended with fluid, and by pressing upon, compress one another. 1. The obstructions found in the tubuli uriniferi are of various kinds, and may consist of coagulated exudation, of pus, of blood, of altered epithelium cells, or of different salts, such as urates, carbonates, phos- phates, etc. etc. The bloody points so frequently observed on the surface of diseased kidneys, most frequently arise from extravasation of blood into the convoluted extremities of the tubes. Small calculi may be formed from mineral deposits, but more commonly the tubular cones present a diffused white appearance from their occurrence. That such a condition is a frequent source of cysts, may be easily proved by exami- nation. The cysts so formed may be of different sizes, varying from that of a millet seed to that of an orange, and the destruction of the secreting portion of the kidney will, of course, be proportionate to their volume and number. The contents of such cysts are also of various kinds, such as serum, blood, pus, fibrous exudation, colloid and fatty matter, fluid hold- ing various crystals in suspension, whether fatty (cholesterine or marga- rine), or saline (phosphates, urates, etc.). I have frequently seen all the forms in the following figure (Fig. 444), and occasionally the radiated bodies represented Fig. 297. 2. That numerous cysts may form from distension of the minute sacs surrounding the malpighian body, I have satisfied myself of by careful examination, and possess preparations demonstrating the fact. In this case, the cysts are generally numerous and scattered through the cortical substance. It would appear to arise from some obstruction at the com- mencement of the excreting duct, although I have never been able to detect any. Fluid collects outside the membrane in immediate contact with the tuft of vessels constituting the malpighian body, and inside another membrane continuous with the basement membrane of the latter. Indeed, it is in cases of this kind that we may satisfy ourselves that the membrane investing the tuft of vessels is really double, forming a shut serous sac, in the cavity of which the fluid accumulates. This fluid is invariably clear, varies in quantity, but each cyst seldom exceeds a small pea in size. As it forms, it gradually presses on the vascular tuft, and causes its atrophy, and so impedes the secretory power of the organ. ^ # 3. The third form of cystic formation in the kidney evidently origi- nates in the secreting cells themselves, as they may be _ seen, on a microscopic examination, to exist in clusters, varying in size from the 748 DISEASES OF THE GENITO-URINARY SYSTEM. 600th to the 16th of an inch in diameter. In such a case, the paren- chyma of the organ seems to be infiltrated with them, and strongly Fig. 444. reminds the observer of a section of the ovary, loaded with Graafian vesicles. Many still retain their nucleus, whilst in others it has dis- appeared. Mr. Simon, of London, who first described this form of cystic formation, says, as explanatory of its formation, " that certain diseases of the kidney (whereof subacute inflammation is by far the most frequent) tend to produce a blocking of the tubes; that this obstruction, directly or indirectly, produces rupture of the limitary membrane; and that then, what should have been the intra-tubular cell growth continues, with certain modifications, as a parenchytic deve- lopment."* One or all of these forms of cystic growth in the kidney may be associated with the next lesion to be treated of, viz., Bright's disease. PERSISTENT ALBUMINURIA, OR BRIGHT'S DISEASE. That albumen in urine was a symptom of certain dropsies, was first noticed by Dr. Wells of St. Thomas's Hospital,! and Dr. Blackhall of Exeter; that it indicated especially renal dropsies, was the discovery of Dr. Bright, who has given us a careful account of the phenomena * Medico-Chirurgical Transactions, vol. xxx. p. 152. f Trans, of a Society for promoting Medical and Surgical Knowledge, vol. iii. pp. 147, 167. Fig. 444. Structures occasionally seen in cysts of the kidney; a and b, Structure- less transparent colloid masses ; c to g, Colloid bodies, composed of one or more nuclei, imbedded in albuminous matter; h to i, Colloid masses, surrounded by con- centric lamina;; k, A colloid mass, with fatty granules arranged in an areolar manner. —( Wedl.) 350 diam. BRIGHT'S DISEASE. 749 which characterize the disease that has since borne his name, as well as of the changes observed in the kidney after death. The subsequent observations of Christison, Martin Solon, Rayer and others, as well as the more recent investigations of Gduge, Johnson, Simon, Frerichs and others, have rendered it certain that the lesions- of the kidney accompanying albuminuria are various. Some are dependent on what may be considered an acute or chronic form of inflammation (see Nephritis), whilst others must be referred to what we now call the fatty and waxy degenerations. In selecting the following cases as illustrative of the disease, I have kept in view its natural progress, and • endeavoured to show how, by judicious treatment, it sometimes terminates in recovery; how at other times it frequently becomes obsti- nate, and in what manner it may ultimately cause death. Of the pathology and treatment I shall speak separately, after describing the facts we have studied at the bedside. Case CLXVII.*—Albuminuria—General Anasarca—CEdema of Lung—Recovery. History.—Elisabeth Brady, set. 30, cook, married—admitted March 19th, 1854. She states that her health was good until four weeks ago, when, after exposure to cold and wet, she was seized with pains in the chest and cough, but without shivering. Three days afterwards her feet began to swell, and gradually the swelling extended upwards, involving her whole body. Symptoms on Admission.—On admission, chest well formed; breathing slightly laboured. On percussion, unusual resonance is perceived over the upper portion of both sides anteriorly. There is marked dulness on the left side below the nipple and lower angle of scapula. On applying the stethoscope over the portion marked as dull, fine crepitation is perceived. Elsewhere on the left side, the inspiration is harsh and the expiration prolonged; pulse 100, small and hard; cardiac sounds normal; tongue covered with a brown fur; complains of nausea and disinclination for food. The abdo- men is distended with fluid, and she has pain in the epigastric region ; bowels consti- pated; urine rather scanty, sp. gr. 1028, is turbid when voided, and on standing deposits a copious sediment, which, when placed under the microscope, presents chiefly amorphous urate of ammonia, with a few tube-casts. On the application of heat and nitric acid a large coagulum is thrown down. Catamenia regular. Her skin is hot; her face flushed and swollen; she suffers from general anasarca ; her lower extremities, however, being especially affected and pitting easily on pressure. Progress of the Case.—March 21st.—Ordered to be bled at the arm to the extent of twelve ounces, fy Pulv. Dover! $i. Tales vi. One to be taken at bed-time. March 22d.—Fifteen ounces of blood were withdrawn from the arm, and the pulse shortly fell to 70. She expressed herself as greatly reheved. After taking the Dover's powder she had a short sleep, but no diaphoresis was produced. The blood withdrawn presents no buffy coat; her urine is voided in larger quantity, but still deposits a considerable sediment; pulse 90, soft and weak. P£ Potass. Acet. Zi;Sp. AVth. Nit. Z vi; Syrup. Aurantii 3 i; Aquee § iv. M. One ounce to be taken three times a day. R. Pulv. Gambogiai gr. v; Potass. Bitart. 3 ij. M. To be taken at bed-time. March 23d.— Her bowels have been well opened, and her general appearance is greatly improved, her face being much less swollen; urine less turbid, and in larger quantity. Intermit- * Reported by Mr. W. W. Clark, Clinical Clerk. 750 DISEASES OF THE GENITO-URINARY SYSTEM. tatur mist. IJ Pil. Scilla; et Digital, xii. One to be taken every sixth hour. March 24///.—Her cough has abated greatly, and she feels herself much better. Repetat. Pulv. Gamb. and Potass. Bitart. vespere. March 26th.—Urine deposits very little sediment on standing; and under the microscope no tube casts can be detected; sp. gr. 1018. A slight coagulum is produced on applying heat aud nitric acid. Her appetite is greatly improved. March 29th.—On examining her chest to-day, the dulness on percussion, which previously existed on the left side, cannot now be detected, and on auscultation over that portion the respiratory murmur is heard normal. Under the right clavicle the inspiration appears unusually harsh. Her urine presents the same character as at last report. Repetantur Pil. Scillce et Digital, et Pulv. Potass. Bitart- Z ss ter indies. April 3d.—She is now nearly convalescent, and has taken no medi- cine for two days. To have steak diet. May 8th.—Complains to-day of pain in the epigastrium and of vomiting; bowels constipated; pulse natural; urine yields no coagulum to the usual re-agents ; sp. gr. 100S ; contains no tube-casts on microscopic examination. Menstruation rather frequent, and iu the intervals of the catamenial periods, she is subject to a leucorrhceal discharge. IJ Napht/nc Medicinal. Z i; Tinct. Cardam. Co. r l > Aquae 5 v. M. A table spoonful to be taken when the vomiting is froublesome. r}. Magnesia; Carb.^ss; Aq. Cinnam. §i; Infus. Sennce. Co. Z 'j. M. Ft. haust. hora somni sumendus. Intermittantur alia. July 20th.—Since last report her urine has remained entirely free of albumen. The cedema has now for the most part entirely disappeared, but still returns slightly after she has been some time in the erect position. General health good. Dismissed. Commentary.—On succeeding Dr. Christison in the charge of the clinical wards on the 1st of May 1854, I was informed that this was a case of Bright's disease. On the 8th of the month, however, as stated in the report, on examining her urine, I found it to contain no albumen on the addition of heat or nitric acid, while the sediment, carefully col- lected, exhibited no tube-casts under the microscope. On looking into the history of the case, however, as recorded in the ward-book, and which is given above, it became clear that the woman had undoubtedly been labouring under albuminuria and chronic renal disease, wbich, well pronounced March 21st, had entirely disappeared at the beginning of May. But the cedema of the feet continued, with stomachic derange- ments ; the former symptoms exhibiting a tendency to return, on assum- ing the erect position for any time; and in consequence, she was not dismissed until the 20th of July. Before saying anything with regard to the treatment, it will be well to attend to the facts exhibited by some other cases. Case CLXVIII.*—Albuminuria—CEdema of both feet and legs, left arm and hand- Recovery. History.—Robert Lindsay, aet. 62, carder of wool—admitted 21st March, 1854. States that, twenty-three years ago, he had a violent attack of rheumatism, which laid him up for ten months. After his recovery, his health continued good, until ten years ago, when he began to suffer from symptoms of stone in the bladder. He underwent the operation of lithotbomy, but made a tardy recovery, being unable to * Reported by Mr. Robert Bird, Clinical Clerk. BRIGHT'S DISEASE. 751 resume his work until upwards of twelve months afterwards, and for two or three years subsequently he was subject to attacks of rigors, which compelled him to keep within doors for several days at a time. He then became tolerably healthy, and continued so until three weeks ago, when he noticed his left wrist somewhat swol- len, and in the course of two days, his lower extremities became likewise cedematous. He suffered from a dull heavy pain in the lumbar region; which has been present more or less ever since he underwent the operation ten years ago. His urine, at the time the swelling commenced, was scanty and high coloured, and he was troubled with a slight cough. He says that about the time when his illness began, he was engaged in cleaning machinery, and may have caught cold. He is not awaie of any other cause which might have brought on his ailment. He acknowledges that for- merly he was a free liver, but since the operation he has been very temperate. Symitoms on Admission.—On admission, both feet and legs are cedematous, pit- ting on pressure. There is also slight swelling of the left arm and haud. He com- plains of a dull pain in the lumbar region on both sides, but that on the left is most severe. Micturition frequent; he is obliged to rise several times in the course of the night for that purpose. It is not attended with pain or difficulty. Sp. gr. of urine 1011; coagulable by heat and nitric acid. He complains of frontal headache. Sleeps badly, being much disturbed by dreams and sudden startings. Tongue moist and clean; complains of great thirst; appetite impaired; bowels regular; has a slight cough, with very little expectoration ; chest everywhere resonant on percus- sion. At the apices of both lungs anteriorly, and at the apex of the left posteriorly) sibilant rales are heard. He has suffered from palpitation for the last three weeks, but the cardiac sounds are normal. R Tinct. Ferri Mur. 3 i. Ten drops to be taken three times a day. 1} Pulv. Doveri gr. x. Mittant. tales, vi. One to be taken morn- ing and night. Progress of the Case.—March 23d.—This morning he had violent vomiting, but it has now abated, and he complains of great thirst. March 26th.—Ordered pills of digitaline, each containing l-74th of a grain. One to be taken three times a day. March 28th.—After taking the pills of digitaline twice, excessive purging came on; their further use was therefore abandoned. The urine was very slightly increased in quantity. April 4th.—The use of digitaline was resumed four days Bgo, and now the coagulability of the urine has entirely disappeared. The oedema of his lower extremities has abated greatly. The purging, caused by the digitaline, was counteracted by opium pills. May 3d.—Since last report the urine has been several times examined, and has been always found to be free of albumen. To day only the slightest haze is caused by heat and nitric acid; the urine is pale coloured; sp. gr. 1014, transparent, and without sediment on standing; 84 oz. are passed in the twenty-four hours. The oedema has not entirely disappeared from the feet and ankles. He continues to take the digitaline pills. His general health is much improved. May 11th.—Two days ago he was ordered the following:—1} Tinct. Ferri Mur. % i. Fifteen drops to be taken thrice a day. To-day he has passed 54 oz. of urine. The oedema of his feet and ankles is abating. A few minute flakes are produced on treating the urine by heat and nitric acid. May 13th.—78 oz. of urine were voided during the last 24 hours. B Sp. AZth. Kit. § iss ; Aq. Potass.; Tinct. Digital, aa 3 ij. M. A tea-spoonful to be taken thrice a day. Con/in. Tinct. Mur. Ferri. May 10lh.—Amount of urine passed during the twenty-four hours is 100 oz. June 22d.—(Edema, of legs almost entirely gone; 68 oz. of urine passed during the last twenty-four hours; sp. gr. 1014; quite unaffected by heat and nitric acid. June 26th.—His feet and ankles are slightly cedematous at night; 60 oz. of urine passed during the last twenty-four hours ; sp. gr. 1017. No coagulum pro- duced by heat and nitric acid. July 11th.—Dismissed quite well. 752 DISEASES OF THE GENITO-URINARY SYSTEM. Commentary.—In this case also, we can have no doubt of the exist- ence of Bright's disease, although on my succeeding Dr. Christison in the clinical wards I found no albumen in the urine, and that the patient was rapidly recovering. Digitaline had been tried, with the effect cf producing excessive purging, and slight increase of the urine. The al- bumen shortly afterwards disappeared from that fluid, but here, as in the last case, the oedema continued, and he subsequently became quite well. These two cases, therefore, indicate that purgatives and diuretics are sometimes very efficient in entirely removing the disease. Case CLXIX.*—Albuminuria—CEdema—Ascites and General Anasarca—Coma and Convulsions—Recovery. History.—Alexander Strachan, aet. 36, a joiner—admitted October 25, 1858. He enjoyed good health up to the 2d October last, when, after exposure to cold and wet, he was seized with a rigor, followed by severe cough and slight expectoration. On the 6th he first remarked swelling of the lower extremities, and in the tvjning, on trying to make water, he with some difficulty passed about half a pint of brown, smoky-coloured urine. On the following morning this presented a sediment of a light colour and viscous consistence. He at this time suffered from constipation, and was ordered a dose of castor oil by his medical attendant. ( On the 7th he had a copious evacuation from the bowels, but his legs continued to swell. On the 8th his water, which was small in quantity, still presented a white, viscous sediment, The legs became more swollen, the abdomen now began to increase in size, and great difficulty of breathing came on. He continued in this state up till the day of his admission. Symptoms on Admission.—There is great oedema of both legs, ascites and general anasarca. He has a good deal of cough and frothy expectoration; but, with the exception of occasional fine moist rale and sibilation posteriorly, the lungs are healthy. Cardiac dulness and sounds normal. Pulse 70, of moderate strength. He com- plains of a dull pain over the region of kidneys. Urine of a dark, smoky colour, highly albuminous, and depositing a whitish, tenacious sediment. Tube casts and blood corpuscles are very abundant, as determined by the microscope. Other symptoms normal. To be dry cupped over the kidneys, and to take 3 j doses of Pulv. Jalapce Comp. three times a day. Progress of the Case.—October 20th.—The cough and expectoration have greatly diminished since he came into the house, but little impression has been made upon the dropsy. Nov. 2d.— Ordered Pil. Digitalis et Scillce xij ; one three times a day, in addition to the powders. Nov. 7th.—Has passed quantities of urine varying from 20 to 44 oz. daily, although generally it has been deficient in quantity. The dropsical symptoms have undergone no change. This morning at four o'clock he was seized with convulsions and loss of consciousness. Had three more fits at intervals during the day. Urine of a smoky tint, containing tube casts and blood corpuscles. Ordered to be cupped to 5 ounces over the region of the kidneys. To have 3 j of the Bitartrate of Potass three times a day. Nov. 8th.—Had three fits to-day, and has been very drowsy. Nov. Oth.—The drowsiness is nearly gone to-day, and he is quite sensible, though complaining of an intense headache. Pulse 108, of fair strength. Urine 40 oz., sp. gr. 1015, albuminous and containing blood corpuscles. Dropsy of the legs has nearly disappeared, and the abdomen feels softer. It measures * Reported by Mr. George Shearer, Clinical Clerk. bright's disease. 753 36 inches round the most prominent part. Nov. 10th.— Oedema of legs entirely gone ; not the slightest pitting on pressure. Complains of seeing objects distorted, and some- times of a haze which appears before his vision. He continues to take the Squill and Digitalis pill, one four times a day, and 3 j doses of bitartrate of potash. Nov. 11th.__ Six dry cupping-glasses were applied over the lumbar region this evening. The pupil of left eye was observed to be considerably dilated. Nov. 12th.—Passed 68 oz. of urine free from albumen. Nov. 13th.—Passed 42 oz. ; and Nov. 14th, 46 oz. of urine. To-day the left pupil was observed to be contracted, the right dilated. Sees whatever object he has been looking at magnified on the opposite wall. Nov. ldih.—Since last report, has passed on the different days, 43, 60, 135, 132, and98oz. of urine. To-day it shows a mere trace of albumen. Abdomen much less tense, measures 34 inches. From the 19th to the 27th has been passing about 90 oz. of urine daily. It has still a dim, smoky tint, reaction acid, sp. gr. 1018. Nitric acid imparts to it a red tint, and after boiling flakes of albumen appear. From this time he gradually recovered. He was for some days troubled with muscse volitantes, bat was dismissed on the 1st of December at his own request, the dropsy having completely disappeared, and only the faintest trace of albumen existing in the urine. Commentary.—In this case the amount of general anasarca was very great, and purgatives and the squill and digitalis pill produced no effect, so that poisoning of the blood with urea, caused coma and severe con- vulsions. These were of an epileptiform character, with foaming at the mouth, each paroxysm being of about ten minutes' duration. From this state the patient was roused by the energetic action of the bitartrate of potash, which, by increasing the flow of urine from the kidneys, rapidly diminished the head symptoms and completely removed the dropsy. The following case,which is the most remarkable recovery I ever saw, still fur- ther points out the value of this drug, in Bright's disease of the kidneys. Case CLXX.*—Third Attack of General Anasarca with Albuminuria—Enormous Dropsical Distension of tlie Abdomen, Scrotum, and Inferior Extremities—Com- plete Recovery under the Action of Super tartrate of Potash. History.—William Herdmann, ast. 49, single, a lithographer—admitted March 31, ] S54. Patient admits that he has been a man of rather intemperate habits, although this has not been the case of late. Twelve years ago, without any premoni- tory symptoms, he was suddenly seized with general anasarca and with ascites. For this he entered the Infirmary, and after treatment was dismissed " Cured." Six years after the first, he suffered from another attack, which was also cured in the Infirmary. Within the last fortnight he has been again attacked by " dropsy," which has been gradually increasing. Symptoms on Admission.—On admission, the quantity of urine passed is small, but he is not obliged to rise during the night to pass his water. No pain in loins, or tenderness on pressure. Abdomen is considerably swollen, especially at the lower part. Circular measurement below umbilicus, 30£ inches. When he lies on his back, the anterior part of the abdomen is tympanitic, and the flanks dull on percussion. On turning him to either side, the one which is uppermost becomes clear on percussion, * Reported by Mr. Robert Byers, Clinical Clerk. 48 754 DISEASES OF THE GENITO-URINARY SYSTEM* and the undermost remains dull. There is slight cedema of the ankles, but he notices every morning, some puffiness in the cheeks, especially on the right side (that on which he usually lies). Bowels rather costive ; appetite very bad ; tongue foul, and covered with a thick brown fur; considerable thirst; complains of cough and shortness of breath ; expectorates a little frothy mucus. Percussion of chest anteriorly resonant on both sides. On auscultation in front, there is heard on both sides har>h inspiration, attended by very prolonged expiration. Posteriorly, at both bases, there are loud sibilant and crepitating rales. Heart sounds indistinct; no murmur; pulse 68, of good strength ; sleeps well; has complained a little of drowsiness for the last few days; skin dry and harsh. Urine very scanty ; lias only passed 12 oz. since admission. The application of heat converts the whole quantity in the test-tube into a firm coagulum; sp. gr. 1024. Casts of tubes and oil globules are found in the sediment. Dcscendal in balneum calidum vespere. Sumat Pil. Scilla; et Digitalis j. ter in die. 1! Tr. Opii Ammoniatce; Sp. Lavandula Co. aa § ss; Mist. Scillce § v. M. Sumat Z j ter in die. Progress of the Case.—April 4th.—Has passed 16 oz. of urine during the last twenty-four hours. Swelling of abdomen increased; it measures below umbilicus 33 inches. lie is very thirsty. April 5th.—Only 9 oz. of urine passed since last report; sp.gr. 1018; highly coagulable; bowels costive; tongue dried and furred; cough still present, with expectoration of tough frothy mucus ; sibilant and crepi- tating rales still heard at bases of both lungs posteriorly. Repeat the warm bath. Injiciatur enema fcetidum. Habeat Pulv. Ipecac. Co. gr. x. hacnocte, et repetatureras mane. April 6th.—Obtained little relief from the injection ; skin of chest, abdomen, and loins pits upon pressure. Abdomen measures 34J inches in circumference; passed only 9 oz. of urine since last report, of same character as before. Breath has a urinous odour. Continuent. Pil. Scilla et Digitalis, et sumat. Potass. Bitart. " j ter in die. Repetatur Pulv. Dover!. April \5th.—Urine passed daily has been from 8 to 15 oz., of sp. gr. about 1020, and highly coagulable. Omittantur Pil. Srilla it Digitalis. To apply spongio-piline constantly to the abdomen, saturated with a strong solution of Infus. Digitalis. April 22d.—Urine not increased in quantity, varies from 9 to 15 oz. per diem; abdomen measures 371 inches. The Inf. Digitalis has produced a rash of a papular character over the surface of the abdomen. R, Sp. AZth. Nitric! Z vj : Aq. Cinnamomiz vss. M. Habeat 5j ter in die. April 25th.—Says that the last mixture has given him great relief; has passed 26 oz. of urine after it. The spongio-piline to be removed, owing to the irritation which it has caused in the skin of abdomen. May 2d.—Base of left lung dull on percussion posteriorly; no rale; a good deal of pain in abdomen ; bowels costive ; skin dry; has pas-cd 25 oz. of urine to-day. May 3d.—Urine 24 oz.; Habeat Potass. Bitart. 3j ter in die. OmitUmtnr alia. May 5th.—Urine 18 oz.; swelling of abdomen much increased, thighs and legs greatly distended. Abdomen measures forty inches in circumference. Had Pil. Rhei Co. gr. x. last night. To take Gin § j daily. May 7th.—Urine 20 oz.; sp. gr. 1018; his condition at present seems almost hopeless. The abdomen is enor- mously distended, with a peculiar diffuse indurated feel over the region of the epigas- trium, which, however, is tympanitic on percussion. The scrotum, thighs and legs are greatly enlarged; appetite impaired; the pulse 86, weak. To be dry cupped over the loins. To have Gin * jj daily. May Oth.—Xo change. Habeat Potass. Bitart. Z ss ter in die. May 11th.—Urine 34 oz.; sp. gr. 1015; still highly coagu- lable ; numerous casts of tubes are seen in the urine under the microscope. May 15th.—Urine 38 oz.; sp. gr. 1014; is less coagulable; complains of severe frontal headache. To continue with the Bitartrate of Potass. May 16th.—Urine 61 oz.; sp. gr. 1010 May 17th.—Urine 58 oz.; sp. gr. 1013; no headache; bed sore on sacrum ; right side more swollen than left (he lies on this side); bowels costive. F bright's disease. 7,35 Habeat Pil. Colocynth. Co. gr. x. hord somni. May 18th.—Urine 67 oz.; cedema of limbs very much diminished; swelling of abdomen less. May 21st.—Urine 08 oz. • sp. gr. 1010 ; appstite good ; pulse 96, full and strong. May 22d.—Urine 120 oz . Mag 23d.—Urine 128 oz. ; sp. gr. 1014 ; it still contains albumen in considerable quantity; the abdomen has greatly diminished in size, and the thighs and legs are of natural appearance, though there is some pitting on pressure at the ankles ; every second day of late he has been attacked about noon with a severe frontal headache. fy Quiiiee Sulphatis gr. iij ter die sumend. May 24th.—Urine 107 oz.; sp. gr. 1018 ; still contains much albumen ; no headache. May 25th.—Urine 126 oz. ; sp. gr. 1016; very slight headache to-day; has taken four of the quinine powders. Still takes the Bitartrate of Potash. May 28th.—Urine 100 oz.; sp. gr. 1020. May 30th. —Urine 50 oz. May 31st.—Urine 80 oz. ; sp. gr. 1014; perfectly free from all trace of albumen ; cedema of legs and ascites have completely disappeared; no headache; appetite good. June 8th.—No return of albumen in urine ; quantity varies from 60 to 114 oz. daily. June 9lh.—A slight trace of albumen in the urine to-day, and feet slightly cedematous. June 15th.—Still a faint trace of albumen in the urine; his ankles become cedematous if he sits up long. June 19th.—Urine 100 oz. in twenty-four hours; sp. gr. 1010; contains an exceedingly faint trace of albumen, dune 27th.—The quantity of urine passed in twenty-four hours averages 100 oz.; sp. gr. varies from 1010 to 1015 ; his ankles after he has been long up pit slightly on pressure. July 2d.—Albumen has quite disappeared ; bandaging prevents his ankles from swelling. He sits up the entire day. The appetite is good. Urine passed daily about 40 oz. In fact he is quite well. July 3d.-,—Dismissed cured. Commentary.—In this case the man described his dropsy as being the third attack of the kind he had experienced, although it was by far much more severe than the preceding ones. I found him in the ward at the same time with Cases CLXVII. and CLXVIIL, but, unlike them, the treatment seemed to have been of no avail. The abdomen was enormously distended from fluid collected in the peritoneum and the scrotum; the thighs and legs were also so greatly swollen from dropsy, that to all appearance the case was hopeless. The urine, when heated, presented almost a solid mass of albumen, as if it had been serum of the blood, and the sediment exhibited, under the microscope, numerous fatty cells, and casts of the tubes, proving the disease to be renal. A singular circumstance is, that from his admission in March, until May 11th, not- withstanding a diaphoretic, purgative, and diuretic treatment had been employed, he continued to get worse, and the anasarca increased. In April also he had taken the bitartrate of potash in drachm doses without benefit. But after I resumed the same remedy in May, in half drachm doses, its diuretic effect was extraordinary. From the 11th to the 28th of May, the quantity of urine was greatly increased, and I ordered it to be measured daily. On some occasions, 126 oz. of fluid were voided, and coincident with this diuretic effect, the enormously swollen abdomen, scrotum, and inferior extremities diminished in size, and gradually returned to their normal condition. On the 31st of May there was no albumen in the urine. The ankles still remained puffy, especially after sitting up for any time, but on the third of July he was dismissed perfectly well. The anasarca in this case had reached its ultimate limits, the scrotum was as large a3 an adult head, the prostration of the patient was extreme, and we daily feared the coming on of coma, and sloughing sores on the 756 DISEASES OF THE GENITO-URINARY SYSTEM. back. Although dry cupping was tried over the loins, on the 7th of May, I have myself no doubt that the good effects are entirely to be attributed to the diuretic ordered on the Oth, and the increased discharge of fluid from the kidnoj-s which followed. The cases now recorded, in which advanced Bright's disease was perfectly cured, exhibit the groundlessness of the fears entertained by some as to the use of diuretics in that disease. In all they were freely employed, and it may be observed that improvement invariably coin- cided with the coming; on of the increased flow of urine. The case of Herdmann (Case CLXX.) is extraordinary in this respect. Case LX VII. also, in which there was a permanent cure of albuminuria in connection with hepatic disease, may be consulted with advantage. Case CLXXI.*—Second Attack of Albuminuria with Anasarca—Dismissed relieved. History.—Mary Donaghan, set. 43—admitted July 12th, 1S54, out worker. She states that three weeks ago, she came home from her usual employment in the open fields in good health, but awoke next morning with pain in the epigastric region, and found her legs, arms, body, and face, much swollen. She was not aware of having been exposed to unusual cold or wet previously, and had no shivering. She had no pain in the loins, and passed her urine in usual quantity. Two years ago, she was admitted into this hospital, suffering in the same way as at present. The swelling of her body at that time, however, was much greater. Symptoms on Admission.—On admission, her lower extremities only are cedema- tous, pitting on pressure. Her skin is moist, and she perspires moderately. Urine passed in normal quantity. On standing, a thick white deposit subsides, which, under the microscope, is seen to consist of epithelial scales, numerous tube-casts filled with oily globules, and compound granular bodies. Urine deposits a considerable coagulum by heat and nitric acid, also an abundant precipitate of chlorides by nitrate of silver; sp. gr. 1012. She complains of pain on pressing firmly the left lumbar region, ner tongue is moist at the edges, and furred in the centre. She complains of thirst, and bad appetite. Epigastric region somewhat tender on pressure. Bowels constipated. R- Pulv. Potass. Bitart. 3 ss ; in Pulv. xii. divid. One to be taken three times a day. Progress of the Case.—July 23d.—Conjunctivae somewhat inflamed. Two leeches to be applied to external angle of both eyes. July 26th.—Conjunctivitis less acute. R^ Nit. Argent, gr. ij ; Aquae 3 i; Ft. Collyrium. August 2d.—Her eyes are now nearly well. Urine still very coagulable, and its general characters are much the same as on admission. The cedema of the legs is abating a little. Aug. 15th.— She has been sweating profusely for the last few days. The characters of the urine are much the same as at last report. The oedema disappears almost entirely when she retains the recumbent posture for some time, but returns again when she walks about. She continues to use the powders of Potass. Bitart. Aug. 2lst.—Urine pale coloured: sp. gr. 1012. Yields a considerable coagulum on the application of heat and nitric acid. The swelling of her legs has abated very much. Scarcely any pitting can be produced, except after she has been walking about a good deal. Her general health is very good. She is able to be out of bed during the whole day, and is now anxious to be dismissed. Aug. 21st.—Dismissed relieved. * Reported by Mr. James Thorburn, Clinicd Clerk. bright's disease. 757 Commentary.—In this case the same diuretic treatment we have pre- viously seen to be so beneficial, produced great relief and rapid disap- pearance of the anasarca. No doubt every symptom would have soon disappeared, had she not insisted on leaving the Infirmary. Case CLXXII.*—Second Attack of Albuminuria after an interval of twenty-nine years, with Anasarca—Bronchitis—Dismissed relieved. History.—James M'Kay, set. 62, armourer—admitted January 6th, 1853. He states that he enjoyed excellent health, till twenty-nine years ago, when he was ad- mitted to the I!oyal Infirmary under Dr. Spens, for swelling of the limbs, trunk, and face, supervening after exposure to cold and wet. He continued under treatment for nine days when he was dismissed cured, and since then, he continued free from any complaint, till about five weeks ago, when he observed that his urine was diminished in quantity, was of a high colour, and deposited a thick white sediment. A few days after, he was exposed to cold, while perspiring, having freely indulged in spirituous liquors. This was followed by distinct rigor, lasting for a short time, and followed by general uneasiness and feverishness, with headache and feeling of soreness in the loins. Ten days after the rigor, swelling appeared in the feet and gradually increased, extend- ing to the legs, thighs, and scrotum, but during the last few days, the cedema has con- siderably diminished. He has been a good deal addicted to the use of ardent spirits for the greater part of his life. Symptoms on Admission.—On admission, the skin is soft and dry; the legs are somewhat cedematous, and pit on pressure. The urine is passed more frequently than usual, and in small quantities at a time ; the whole amount of urine voided is consid- erably under the normal standard; it is of a pale colour; sp. gr. 1012 ; highly coagulable with heat and nitric acid; no distinct sediment is deposited on standing. He has no pain at present in the situation of the kidneys or bladder ; tongue dry ; has no appetite, but troublesome thirst; bowels regular ; pulse 96, natural; heart's sounds normal; he has some cough and dyspneea on exertion, but the chest is otherwise nor- mal ; other functions natural. To have warm bottles applied to the limbs and feet with twelve grains of Dover's powder at night, followed by a draught of twenty-five minims of Morphia if he docs not sleep. Progress ofthe Case.—January Oth.—Slept towards morning after the morphia; no sweating; urine coagulable as before ; sp. gr. 1018 ; passed without pain or diffi- culty, and iu good quantity, viz., 48 oz. The cedema has quite disappeared from the limbs; bowels costive. Ordered two Colocynth and Hyoscyamuspills. Jan. 12th.— On the 10th he was much in the same state ; no sweating ; appetite bad; great thirst; for which he was ordered milk and lime water. Being no better last night, he was ordered the warm bath, followed by fifteen grains of Dover's powder. To-day he states that he felt more weak after the bath, had slight perspiration, which was confined to the face and legs. To have twelve grains of Dover's powder, with six of James' powder at bed time. Jan. 14th.—The diaphoretic has been continued since last report, but no sweating has been produced; passed, during the last twenty-four hours, 58 oz. of urine; bowels are rather costive. R. Bitart. Potass. 3 iss ; Pulv. Gambog. gr. iv. M. To be taken immediately, and repeated in six hours if necessary. Jan. 17th.—The bowels were well opened on the 15th, the stools being of thin consistence after the second powder, which afforded considerable relief; but they have not been opened since; appetite still bad, but less thirst. The urine to-day is of nearly natural colour ; * Reported by Mr. Win. Calder, Clinical Clerk. 758 DISEASES OF THE GENITO-URINARY SYSTEM. sp.gr. 1022; quite as coagulable as before; the quantity passed in the last twenty- four hours is 58 oz., with a slight sediment of urate of ammonia. Ordered a scruple of Bitartrate of Potass, three times a day. Jan. 10th.—The quantity of urine passed yesterday was 60 oz., but to-day it has diminished to 36 ; he complained of much thirst, and was ordered cream of tartar ivater as a drink ; he did not sleep well during the night, and is somewhat incoherent in his remarks to-day, though quite sensible when promptly spoken to ; bowels still costive ; repeat the powder of Bitartrate of Potass, and Gamboge ; to have ten grains of Dover's powder after the bowels have been well opened. Jan. 20th.—Was a good deal better last night, felt himself warm and comfortable after the Dover's powder, but he did not sweat; he has had three loose stools since ; the quantity of urine is now 50 oz. ; sp. gr. 1020 ; still highly coagula- ble ; his thirst is considerably diminished. Jan. 22d.—The urine examined under the microscope yesterday exhibited a few pale casts of the urinary tubes, which are also present to-day; during the last two days he has passed about 58 oz. of urine in the twenty-four hours, and he states that altogether he feels much better. March oth.— Since last report has gradually improved in health. To-day, wishes to go out, as he now has no complaint but weakness; voids from 50 to 60 oz. of urine daily. It is of rather pale colour; sp. gr. 1020 ; about one-sixth coagulable. A few sibilant rales are heard occasionally over the chest, but otherwise the systems are healthy. Is dis- missed accordingly much relieved. Commentary.—In this case the diaphoretic plan of treatment was tried at first, but with inconsiderable success. It is true the cedema disappeared from the legs, a result probably as much owing to the recum- bent position and general comforts of the hospital, as to the medicines employed. When the bitartrate of potash was administered, afterwards combined with purgatives, the effects were more rapid, and the anasarca soon disappeared. The coagulability of the urine, however, still con- tinued, though in a diminished degree, when he left the house. Case CLXXIIL*—Third Attack of Albuminuria with Anasarca—Dismissed relieved. History.—James Smith, set. 38—admitted 25th November, 1852. States that he enjoyed good health till about three and a half years ago, when, after exposure to a draught of cold air, his ankles began to swell, which swelling in four days extended up to the thighs, and induced him to apply for admission to the hospital, where he remain- ed three weeks, and was dismissed cured. The same symptoms reappeared in twelve months, and he was again admitted a patient, remained for a few weeks, and went out feeling quite well. He continued in excellent health till four months ago, when he began to complain of shortness of breath and palpitation when at work; the palpita- tion was reduced by cupping, but the dyspneea continued upon taking exertion. Four weeks ago the swelling at the ankles returned, and he was again admitted into the hospital, ward 6, where he has been under treatment till the date of his admission int.o the clinical ward. His habits were rather intemperate previous to his first attack, but since then he has never indulged in any kind of intoxicating liquors. Symptoms on Admission.—On admission there is some cederna of the limbs and trunk, which pit slightly on pressure; the skin generally is very dry, but of the usual temperature. The quantity of urine voided in the twenty-four hours is 66 oz. ; it is * Reported by Mr. Alexander T. Macarthur, Clinical Clerk. BRIGHT'S DISEASE. 759 of a pale straw colour, slightly turbid, and highly coaguable ; sp. gr. 1014, depositing a slight sediment like thin whey. Viewed under the microscope, it presents numerous fragments of desquamative casts ; some very long, some containing nuclei and granular cells more or less fatty, and some filled with minute fatty molecules. There are numerous pus cells; some epithelial cells, isolated and in groups, from the ureter or bladder. There are numerous columnar crystals of uric acid, and some mineral salts aggregated in masses of minute angular crystals. Tongue clean and moist; appetite good; bowels regular: pulse 68, of moderate strength. There is slight irregularity ofthe heart's action ; first sound prolonged, and accompanied with a soft blowino- mur- mur heard loudest at the apex. Other functions normal. Progress of the Case.—He was dismissed at his own desire on the 29th of Xovember, but returned with all his former symptoms aggravated on the tilth of December. He states that after leaving "the hospital, he returned to his usual em- ployment for about a week, when he caught cold, and he has been confined to the house ever since. The cough became very severe, with dyspneea aud great debility after passing his urine. On examination, the quantity of urine excreted is 50 oz. ; it is passed without pain ; is of pale colour resembling whey, is slightly turbid, and deposits, on standing, a small quantity of white sediment, which, on examination by the microscope, presents numerous casts, as before noticed, but no crystals; sp. gr. 1013, highly coaguable. On auscultation, sibilant rales are heard all over the chest, expiration prolonged, but no dulness on percussion. He has a frequent cough, with frothy mucous expectoration. B Sol. Antim. 3 ii; Mist. Camph. |iv; Misce. Sumat z ss quartd qudque hord. Descendat in balneum calidum secundd qudque node. Dec. 29th.—Still rather feverish, complains of intense thirst, constant craving for drink, which is unrelieved by water. To have as drink 3 xij of milk mixed with 3 vj. of lime water. Jan. 1st.—Cough much the same as on admission; cedema of legs much diminished, but the skin is still dry, diaphoresis never having been induced. About 90 oz. of urine are passed in the twenty-four hours, still very coagulable with heat and nitric acid; slight deposit, still containing granular casts ofthe urinary tubes. Jan. 6th.—Cough much relieved; pulse .68, of good strength; swelling of the legs now quite gone; urine passed in large quantity; still complains of great thirst. Continuentur medicament. Jan. 13th.—Voided 130 oz. of urine during the last twenty-four hours ; has still considerable thirst; pulse 80, of good strength. Expresses himself as feeling quite well. On standing for twenty-four hours the urine deposits a slight sediment, in which casts of the urinary tubes are still visible, crowded with fatty granules. Jan. 17th.—Feels better than he has done for several years, and wishes to return home. He is accordingly ordered to be dismissed. Commentary.—In this case it was evident that improvement had commenced on his entering the clinical ward, the urine was passing copiously, and diuretics were not directly indicated. Under these circumstances the diaphoretic plan of treatment was persevered in, and although not with the result of entirely freeing his urine of all trace of albumen, yet with such good effect, that he insisted on leaving the house, which he did nearly well. In the last three cases it will be observed that great relief was expe- rienced, althougli perfect recovery was not established. The dropsical symptoms were removed, whilst the albuminuria remained, a condition which constitutes the majority of those cases which enter into the hos- pital, and are dismissed as " relieved." 760 DISEASES OF THE GENITO-URINARY SYSTEM. Case CLXXIV.*—Albuminuria, with general Anasarca, terminating fatally—Waxy Kidneys, Spleen and Liver, with Extensive Deposition of Tubercle. History.—Sarah Wilson, ast. 7—admitted November 11th, 1853. Three years ago she suffered from scarlatina, and has ever since been a weakly child, with a capricious appetite. In the course of last summer cedema of the feet and legs was first observed, together with diarrhoea, which has continued more or less ever since. Symptoms on Admission.—On admission her countenance is puffy and pallid, and the whole surface blanched. Her feet and legs are cedematous, pitting on pressure. The urine is of a pale colour ; sp. gr. 1006. On applying heat, and adding nitric acid, a coagulum is thrown down, which occupies a space in the test-tube equal to that of half the quantity of urine. She has never felt any pain in the lumbar region. Tongue moist, and covered by a slight fur; no thirst; appetite good. The abdomen is greatly distended, and there is distinct fluctuation. Pulse 86, weak and compressible ; cardiac sounds normal. She has no headache, and sleeps well at night. B Acet. Potass. 3 i; AEth. Nit. 3 ij ; Syrupi Z i; Aquae § v. M. A iablespoonful to be taken three times a-day. Progress of the Case.—November 17th.—Diarrhoea continues, and she lies in a very weak state. B Mist. Cretce 3 iv. An ounce to be taken three or four times a-day. To have 1 oz. of Gin daily. Nov. 25th.—Urine passed in great quantity; sp. gr. 1002 ; not so coagulable. The diarrhoea, which abated for a few days after last report, has again returned. Ordered a stringent mixture. Nov. 30th.—The puffiness of the face, which, on some days after her admission, abated considerably, is now as bad as ever. Her urine has been passed involuntarily for the last three days ; the diarrhoea is less severe. Dec. 10th.—Since last report, the cedema has wholly disappeared. The foeces and urine are both passed involuntarily. The constant dribbling ofthe latter over the labia and nates has produced excoriation. She takes her food pretty well, but vomits it occasionally. Her pulse is very feeble, and her strength much impaired. She is at present taking 2 oz. of gin, and an equal quantity of wine daily. For the last five or six days she has been very drowsy, sleeping almost constantly although she can easily be aroused, and answers questions readily. Dec. 13th.—The cedema has not returned, but the drowsiness gradually increased until this morning, when she expired. Sectio Cadaveris.—Forty hours after death. Body greatly emaciated ; slight cedema of feet. Thorax.—The lungs, which looked quite healthy, presented to the touch some indurated points ; these, on being cut into were found to consist of clusters of minute grey granulations, generally about the size of small marbles. At the apex of the right lung was a small cretaceous concretion. The heart weighed 3 oz., and was quite healthy. Abdomen.—There were adhesions between the upper surface of the liver and the diaphragm. The liver weighed 3 lb. 16 oz. There was a little hepatic congestion, but the intervening tissue was pale; the whole presented the usual appearance of the waxy degeneration. The spleen weighed 2\ ounces, specific gravity 1054. It felt firm, and presented on section a waxy appearance. Throughout its substance were numerous enlarged semi-translucent, grey malpighian bodies, closely aggregated together. Their average diameter was about the 16th of an inch. The kidneys were enlarged, weighing each Of oz. On stripping off the capsule they presented a * Reported by Mr. Peter W. Wallace, Clinical Clerk. bright's disease. 761 mottled appearance from the presence of irregular vascularity, contrasting with the pale cortical substance. On section they presented a well-marked waxy appearance ; the cortical portion was of a pale yellowish colour ; the striae generally absent or indis- tinct. At some places there was a number of minute opaque yellowish spots. On opening the intestines, tubercular ulcers were found ; they occurred in the lower third of the small intestine, presented the usual characters, and occupied the whole circum- ference of the gut. The mesenteric glands were much enlarged, and were infiltrated with tubercle. Microscopic Examination.—The liver was found to contain much fatty matter, both free and contained in the hepatic cells. But the majority of the cells were pale and very indistinct (see Fig. 295, p. 214). Thin sections of the cortical substance of the kidneys presented a very transparent appearance, particularly the malpighian bodies, At some places, there were collections of fatty granules, but this did not occur very frequently, and only in isolated points. The enlarged malpighian bodies in the spleen contained a translucent matter, closely resembling colloid, and which presented the blue reaction of cellulose, on the application of iodine and sulphuric acid. Commentary.—This case presented all the symptoms of Bright's dis- ease, in a young girl who had been in a state of ill health for three years, in consequence of an attack of scarlatina. On dissection after death, the kidneys, liver, and spleen were found to have undergone that chronic con- dition now known as waxy, and which is very commonly associated, as in this case, with tubercle. The nature of this morbid alteration I shall speak of subsequently. Case CLXXV*—Albuminuria coming on during the progress of Phthisis Pulmonalis terminating fatally—Extensive Deposition of Tubercle—Waxy Kidney, Liver, and Spleen. History.—William Sibbald, set. 31, clerk—admitted September 7th, 1852. States, that six months ago, after exposure to cold and wet, he was seized with rigors, pain in the shoulders, sore throat, and hard dry cough. Has not enjoyed good health in many years past, having been very liable to catch cold on the slightest exposure, followed by slight cough, which was sometimes attended with expectoration, and pain in the side. During the last six months, the above symptoms have become much aggravated, and, for some time back, he has suffered from dyspnoea, occasional night sweats, frequent nausea, and loss of appetite. Symptoms ox Admission.—On admission, there is slight flattening of the chest beneath both clavicles. On percussion, there is comparative dulness below the right clavicle, together with a cracked-pot sound ; chest elsewhere appears resonant. Below the right clavicle, very fine but distinct moist rales are heard, chiefly with inspiration; there is also loud-pealing vocal resonance, of a somewhat metallic character. Towards the base of the lung, on the same side, the respiratory murmurs are slightly exagger- ated, but otherwise normal. Below the left clavicle, also, there are fine moist rales, but less marked' than on the right; the breathing is harsh, and the expiration pro- longed, though not to the same extent as on the right. Vocal resonance slightly in- creased. There is also considerable muco-purulent expectoration, but no appearance of blood. Pulse weak, 90. Tongue furred; appetite impaired; frequent nausea; * Reported by Mr. Wm. M. Calder, Clinical Clerk. 762 DISEASES OF THE GENITO-URINARY SYSTEM. bowels rather costive. Urine normal, but he has frequent calls to micturition, oblig- ing him to rise frequently during the night. Other functions appear normal. To use the opiate linctus, when the cough is troublesome^ To have a dessert-spoonful of cod- liver oil three times a day, and full diet. 3 iv of wine daily. Progress of the Case.—October 1st.—He has been taking the linctus, and also the oil, which, however, he has been occasionally obliged to vomit, owing to the nausea and disagreeable eructations which it produces. With the exception of some increase of harshness posteriorly, the respiratory sounds are unchanged. Oct. 21st.—His cough has been more troublesome for some days back, for which he had a squill mixture and a blister applied to the chest, on the 17th. His appetite is bad, and the bowels costive. Omit the mixture. Oct. 20th.—His appetite is now improved; he complains of some pain in the throat; bowels rather costive ; takes the cod-liver oil without difficulty. December 16th.—Since last report has been alternately better and worse, in proportion to the quantity of food and cod-liver oil his stomach has been able to retain. The dis- ease, however, has steadily made progress. The report to day is—Cough still continues hard and frequent. Loud gurgling rales are heard under both clavicles, but dry throughout the rest of the chest, with prolonged expiration. Vocal resonance and dulness on percussion same as before. The appetite is very bad; bowels have been rather loose during the last three days. Urine, of specific gravity 1012, of a dark amber colour, slightly albuminous. B Tinct. Colomb. 3 iss ; Liquoris Potass. 3 ss"; Syrup! Aurantii 3 j.; Infus. Gentianw Comp. § ix. M. An ounce to be taken three times a day. January 1st, 1853.—Continues much in the same state; sleeps ill at night, and is frequently troubled with cold perspiration. Cough is very severe, with copious mucopurulent expectoration of a nummular character. Micturition frequent; urine strongly coagulable by heat, and nitric- acid. OZdema of feet and legs, with puffiness of the face. Jan. 12th.—Feels very weak, and seldom leaves his bed; loud gurgling is heard beneath both clavicles; the voice is very husky, and there is some ulceration at the back of the pharynx. Appetite still very bad, and bowels costive. Takes a tablespoonful of cod-liver oil three times a-day. To have six ounces of wine daily, and a Morphia draught at night. Jan. 20th.—Is getting gradually weaker and more emaciated. Pulse 114, of moderate strength. He has no pain in the loins, but micturition is frequent; urine of a dark amber colour, specific gravity 1012, very coagulable on the application of heat and nitric acid. Jan. 26th.—After last report he continued gradually getting weaker and more emaciated. He could take no food, except a little chicken soup, and died to-day at 2 p.m. Sectio Cadaveris.—Forty-six hours after death. Body emaciated in the extreme ; very slight dropsy of feet. Thorax.—Both lungs very firmly adherent throughout, with thickening of pleune to \ inch at upper and back parts. On incising the lungs they were found, on both sides, to present, in their upper portions, cavities containing a little pus, with thick flocculent membranes. These cavities were nowhere larger than f inch diameter, and invariably surrounded by much indurated and atrophied tissue, which, in the upper lobes, almost entirely occupied the place of normal lung. In the lower and middle parts of the lung, there were many miliary tubercles quite semi-transparent, "but of nearly cartilaginous hardness. No calcareous masses were observed. In the upper lobe of the left lung was a cavity near the surface, about an inch in diameter, filled with air, and lined by a smooth membrane. Several others, smaller, but of the same character, were discovered in other parts of the lung. In the thick - ■ ened pleurae there was found, at several points, an atheromatous debris, enclosed BRIGHT'S DISEASE. 763 between the layers, having an opaque yellowish colour, and consisting of minute fatty granules. Bronchial glands were large and dark-coloured, and contained some mili- ary tubercles. Abdomen.—Liver rather large, weighed 5\ lbs., very firm and dense, presented the well-marked " waxy character," but without pallor; hepatic veins well-con- gested. At one of the thin edges the organ was deformed by the turning inwards of the edge at an acute angle. Spleen very firm and waxy in character; the mal- pighian bodies large and solid, but not easily distinguished from the pulp. Kidneys also very firm and dense, with partial atrophy of the cortical substance, presenting a sbVht deoree of the waxy degeneration ; surface irregular and dimpled; cortical substance, however, exhibited its natural vascularity at most points; malpighian tufts not well injected; no granulations. Intestinal canal presented thickly scat- tered tubercles, and tubercular ulcers throughout ileum, and less numerous ulcers in colon. The ulcers were not more numerous near the ileo-colic valve than for some feet above it. The vermiform appendix was impacted with fcecal matter, and pre- sented a very extensive ulceration of its mucous membrane, leaving only about half an inch at the upper end quite intact. Numerous mesenteric glands were converted into calcareous masses from the size of a pea to that of a bean; others were large and pulpy, and contained tubercular matter. The pancreas was rather hard, but other- wise normal. Commentary.—The albuminuria and waxy degeneration of the kid- neys were observed, in this case, to come on in the ward, as a sequela of phthisis pulmonalis. Drs. Christison and Peacock have pointed out how frequently Bright's disease is a complication of phthisis, and I have not only confirmed that observation, but observed that this is, in most cases, connected with the waxy degeneration of the renal organs. The present was one of these cases of phthisis, in which derangement of the alimentary canal prevented all possibility of nourishment. The waxy transformation of the kidneys, liver, and spleen, though it had not ad- vanced so far as it did in the last case, was sufficient, when added to the more extensive tubercular disease that existed, to prove fatal. Case CLXXVI.*—Albuminuria, with Phthisis Pulmonalis, terminating fatally- Extensive Deposition of Tubercle and Colliquative Diarrhoea—Atrophied Fatty Kidney—Ulcerated Intestines. History.—John Montgomery, aet. 60, weaver—admitted November 19th, 1852. States that for several years past he has been exposed to great privations, and that he has been frequently troubled with bowel complaint during that time. The attacks have sometimes been severe, and of long duration, but have generally lasted for a few days only. About a month before admission, the diarrhoea became much aggravated, there having been sometimes as many as twelve stools in twenty-four hours. This has continued more or less since that time, reducing him greatly in flesh and strength. As far as he has observed, he has never passed blood by stool. He has also had a short dry cough, but only for a few weeks past, and unaccom- panied with expectoration or dyspneea. He was brought into the hospital in a state of great weakness and exhaustion, having fallen down in the street, supposed to be in a state of intoxication. He states that he has not taken any spirits for some days * Reported by Mr. W. M. Calder, Clinical Clerk. 764 DISEASES OF THE GENITO-URINARY SYSTEM. past, although he has been much addicted to intemperance during the greater part of his life. Symptoms on Admission.—On admission, the tongue is very dry, but not furred; but there are some sordes on the teeth and gums. He experiences difficulty in degluti- tion, as if there was some obstruction about upper part of sternum; appetite bad; troublesome thirst; no sickness or vomiting; no pain in epigastrium, but frequent griping pains in abdomen. Bowels are very loose ; much straining and great tenes- mus when at stool; evacuations of an almost watery consistence and reddish-brown colour. They present no appearance of blood, but contain a few shreds of mucus. Occasionally he passes nothing but a small quantity of frothy slime : no haemorrhoids. On physical examination of the abdomen, the parietes are tense and retracted. The liver is slightly enlarged, the dulness measuring five inches from above downwards. Chest appears contracted, and does not expand freely. There is no comparative dulness on percussion. The respiration is feeble, and the expiration prolonged; under the right clavicle it is of a somewhat tubular character. Vocal resonance is also increased over the same part. At the lower part of right side anteriorly there is a fine friction sound. Sputum in very small quantity; muco-purulent, un- tinged with blood. Pulse 124, small and feeble; heart sounds normal; urinesp.gr. 1012, becomes slightly clouded with heat and nitric acid, but no distinct coagulum is formed; other functions normal. R> Sol. Mur. Morph. 3 ij; Tinct. Catechu Z vj; Mist. Cretce, § vj. M. Sumat § j tertid qudque hord. To have 6 oz. of wine and steak diet. Progress of the Case.—November 20th.—Wandered a good deal during the night; is exceedingly weak to-day, but the diarrhoea is less severe. Nov. 22d.— Complains more of cough and pain in right side, striking across the chest to the left; no dulness on percussion; still friction on right side with fine moist rales; marked increase of vocal resonance ; urine diminished in quantity; of natural colour, with slight flocculent precipitate on the application of heat and nitric acid. Diarrhoea stopped; pulsi 112, small and weak. Nov. 24th.—Was much weaker yesterday, and evidently sinking; too weak for examination of the chest; bowels were once opened; no urine voided since last report. Died this morning- at four oclock, comatose. Sectio Cadaveris.—Fifty-six hours after death. Body somewhat emaciated; very little subcutaneous fat; muscles well nourished. Thorax.—Heart normal; adhesions of both pleurae over limited space of upper lobes. Both lungs contained many scattered groups of tubercle, chiefly miliary; some few of them softened, and with small dry excavations at the apices; the pulmonary tissue around the tubercles mostly indurated and dark coloured from carbonaceous infiltration ; the bronchial glands dark and enlarged. Abdomen.—Stomach and jejunum and upper two-thirds of ileum normal. In lower third several scattered ulcers, not exceeding eight or twelve in number, from one-quarter to three-quarters of an inch in diameter; some of them slightly con- gested at edges; their characters in all respects those of tubercular ulcers. Colon contracted at lower part. In the ascending portion, there are four or five small tubercular ulcers; the largest half an inch in diameter, edges pale and slate coloured, the floor somewhat indurated. Spleen pale, peritoneal capsule thickened, the organ rather small, no distinct morbid appearances. Liver slightly enlarged, presenting very distinctly, and in a considerable degree, the fatty degeneration. Kidneys unusually small (dimension of right three and a half inches long, one and three- quarter inches broad, three-quarters of an inch thick; left kidney of nearly the same size, weight not ascertained); capsule easily stripped off; surface slightly BRIGHT'S DISEASE. 765 uneven, not distinctly tuberculated; venous vascularity of surface considerable but irreoular; on section, cortical substance much diminished (average three-eiobths of an inch in diameter from base of pyramids); limiting line of pyramids tolerably distinct; faint appearance of opaque granulations. On examination with a lens, many very mi- nute cysts were discovered in cortical substance; most of them required a power of half an inch focal distance to bring *hem into view. A similar power, or even the naked eye, distinguished easily a number of opaque light gamboge yellow points in the corti- cal substance; the largest was about one-fiftieth of an inch in diameter, accurately limited, and yielding, on being punctured, a fluid of the same colour. In the cortical substance there were also some minute hemorrhagic petechia?, having the usual appear- ance of extravasation. Microscopic Examination.—With high magnifying powers, the tubuli uriniferi were seen in some places to be of normal character, with the exception of a very few granules in the epithelium; on the contrary, in others, the tubes were crowded with fatty granules. The epithelium generally was normal in form and appearance in the tubes which had fewest granules. In many places the cortical substance of the kidney was studded with minute cysts, constituting the third form which they present (see p. 747.) In the fluid squeezed from the yellow points, in the cortical substance, there was an immense number of fatty granules, partly loose, partly agglomerated into amorphous collections, partly composing distinct rounded granular masses up to the one-nine- tieth of an inch in diameter, and partly contained in cells of a very fine delicate trans- parent character, representing much of the appearance of a tesselated epithelium. The cells of this epithelium were more transparent, and generally one-third smaller than those usually found in the renal tubules. Commentary.—In this, as in the two previous cases, the renal disease was associated with phthisis, but was more chronic, further advanced, and exhibited the ultimate effects of the fatty rather than of the waxy dege- neration. The report states that the urine was not highly coagulable, presenting only a slight cloud on the addition of heat and nitric acid. The fluids of the body, however, seemed to have been discharged to a great extent by means of stool. Before death, the urine was suppressed, causing coma. In the three fatal cases now given, we have seen—1st, Extreme waxy degeneration of the kidneys in a child. 2d, Incipient waxy degeneration coming on in the ward in an adult. 3d, The last stage of the fatty de- generation, with atrophy. It would be easy to multiply cases, where, on dissection, all kinds of intermediate conditions of the kidneys had been observed ; but those now recorded, together with the six which recovered or were relieved, present the leading characters illustrative of the patho- logy, diagnosis, and treatment of Bright's disease. A few words on each of these topics may now be added with propriety. Pathology of Brighfs Disease. Many names have been proposed by various pathologists for the dis- ease called after Dr. Bright. Up to the present time, however, none of them has been sufficiently good to comprehend all those lesions which occasion renal dropsy, with persistent albuminuria. Hence we still retain the designation it has so appropriately borne, to express a disorder cha- 766 DISEASES OF THE GENITO-URINARY SYSTEM. racterized by more or less dropsy, caused by obstruction to the renal func- tions, and accompanied by the presence of albumen in the urine. The nature of the obstruction to the renal function differs under a great variety of circumstances, but such as occasion dropsy, with persis- tent albuminuria, it appears to me may now be classified under three heads—1st. Inflammation, acute or chronic ; I'd, Waxy degeneration; 3d, Fatty degeneration. 1. The Inflammatory Form.—This may be acute or chronic; the first is generally induced by all those causes which excite inflammation in other internal organs, and is ushered in by rigors and febrile symptoms, and accompanied by pains in the lumbar region, and the phenomena generally described as those peculiar to nephritis. (See Nephritis.) The chronic disease may follow the acute, may come on more slowly, as the result of the same causes, or proceed so imperceptibly from causes which have escaped observation, that the occurrence of dropsy, more or less extensive, may be the first s}rmptom which excites attention. Ou test- ing the urine chemically, it is found to be albuminous, and on examining the sediments microscopically, various kinds of casts with epithelial cells, blood corpuscles, different salts, and other morbid products, may be seen. These casts of the uriniferous tubes are finally molecular and fibrinous (exudative casts), or mingled with the fibrinous matter, there are epi- thelial cells and free nuclei of the tubes (desquamative casts). Other pro- ducts, which vary according to the period of the disorder and the tissues involved, may also be present, to which we shall allude under the head of diagnosis. On examining the kidneys of individuals who have laboured under this form of the disease, we find that in the acute stage they are more or less congested and tinged of various colours, from a bright red to a dusky brown. The surface is not unfrequeutly covered over with minute ecchymotic spots, dependent on the extravasation of blood into the tubes, iu their convoluted portions. The excessive congestion and extravasation of blood, by obstructing the tubes and interfering with the secreting function of the organ, form the chief source of danger in tliese cases. There may also be frequently observed a fibrinous exudation filling the tubes, in which are intermixed the epithelial cells, and here again the extent of the obstruction so occasioned is, sometimes without much congestion (Case CLX.), commensurate with the danger of the case. As the disease becomes more chronic, the intense uniform coloration diminishes, leaving irregular arborizations, which mottle the surface— the blood extravasated is absorbed—the exudation, if not dislodged and passed in fragments by the urine, gradually disintegrates, and may or may not undergo the purulent or fatty transformation. This, by long- continued pressure, causes permanent obstruction of the tubes and atro- phy of the renal structure, so that at last the organ becomes smaller and smaller, less and less able to perforin its functions, and ultimately causes death (Case CLXXYI). 2. Tlie Waxy Form.—This form of the disease is generally chronic, and for the most part accompanies scrofulous or tubercular complications. Dropsy, and a peculiarly cachectic and emaciated look, constitute its chief symptoms; and the urine, as the disease slowly progresses, becomes bright's disease. 767 more and more suppressed, death taking place by coma. The sediment is usually small, and presents pale casts of the tubes (waxy casts), with a few epithelial cells, unusually colourless and transparent. Not unfre- quently, however, at an early period, desquamative casts, with little fibrin, and composed of closely aggregated cells, of the tubes, may be seen. This form of the disease is so mixed up with the various other lesions which usually accompany it, as not to admit of any distinctive descrip- tion, referable to the mere renal disorder. On examining kidneys which have undergone the waxy degeneration, we generally find that they are more dense to the feel than natural, sometimes smaller, at others larger than usual, and of a colour resembling various shades of dirty bees' wax, or of a light fawn tint. On section the surface is smooth, and the edges more or less translucent; a circumstance dependent on the diminished vascularity which everywhere prevails, and a peculiar transparency whicii all the structures of the organs have under- gone. A thin slice, when magnified under a power of 250 diam. linear, exhibits the vessels of the malpighian bodies more transparent and re- fractive than usual (Fig. 445). The tubules are colourless, often destitute of epithelium, and of a pecular whiteness. Such cells as are discovered have their nuclei more or less atrophied, and closely resemble those seen in the liver, when similarly affected (see Fig. -95, p. 214). Indeed this change in the kidney is frequently associated with a similar transformation of the liver and spleen. The nature of this waxy degeneration of tissue is unknown, although probably it is some change in the chemical composition of the structure affected. (Cases CLXXIV. and CLXXV.) 3. The Fatty Form.-^-This, as we have seen, may be a result of the in- flammation, but it is not unfrequently produced independent of it. Here, Fig. 445. again, the progress of the disease is chronic, is not so frequently associated with scrofula and tubercle, but occurs rather in individuals, more advanced in life, suffering from cardiac and bronchitic disorders, or who are addicted to intemperance. It is also frequently associated with fatty degeneration of the heart and liver. Dropsy and persistent albuminuria are constant symptoms, and the sedi- ment is loaded with casts of the' tubes containing oil granules (fatty casts) and granule cells. On examining the kidneys of individuals who have died of this form of the disease, we observe the tubes more or less obstructed by fatty granules, which have gradually accumulated in the epithelial cells Qf the tubes. These separate, and even burst, liberating their contents, and in this way obstruct the tubes, and compress the secreting and Fig. 445. Waxy degeneration of a malpighian body, with a few granule cells.— (Wedt.) 300 diam. 768 DISEASES OF THE GENITO-URINARY SYSTEM. Fig. 446. surrounding textures (Fig. 446, a, and b). Gradually the vessels arc so compressed, that the or- gan affected looks bloodless, and though, on the whole, en- larged, is of a light fawn or dirty white colour. Tlie fi- brous texture is occasionally liypertrophied, causing con- tractions round the convoluted tubes, thus producing irre- gularities on the surface. Oc- casionally, also, large accumu- lations of the fatty granules take place, causing the tubes to burst, and presenting to the naked eye light fawn-coloured spots of granulations, more or less numerous, which are scattered over and through the cortical substance. It is easy to conceive how such accumulations of fat, and consequent pressure and obstruction, must at length so interfere with the kidneys, as to be incompatible with the performance of their functions (Case CLXXVI.) On scraping the surface of a fatty kidney, and adding a drop of water, we are enabled to see, under a magnifying power, fragments and cells such as are given Figs. 446, 447. They exhibit portions of uriniferous tubes loaded with free fat granules and epithelial cells, also containing similar fat granules. On making a thin section of a fatty kidney, we not unfrequently see the tubes in situ loaded with similar granules, and the fibrous tissue so increased and thickened between them, as to occasion a lesion identical in many respects with the so-called cirrhosis of the liver, to which an atrophied and granular kidney is strictly analogous. Sections of the cortical substance of such kidneys are represented Figs. 448, 44!). The above is a condensed description of what appear to me the three pathological forms of Bright's disease of the kidney. These lesions, although they are met with separately and distinct, may, however, be more or less conjoined. One part of the kidney may be congested or in- flamed, whilst another is fatty; or we may have the fatty and waxy conditions united together. It is only in this way that we can account for the various shades of alteration which the kidney may at different times present during the continuance of persistent albuminuria with dropsy. All these alterations, by interfering with the secreting functions Fig. 446. Structures in a fatty kidney, a and 6, Tubes filled with fatty granules, having in one of them the transparent basement membrane visible, c, Transverse sec- tion of similar tube, d, Fatty epithelium of the tubes, e, Amorphous fatty matter in the tubes. /, Crystals of uric acid in a tubule.—( Wedl.) 350 diam. Fig. 447. Portion of fatty tube, with fatty epithelial cells, scraped from the surface of a fatty kidney. BRIGHT'S DISEASE. 769 of the cells, more or less impede the excretory power of the kidneys, and if continued, ultimately tend to overload the blood with the effete Fig. 448. Fig- W9- elements which ought to be discharged with the urine. At the same time, by causing more or less congestion of the vessels, or by pressure on the malpighian bodies, and obstruction of the tubules, a serous effusion takes place, the albumen of which, passing into the urine, communicates to it that property of coagulability which constitutes its pathognomonic character. Diaynosis of Brighfs Disease. The diagnosis of Bright's disease of the kidney is dependent on three kinds of observation:—1st, Symptoms; 2d, Chemical—aud 3d, Micro- scopical examination of the urine. 1. Diagnostic Symptoms.—In. the acute forms, pains in the lumbar region, high-coloured urine, and other indications of nephritis, followed by dropsy; and in the more chronic forms, the occurrence of dropsy, frequently without the local renal symptoms, are the chief diagnostic symptoms. But these symptoms must always be very vague until, by a chemical examination of the urine, the presence of albumen is determined. 2. Chemical Examination of the Urine.—In testing the urine, you should be careful to employ both heat and nitric acid. Heat alone, frequently separates earthy salts, which to the eye may resemble a slight cloud of albumen—and nitric acid alone, frequently throws down a precipitate of uric acid, where urate of ammonia is in excess. But if the coagulum produced by heat also resist the action of nitric acid, we may be pretty sure that the urine contains albumen. Ihe mere ^Fig. 448. LongrtudTnal^tionofTfatty kidney, showing the tubes loaded with fattv granules. , . , . , , mh~-»f; Fig. 449. Transverse section to the former one, (*) malpighxau ™y--}tj«"*«- ,on.) 250 diam. , 49 770 DISEASES OF THE GENITO-URINARY SYSTEM. presence of albumen in the urine does not constitute Bright's disease. It may accompany cystitis, or hematuria—may follow the action of a blister affecting the kidneys, or result from mercurialism, errors in diet or confirmed dispepsia. In all such cases, however, it is temporary, and does not present the diagnostic character of persistence. 3. Microscopical Examination of the Urine.—The method I have found best, for determining the form and structure of the organic matters dis- charged in the urine, is to allow the fluid to repose for twelve hours then pour off the supernatant liquid, and put the turbid sediment into a test-tube. Allow this to repose for another twelve hours, when the concentrated precipitate containing the organic matters collects at the bottom, and can now easily be brought into the field of the microscope. Or some ounces of the urine may be put into a conical o-lass, like au ale glass, and the precipitate allowed to deposit itself, as recommended by Dr. Johnson. From thence it can easily be obtained by pouring off the supernatant fluid, or by removing the sediment with a pipette for microscopic examination. The objects so brought into view are vari- ous, comprising different salts, cells, fungi, aud casts of tubes (see pp. 88 to 93, and Figs. 75 to 84), the discrimination of which necessitates a knowledge of histology. The diagnostic elements, however,- in Bright's disease, may be considered to be the separated casts of the tubuli urini- feri. Tliese are of four kinds. 1. Exudative Casts.—Tliese casts consist ofthe coagulated exudation or fibrin, which, in the inflammatory form, is poured into the tubes, so as to present a mould of their inte- rior. They are analogous to similar casts which oc- cur in the minute bronchi, in all cases of pneumonia, and are recognised under the microscope by their uni- form molecular structure. They mostly occur in acute cases, are frequently associated with blood corpuscles, and not unfrequently with desquamative casts aud epi- thelial cells. Figs. 81 b, and 450. 2. Desquamative Casts.—These casts consist of masses of the epithelium lining the tubules, sometimes closely aggregated together side by side, at others agglutinated by means of the molecular exudation, formerly allu- ded to. They result from a separation of the lining cell membrane from the interior of the tube, in patches of greater or less extent, and may be associated in acute cases with exudations, and in chronic cases with the fatty or waxy transforma- tions next to be mentioned.—(See Fig. 81, a, p. 90, and 451.) 3. Fatty Casts.—These casts consist also of patches of epithelium, which, however, have previously under- gone the fatty transformation, by the accumulation of a greater or less number of fatty granules in their cells. Occasionally lig. 450. Exudative casts, with epithelial cell and mass of coagulated exudation, Fig. 451. Desquamative casts, with blood corpuscles, naked nuclei, and cells. 200 diam. Fig. 450. bright's disease. 771 the cells burst and fill the tubes with fatty granules, among which no epithelium can be distinguished.—(See Fig. 82, p. 90, and Fig. 44G.) At others the cells are less changed, the fatty accumulation a8 it were only commencing as in Fig. 452. are often associated with fragments of desquama- tive ones, with a few cells, more or less fatty, and frequently with the kind of cast to be noticed (Fig. 452). Waxy Casts. — These casts present an exceed- ingly diaphanous and struc- tureless substance, which, according to Dr. Johnson, is secreted by the basement membrane after the destruction of its epi- thelial cells. But may it not consist of the basement membrane itself which has undergone some chemical transformation, the nature of which has yet to be ascertained ? The waxy are frequently associated with the two kinds of casts last described, but especially with the fatty ones. (Figs. 452, 453.) Not unfrequently all stages of transformation may be seen in the same demonstration, between one tube containing epithelial cells, more or less fatty, and another, which being empty, presents the translu- cent or waxy appearance. (Figs. 44G, 453.) The exact signification of all these various kinds of casts has yet to be fully determined by clinical investigation. But it appears to me that the exudative casts indicate the most acute form of lesion—the desquamative a sub-acute, the fatty a chronic lesion, and the waxy a lesion destructive Fig. 452. Fig. 453. Fig. 454. Fig. 455. of the tubular textures. But as all these different changes may be going on in the kidney at the same moment, so we may find these various casts Fig. 452. Fatty casts with granule cell. Fig. 453. Waxy casts of various sizes. Fig. 454. Tyrozin masses in the urinary sediment of a man with atrophy of the liver.—(Frerichs.) Fig. 455. Leucin in a drop of the same urine, allowed to evaporate.—(Frerichs.) Fig. 456. Pure tyrozin from the same urinary sediment.—(Frerichs.) 200 diam 772 diseases of the genito-urinary system. mino-led with one another in various proportions, combined with other structural elements. The predominance in number of one kind of cast over another, will, however, serve to indicate to the pathologist, with tolerable correctness, the nature of the change which is going on in the renal organs. They undergo great variety in size, often being much smaller than any kind of uriniferous tubes, a circumstance indicating con- siderable contraction of their calibres. In addition to the elements now and previously described (p. 88), as occasionally met with in urine, there .should not be overlooked two pro- ducts, viz., Tyrozin and Leucin. According to Frerichs* they occur in that fluid in certain diseases of the liver, and especially in atrophy of that organ. Hitherto they have not been much studied, having commonly been mistaken for fatty, starchy, or mineral bodies. But their clinical history, in relation to hepatic and renal disease, having been commenced by so able an investigator as Frerichs, justifies my placing before you the forms which they assume (Figs. 454, 455, 450). Treatment of Briyhfs Disease. The acute forms of Bright's disease should be combated externally by cupping over the loins, and warm fomentations—internally by diaphore- tics, and later by diuretics. I have seldom found it necessary to have recourse to general bleeding, and then only as a palliative to relieve pul- monary congestion. The chronic forms, in addition to appropriate reme- dies, require attention to diet and exercise. A non-fatty diet is evidently indicated in the fatty degeneration of the kidney. Exercise, change of air, and sea voyages are also beneficial. Care also should be taken that the surface be kept warm, and cutaneous transpiration favoured. The complications and sequelae must be managed according to circumstances, and the general indications special to individual diseases. In this place I shall only allude to the effects of two classes of remedies, namely, dia- phoretics and diuretics. Diaphoretics.—The connection which necessarily exists between the kidneys and the skin as excretory organs, is well known. In health, impeded function in the one is, to a certain extent, compensated for by increased function in the other; aud diseases in the skin, especially scarlatina, or other causes which tend to check cutaneous transpiration, are peculiarly liable to induce renal disorders. Such being the case, it seems highly judicious, in our efforts at cure, to excite, by all means in our power, the functions of the skin in cases of Bright's disease of the kidney; and with this view, Dover's power, keeping the surface warm, hot air baths, warm water baths, and a warm climate, are among the means which have been proved to be most useful. Should, however, as frequently happens, tliese remedies be of no avail, and the dropsical symptoms increase, then we must have recourse to the next class of remedies. Diuretics.—It has been thought that in the acute inflammatory cases, where the kidney is more or less congested and loaded with exudation, * Atlas zur Klinik der Leberkrankheiten. Taf. iii. bright's disease. 773 diuretics, by stimulating the organs and exciting them to increased action, would add to, rather than diminish, the excitement. But when it is considered that the dropsy is induced by obstruction in the secreting tubes, which presents a mechanical obstacle to the outward flow of fluid, it seems probable that, by increasing that flow, the accumulations pro- ducing the obstruction may be washed out. Besides, by augmenting the amouut of fluid from the malpighian bodies through such tubes as still remain pervious, a compensation is frequently to be found for the diminished flow which takes place in the obstructed ones. Certain it is, that I have given diuretics in all stages of the disease with the best effects, as soon as it became manifest that the remedies formerly alluded to were of no avail. Nor have I ever seen any bad results from the practice. On this point I fully coincide with the observations made by Dr. Christison, in a most important lecture he has published on this subject.* Besides, in acute cases with diminution of urine and rapid dropsy, no other course is left open to us, as diaphoretics under such circumstances are seldom effectual. The whole class of diuretics may be tried in Bright's disease, in com- bination with other remedies; but the most valuable, so far as I have been able to determine, is the bitartrate of potass, which I have fre- quently seen to produce a most powerful effect, when every other had failed. The spongio-piline, saturated in a strong solution of infusion of digitalis applied^ externally, and digitaline administered internally in minute doses, both recommended by Dr. Christison, are useful. But here again I have seen the cream of tartar operate after both these had failed. Sometimes also, after it has been given without effect at an early period of the disease, it has succeeded remarkably well at a later one. Of this, the case of Herdmann (Case CLXX.) is a remarkable example, which warrants our having recourse to the remedy again and again after certain intervals, should it not act. It is very possible that the casts which obstruct the tubes may be more loosened at one time than at another, and that a powerful diuretic may, in consequence, have a greater effect in washing out the obstruction and restoring the func- tion of the organs. At all events, I have rarely seen other diuretics succeed, when repeated attempts by means of the bitartrate of potass had failed. * Monthly Journal of Medical Science. June, 1851. SECTIOX IX. DISEASES OF THE INTEGUMENTARY SYSTEM. Notwithstanding the great advances which have been made in our knowledge of diseases of the skin, it cannot be denied that very inexact notions prevail regarding this cla^s of disorders. I do not here allude to the eruptive fevers which, from their frequency aud danger, neces- sarily demand the attention of every professional man, so much as to the lighter and more chronic disorders to which the skin is subject. Ignorance, however, here, although it seldom occasions daDger to human life, produces great inconveniences, exasperates the j>rogress of other maladies, renders life miserable, and frequently destroys those social relations and ties which constitute happiness. A lady was seized with an eruption on the genital organs, which ren- dered the slightest contact unbearable. Her husband suspected that she laboured under syphilis, and accused her of infidelity. A medical man, who was consulted, pronounced her disease venereal—a separation took place between the parties; the lady always maintaining her innocence, but anxious to escape the unfounded suspicions and ill-treatment of her husband. Mercury and an anti-venereal treatment was continued for some time, but the disease increased in intensity. At length another physician, skilled in the diagnosis of skin diseases, was consulted, who pronounced it to be an eczema rubrum, quite unconnected with syphilis; and on the application of appropriate remedies, a speedy cure confirmed his diagnosis. A lady in the country sent one of her servants into town, to obtain advice for an eruption which had broken out on her body, and which she was afraid might be communicated to her children. The practitioner consulted was much puzzled, and asked me to see the patient, who, ac- cording to him, was labouring under a rare form of skin disease. I found a herpes zoster extending round one half the trunk, and told him it would disappear spontaneously in a few days, which it did. Nothing is more common in practice than to meet with cases among servants, where prurigo has been mistaken for itch, causing great alarm to the family, and much injury to the servant. The various diseases of CLASSIFICATION OF SKIN DISEASES. 775 the scalp also are continually confounded together. Indeed, examples might easily be accumulated, proving the inconvenience which an unac- quaintance with skin diseases may occasion both to patient and prac- titioner. A young medical man is especially liable to be consulted in cases of trifling skin eruptions ; and nothing is so likely to establish his credit, as the ready diagnosis and skilful management of such disorders especially when (as frequently happens) they have been of long standing' and baffled the efforts of older practitioners. Conceiving, then, that this subject deserves more careful consideration than it usually meets with in a clinical course, I propose directing your attention to the classification, general diagnosis, and treatment of these disorders, as an introduction to the study of individual cases in the wards. CLASSIFICATION OF SKIN DISEASES. Skin diseases are so various in appearance and in their nature, that many experienced practitioners have endeavoured to facilitate their study by arranging them in groups. There are three kinds of classification which deserve notice:—1st, The artificial classification of Willan; 2d, The natural arrangement of Alibert; and 3d, A pathological arrangement founded on the supposed morbid lesions. Of these, the best, and the one which most facilitates the study of cutaneous diseases, is certainly that of Willan. No doubt it has its faults and inconveniences, but many of them have been removed by Biett. This classification is founded upon the character presented by the erup- tion, which, when once known, determines the disease. It is an old saying, that it is much easier to play the critic and to find fault, than to construct something better. This remark may be well applied to those who have ventured to set aside the principles on which Willan's arrange- ment is founded, and to bring forward others. The natural classification of Alibert can never be followed by the student, and presupposes a con- siderable knowledge of the subject. The pathological arrangement again is decidedly faulty. The morbid anatomy and pathology of many skin diseases are unknown; how, then, can we found a classifica- tion upon them ? Indeed, the very foundation on which such clas- sifications are based, is continually undergoing changes as pathology advances. On the whole, therefore, the arrangement best suited to the student and for practical purposes is that of Willan and Bateman, with the modifications subsequently to be noticed. Definitions.—Before we can proceed to refer any particular disease to its appropriate class, we must be acquainted with the characteristic appearances which distinguish the different orders. They are as fol- lows :— 1. Exanthema (Rash).—Variously formed, irregular-sized, superficial red patches, which disappear under pressure, and terminate in desqua- mation. 2. Vesicula (Vesicle.)—A small, acuminated, or orbicular elevation of 7(6 DISEASES OF THE INTEGUMENTARY SYSTEM. the cuticle, containing lymph, which, at first clear and colourless, becomes often opaque or pearl-coloured. It is succeeded either by scurf or a laminated scab. 3. Bulla (Bleb).—This differs from the vesicle in its size, a large por- tion of the cuticle being detached from the skin by the interposition of a watery fluid, usually transparent. 4. Pustula (Pustule).—A circumscribed elevation of the cuticle, con- taining pus. It is succeeded by an elevated scab, which may or may not be followed by a cicatrix. 5. Papula (Pimple).—A small, solid, acuminated elevation of the cuticle, in appearance an enlarged papilla of the skin, commonly termi- nating in scurf, and sometimes, though seldom, in slight ulceration of its summit. 6. Squama (Scale).—A lamina of morbid cuticle, hard, thickened, whitish, and opaque, covering either small papular red elevations, or larger deep-red, dry surfaces. 7. Tubercula (Tubercle.)—A small hard, indolent, primary elevation of the skin, sometimes suppurating partially, sometimes ulcerating at its summit. 8. Macula (Spot).—A permanent discoloration of some portion ofthe skin, often with a change of its structure. These stains may be white or dark-coloured. The different appearances thus described characterize the eight orders of Willan and Bateman, viz., 1. Exanthemata; 2. Vesiculae; 3. Bullae; 4. Pustulae ; 5. Papulae ; 6. Squamae; 7. Tuberculae ; 8. Maculae. The principal modifications made by Biett consist in removing from these groups certain diseases which have no affinity with them, and forming them into extra orders of themselves. Thus he makes altogether fifteen orders, as seen in the following classification given by his pupils Schedel and Cazenave, which als6 indicate the subdivisions into which each order is divided :— Okder I.—Exanthemata. Ecthyma. Order VIII.—Macula. Rubeola. Impetigo. Lentigo. Scarlatina. Acne. Ephelides. Erythema. Mentagra. Nffivi and Vitiligo. Erysipelas. Porrigo. Order IX.—Purpura. Roseola. Equinia. X.—Pellagra. Urticaria. Order V.—Papula. XL—Radesyge. Order II.— Vcsiculce. Lichen. XII.—Lepra Astra- Eczema. Prurigo. chanica. Herpes. Order VI.—Squamce. XIII.—The Aleppo Scabies. Psoriasis. Evil, or Malum Miliaria. Pityriasis. Alepporum. Varicella. Ichthyosis. XIV.—Elephantiasis Order III.—Bulla;. Order VII.—Tubercuhe. Arabica. Pemphigus. Lepra Tuberculosa. XV.—Syphilids or Rupia. Lupus. Syphilitic Erup- Okder IV.—Pustula;. Molluscum. tions. Variola. Frambcesia. Vaccinia. Cheloidea. Even this classification is very complicated, and appears to me to admit of still further modifications, which will render the subject more CLASSIFICATION OF SKIN DISEASES. 777 simple and practical at the bed-side. I shall point out to you, in the first instance, the reasons which have induced me to make these modifi- cations, and then give, in a tabular form, the classification which we shall in future adopt. In the orders of Exanthemata and Pustula?, we find several diseases which are characterised by excessive fever, so that they have long been spoken of under the term of eruptive fevers, as well as under that of febrile eruptions. With them, in short, fever is the characteristic, and they are influenced by laws of a peculiar character, altogether different from those which regulate the production of other cutaneous affections. I propose, then, to remove these disorders from the category of skin diseases altogether, and to leave only three in the first order, namely, erythema, roseola, and urticaria. I am aware that, strictly speaking, these may be accompanied by slight fever, which may also occur in several other skin diseases. But 1 do not pretend to form a classifica- tion which is perfect, or even pathological, but one which some experi- ence in the teaching of these diseases has convinced me is useful and practical for the student. In the order Vcsiculce we find five diseases. I propose cutting out miliaria, as being very unimportant, and a trifling sequela of fevers. Varicella I believe to be a modified small-pox, and I omit it for the same reasons as I do variola. Scabies, on the other hand, though dependent upon the presence of an insect, the Acarus Scabiei, presents such distinct characters, as to warrant its retention. I propose expunging the order Bullae altogether. We find in it two diseases. The first of tliese, pemphigus or pompholyx, is a vesicular disease in every point, appearing sometimes in successive crops, and forming a laminated scab. Rupia, on the other hand, is evidently a pus- tular disease, forming a prominent scab, producing ulceration, and leaving a cicatrix. I shall therefore add pemphigus to the order vcsiculae, and rupia to that of the pustulas. From the Pustula, for the reasons formerly stated, I expunge variola, vaccinia, and equinia. Mentagra, so far as I have been able to study it in this country, has always consisted of eczema or impetigo on the chin of the male. In syphilitic cases it is more or less tubercular, aud it has been described also as consisting of a vegetable parasite. Although I have never seen the appearance figured by Cazenave (Plate 16), I can understand that such a mentagra might really consist of vegetable fungi. At all events, mentagra is not a special pustular disease. Porrigo means any eruption on the head, whether vesicular, pustular, or squamous. Favus, to which it has long been applied, is undoubtedly a vegetable parasite, and ought, with others of a like nature, to constitute a distinct class. Moreover, it is neither vesicular nor pustular. Hence the class of pustulse will with us contain only impetigo, ecthyma, acne, and rupia. The orders Papula; and Squama remain the same. The strophulus of many English writers is certainly only lichen occurring in the child; and what has been called lepra, as distinguished from psoriasis, is the latter disease presenting an annular form. From the class TubcrcuU I cut out frambcesia, as being a disease unknown in this country, together with cheloidea, which, as I understand it, means either cancer or tubercle of the skin. 778 DISEASES OF THE INTEGUMENTARY SYSTEM. As regards the order Macule, I place purpura in it, as did Willan, because, although sometimes it may depend on constitutional causes of an obscure nature, and at others be allied to scurvy, it still, in an arbitrary classification of this kind, constitutes an undoubted spot or macula. All the other orders of Biett I shall take the liberty of expunging— pellagra, lepra Astrachanica, and malum Alepporum, are unknown in this country. I agree with Hebra, in thinking that Radesyge is only a modi- fied form of lupus. The elephantiasis Arabica is an hypertrophy of the areolar tissue or chorion, and belongs more to the subject of fibrous growths than that of skin diseases. Syphilitic diseases I do not regard as a distinct order, but as any of the ordinary skin affect-ions, more or less modified by a peculiar state of constitution. AVhilst I have cut out many diseases from the eight orders originally established by Willan, and subsequently modified by Biett, I find it necessary to add two orders, which the advance of pathology and histo- logy shows ought to be considered apart. I allude to those which depend on the presence of parasitic animals and plants, and which may be called respectively Dermatozoa and Dermatophyta. It has now been shown by M. Bourguignon, that scabies is dependent on the presence of an acarus, but that the insect is only indirectly the cause of the eruption. Hence I put acarus among the dermatozoa, although it certainly forms, when present, a constituent of itch. Among the dermatophytes will be placed favus and mentagra,—both removed from the class pustulae. Other diseases, such as plica Polonica, and pityriasis, have been con- sidered as parasitic, but the former is unknown in this country, and the latter, when it presents epiphytes among the scales, constitutes a form of favus. The classification, then, we shall in future adopt is as follows:— Order I.—Exanthemata. Order IV.— Papulae. Xrevi. Erythema. Lichen. Purpura. Roseola. Prurigo. Order VIII.—Dermatozoa. Urticaria. Order V.—Squamce. Entozoon folliculo- Order II.— Vesicula. Psoriasis. rum. Eczema. Pityriasis. Acarus. Herpes. Ichthyosis. Pediculus. Scabies. Order VI.—Tuberculce. Order IX.—Dermatophya?. Pemphigus. Lepra Tuberculosa. Achorion Schonleini Order III.—Pustulce. Lupus. (Favus). Impetigo. Molluscum. Achorion Grubii Ecthyma. Order VII.—Macula?. (Mentagra)." Acne. Lentigo. Rupia. Ephelides. * It has been objected to the words porrigophyte and metagraphyte, introduced by Gruby, that they are unclassical; and as the celebrated botanist Link, after carefully examining these vegetations, has described the former as a new genus, under the head of Achorion (from achor, the old term given to a favus crust by Willan), I have thought it best to adopt that term. To mark the variety in favus, he has ad led the name of its discoverer, Schonlein; and I have ventured, at all events provisionally, to distinguish the one described as existing in metagrn, by adding to it also, that of its discoverer, Gruby. DIAGNOSIS OF SKIN DISEASES. 779 DIAGNOSIS OF SKIN DISEASES. The recognition of skin diseases, and the separating of one class from another, is of essential importance to a proper treatment. On this point I fully agree with a writer, who says, " The treatment of a great many cutaneous diseases is but of secondary importance, compared with their differential diagnosis. Many of them will get well without any treat- ment, provided they are allowed to pursue their natural course ; and, on the contrary, a mild and simple eruption by being mistaken, from a simi- larity of external appearances, for one of a severe or rebellious character, and treated accordingly, may be aggravated and prolonged for an indefi- nite period." (Burgess.) This differential diagnosis, however, to the inexperienced, is a matter of great difficulty, because not only is con- siderable tact generally necessary to discover the original element each disease presents, such as a rash, vesicle, pustule, scale, and so on; but often this is impossible. Under such circumstances the diagnosis is fre- quently derived from the scab, or other appearances presented, such as the cicatrix. The whole subject has been rendered very confused and complicated by systematic writers, who have often given different names to the same disease, or unnecessarily divided them into forms and vari- eties. I advise you not to pay any attention to these forms and varieties for the present, and to confine your efforts only to the detection of the diseases enumerated in the table under each order; and with a view of facilitating your endeavours, the following short diagnostic characters and definitions should be attended to. I. Exanthemata. 1. Erythema.—A slight continuous redness of the skin in patches of various shapes and sizes. _ 2. Roseola.—Circumscribed rose-red patches, of a circular, serrated, or annular form. 3. Urticaria.—Prominent red patches of irregular form, the centre of which is often paler than the surrounding skin. II. VESICULJ3. Eczema.—-Very minute vesicles in patches, presenting a shining ap- pearance, yielding a fluid which dries into a laminated or furfuraceous crust. The skin is of a bright red colour. Eerpes.—Clusters of vesicles, varying in size from a millet seed to that of a pea, surrounded by a bright red areola. They yield a fluid which dries into a thin incrustation, that drops off between the eighth and fifteenth day. , , A Scabies.—Isolated vesicles of an acuminated form, commonly seated between the fingers and flexor surfaces of the arms and abdomen—never on the face. 1 , , Pemphiqus.—Large vesicles or blebs (bullae), surrounded by an ery- thematous circle, the fluid of which forms, when dry, a laminated crust When chronic, they appear in successive crops, and the disease is called pompholyx. 780 DISEASES OF THE INTEGUMENTARY SYSTEM. III. PrSTULiE. Impetigo.—Small pustules, commonly occurring in groups, and form- ing an elevated crust. Ecthyma.—Large isolated pustules, depressed or umbilicated in the centre, and leaving a cicatrix. Acne.—Isolated pustules situated on a hardened base, which form and disappear slowly. They only occur on the face and shoulders. Rupia.—Large pustules, followed by thick prominent crusts, and producing ulcerations of various depths. IV. Papula. Lichen.—Minute papulae occurring in clusters or patches. Prurigo.—Larger and isolated papulae generally seated on the extensor surfaces of the body. V. Squama. Psoriasis.—Whitish laminated scales slightly raised above the red- dened surface of the skin. Lepra is psoriasis occurring in rings. Pityriasis.—Very minute scales, like those of bran, seated on a red- dened surface. Ichthyosis.—Induration of the epidermis, and formation of square or angular prominences, not seated on a reddened surface. VI. TlJBERCULiE. Lepra Tuberculosa.— (Elephantiasis ofthe Greeks.)—Tubercles vary- ing in size, preceded by erythema and increased sensibility of the skin, and followed by ulceration of their summits. Lupus.—Induration or tubercular swelling of the skin, which may or may not ulcerate. In the former case, ulceration may occur at the sum- mit or at the base of the tubercles, and frequently extends in the form of a circle more or less complete. Molluscum.—Pedunculated, globular, or flattish tubercles, accom- panied by no erythema or increased sensibility, occurring in groups. They are filled with atheromatous matter. VII. Maculjs. Lentigo or Freckle.—Brownish-yellow or fawn-coloured spots on the face, bosom, hands, or neck. Ephelis.—Large patches of a yellowish-brown colour, accompanied by slight desquamation of the cuticle. JVovvi or Moles.—Spots of various colours and forms, sometimes ele« vated above the skin. They are congenital. Purpura.—Red or claret-coloured spots or patches, which do not disappear under pressure of the finger. VIII. Dermatozoa. These minute animals require a lens of considerable power to ascertain DIAGNOSIS OF SKIN DISEASES. 781 their characters, which need not be particularised here, as they will be subsequently described and figured. (See p. 789, et seq.) IX. Dermatophyte. These minute plants require a high magnifying power to distinguish them with exactitude. But they communicate peculiar characters to certain cutaneous diseases as follows :— Favus.—Bright yellow, unbilicated crusts, surrounding individual hairs, which agglomerate together to form an elevated friable crust, of a peculiar musty or mousy smell. Mentagra.—Grayish or yellowish dry crusts, of irregular form, origi- nating iu the hair follicles of the beard. In forming your diagnosis, therefore, you will be guided principally by three characters:—1st, The primitive and essential appearance—that is, whether a rash, vesicle, pustule, and so on. 2d, The crust,—whether laminated or prominent, composed of epidermis only, etc. 3d, Ulcer- ation,—whether present or absent; and if so, the kind of cicatrix. These and other characters I shall point out at the bed-side, so as to familiarise you with their appearances. You will remember that the classification formed by Willan is wholly artificial. It is like the Linnaean classification of plants. The difficulty for the learner is to recognise the essential character, the more so as many diseases pass through various stages before this is formed. Thus herpes presents, 1st, a rash; 2cl, papules ; 3d, vesicles ; 4th, pustules; yet the disease is considered vesicular. Ecthyma passes through the same stages, yet it is considered pustular. In the vesicular disease, however, the crust is laminated,—in the pustular, it is more or less prominent. Again, it not unfrequently happens that two or more diseases are com- bined together in one eruption. Thus it is very common to meet eczema and impetigo combined, when the disease is called Eczema impetiginodes. Favus occasionally causes considerable irritation, producing a pustular or impetiginous margin around it. The vesicles of scabies are often ac- companied by the pustules of ecthyma, and so on. In very chronic skin diseases, it may happen that it is impossible to say what the original disorder was, whether vesicular, pustular, scaly, or papular. In such cases the skin assumes a red colour, the dermis is thickened, the epidermis rough and indurated, and a morbid state is occasioned, in which all trace of the original disease is lost, and what re- mains is a condition common to various disorders. As regards varieties, little need be said, and as formerly stated I ad- vise you to postpone their study until you are acquainted with the diseases themselves. Even then an acquaintance with them is of secondary im- portance. These varieties have been formed on account of the most varied circumstances, such as,—1st, Duration, most of them may be acute or chronic; 2d, Obstinacy, hence the terms fugaxfnveterata, acrius etc.; 3d, Intensity, hence the terms mitts, maligna, etc.; 4th, Situation, hence the terms capitis, facialis, labialis, palmaris, etc.; 5th, Form, hence the terms circinnatus, scutulata, iris, ggrata, larvalis, figurata, tuberosa gut- tata, etc.; 6th, Constitution, hence the terms cachectica, scorbutica, syphilitica, etc.; 7th, Age, hence the terms infantilis, senilis, etc.; 8th, 782 DISEASES OF THE INTEGUMENTARY SYSTEM. Colour, hence the terms album, nigrum, rubrum, versicolor, etc.; 9th, Density, hence the terms sparsa, diffusa, con centricns, etc.; 10th, Feel, hence the terms lave, indurata; 11th, Sensation produced, hence the terms formicans, pruritus, urticans, etc.; 12th, Geographical distribu- tion, hence the terms tropicus, AEgyptiana, Xorwegiana, etc. Porrigo. There was a period in the history of skin diseases when they were arranged in two great divisions, viz., those affecting the scalp, and those affecting the rest of the cutaneous surface. All the disorders compre- hended in the first of these divisions received the name of Porrigo, a word said by some to be derived from porrum, on account of the scales or concretions of the scalp resembling the layers of an onion; by others it is derived from porrigo, to spread. Willan described six kinds of Porrigo, viz., P. larvalis, P. furfurans, P. scutulata, P. favosa, P. lupi- nosa, P. decalvans. It is now ascertained that none of these diseases are necessarily peculiar to the scalp,—and that, although they are more or less modified by being connected with and affecting the hairs of that region, they may also occur on other parts of the skin. There can be little doubt, however, that the employment of the term Porrigo, as well as the corresponding word Teignc in France, has thrown great confusion over the subject of eruptions on the scalp. But as this term is still in pretty general use, it will be well to explain to you what diseases these different kinds of Porrigo really are. Porrigo larvalis (larva, a mask) is really Impetigo, or Eczema impe- tiginodes, of the scalp. The former is recognised by crusts more or less prominent or nodulated; the latter, by the circumstance that, in addition to these nodules, there is between them a laminated or brittle crust, spread more or less equally over the surface. They are both very com- mon in infants and children; and as the disease sometimes extends over the face, concealing the features, hence the term larvalis. A very characteristic representation of Impetigo capitis, is given in Willan and Bateman, Plate xii., erroneously called Porrigo favosa. (See also the disease on the face, ibid. Plate xxxvii. Alibert, Planches 13 and 15.) Porrigo furfurans (furfur, bran) is really Pityriasis of the scalp, although Psoriasis of that region has also received the same appellation. There is also a peculiar form of Eczema, or Eczema impetiginodes, in which the crust is friable, and breaks up, or crumbles into minute frag- ments, to which the term furfurans has been erroneously applied. The true Porrigo furfurans (Pityriasis) is well represented.— Willan and Bateman, Plate xxxviii. Alibert, Planches 14 and 15. It is often a form of favus. (See Favus.) Porrigo scutulata (scutulum, a small shield).—The nature of this disease has been much disputed. By some, it is said to be Favus (Erasmus Wilson), by others a form of Herpes (Cazenave). The disease is described by Willan and Bateman, and more recently by Burgess, as consisting of oval or rounded, slightly elevated patches, covered with furfur, and having stunted or filamentous hair projecting from the sur- THE TREATMENT OF SKIN DISEASES. 783 face. It is a form of skin eruption exceedingly rare in Edinburgh. It seems to be represented, Willan and Bateman, Plate xxxix. Willis (Trichosis scutulata). Porrigo favosa (favus, a honeycomb) is a disease, the true nature of which has been only lately determined. It consists essentially of an exudation on the skin, in whicii fungi or phytaceous plants grow. Round, isolated, bright yellow crusts are formed, which, when com- pressed together, assume an hexagonal shape—hence the term favosa. It is well represented. Willis' (Trichosis lupinosa). Erasmus Wilson, Fasciculus I. Alibert, Planche 17. Porrigo lupinosa (lupinum, the lupine).—This is the same disease as the last. The round or oval crusts when isolated, and at an early stage, present a concavity and form, resembling that of the lupine seed—hence its name. Porrigo decalvans (calvus, bald).—Baldness is so common among the aged, that it can scarcely be called a disease; but when it occurs in young persons, and is circumscribed, it constitutes the Porrigo decalvans of Willan. It is said by Gruby to depend on a vegetable parasite grow- ing in the hair. It is well represented, Willan and Bateman, Plate xl. Willis (Trichosis decalvans). From this analysis of the different kinds of the so-called Porrigo, you observe that there is nothing peculiar with regard to them. With the exception of baldness, none essentially belong to the hairy scalp. True favus is far more common on the head than elsewhere; but I have frequently seen it on various parts of the cutaneous surface, and occa- sionally on the cheeks or shoulders, without being on the scalp at all. It follows that instead of the term Porrigo, you should designate the disease as Eczema, Impetigo, Pityriasis, Psoriasis, or Favus of the scalp, as the case may be. Notwithstanding I have endeavoured to place this subject before you in as simple and uncomplicated a form as possible, I am conscious that at first you will still experience considerable difficulty in the diagnosis of skin affections. This can only be removed by practical experience at the bed-side, and by constantly, exercising your powers of observation in detecting the essential elements which their varied forms present. At the same time, I think the modified classification and short characters I have given, will materially assist your studies in this important depart- ment of practical medicine. It must be remembered, however, that they only refer to those cutaneous diseases which you are liable to meet with in this country. Should you ever be called upon to practise in the tropics, or in other places where peculiar skin disorders prevail, it will, of course, be your duty to study them in an especial manner. Here, as they cannot be made the subject of clinical observation, they are alto- gether removed from our consideration. THE TREATMENT OF SKIN DISEASES. Since the addition of a ward for skin diseases to the clinical depart- ment of the Royal Infirmary, I have had ample opportunities of deter- 784 DISEASES OF THE INTEGUMENTARY SYSTEM. mining what are the more common forms of cutaneous eruption met with in Edinburgh, and of trying various kinds of remedies. As the illus- tration of so many forms of integumentary disease by reports of cases is in this work impossible, I propose now to give a condensed account of the treatment I have found most successful. Exanthemata. Few cases labouring under erythema, roseola, or urticaria, enter the Infirmary, and in such as occasionally present these eruptions during their residence there, the mildest remedies suffice for their removal. In the severer cases, a saturnine lotion to diminish local irritation, with a saline purgative, generally suffices for the cure. Vesictl.e. Eczema is by far the most common disease met with, both in the acute and chronic forms. The local treatment I have found most effi- cacious is that which I first recommended in 1S49.* It consists in keeping the affected part moist, with lint or linen saturated in a very weak alkaline solution, consisting of 3 ss of the common carbonate of soda, dissolved in a pint of water. For this purpose it is necessary to cover the moistened lint with oil silk, or gutta percha sheeting, which should well overlap the lint below, so as to prevent evaporation. The usual effect is soon to remove all local irritation, and especially the itch- ing or smarting so distressing to the patient. It also keeps the surface clean, and prevents the accumulation of those scabs and crusts, which in themselves often tend to keep up the disease. After a time, even the indurated parts begin to soften, the margins of the eruption lose their fiery red colour, and merge into that of the healthy skin, and, finally, the whole surface assumes its normal character. Iu private practice, it is often a matter of great difficulty to secure a proper application of the lotion. Individuals are slow to accept the idea that constant moisture of the part is absolutely necessary for the treat- ment, and hence vigilant superintendence and frequent visits are requisite, in order to watch the progress of the ca3e. Even in the hospital constant care is necessary, to see that nurses properly cover the eruption; and when, as sometimes happens, this task is given to the patients themselves, it almost always fails. Then there are some portions of the surface which it is very difficult to keep moist and well covered, such as the face and axillae. But, by carefully adapting lint and gutta percha sheeting, attaching strings to the edges of the latter, so as to keep the whole in its place, I have never failed in ultimately carrying out my object. In the Infirmary I treat vesicular eruptions of the face in this way by means of a mask, having apertures for the eyes, nostrils, and mouth. If the eruption be very general, long soaking in slightly alkaline baths is useful. In addition to stating what I have found to be beneficial, it is import- ant to say what I have, on careful trial, ascertained to be useless or injurious. Perhaps no remedy is more generally employed in this and a variety of other skin diseases than citrine ointment, an application that * Monthly Journal of Medical Science, August, 1849. THE TREATMENT OF SKIN DISEASES. 785 I have always found to irritate and make eczematous eruptions worse. At the same time, there are some very chronic forms of the disease, which I have been told have been cured by this preparation, but what these are I have never been able to ascertain. Indeed, all greasy appli- cations whatever, in acute cases, are useless, and the patients themselves sav, are very " heating." I have tried the freezing process recommended by Dr. Arnott, but the salt of the frigorific mixture, and the cold itself, has caused apparently so much agony, that I have been deterred from using it, especially when the emollient moist alkaline application is so efficacious. In some rebellious chronic cases I have occasionally found the oil of cade a useful remedy, and in others the oxide of zinc ointment. They are most beneficial after a prolonged use of moist alkaline application. In the same way, friction with the hand or a soft flesh brush favours the disappearance of the chronic induration and vascularity of chronic eczema of the inferior extremities, which should be kept as much as possible in the recumbent position. These stimulating applications, whilst useful in the very chronic and non-irritative forms of the disease, or to remove what an emollient treatment fails to accomplish, are most injurious in the acute forms. Jferpes.—This disease generally runs its course in about fourteen days, and requires no treatment whatever, further than an acetate of lead lotion to allay the smarting. It is not very common. Scabies occurs very frequently, and is cured by a host of remedies. A strong lather, made of common soft soap and warm water, twice a day, answers very well. The question with scabies, is not what remedy is useful, but which will cure it in the shortest period. The most extensive experience at St. Louis has shown, that the sulphur and alkaline, or Helmerinch's ointment, cures itch, on an average, in seven days. That sulphur, however, is not the active remedy, I have satisfied myself by experiment. Soft soap, as we have seen, which contains alkali, and even simple lard, if pains be taken to keep the parts constantly covered with it, will cure the disease as soon as sulphur ointment. I have tried the Stavesacre ointment, recommended by M. Bourguignon, in only a few cases, but found it to answer very well. Its superiority, however, over other applications, I am not yet prepared to admit. (See Dermatozoa.) Pemphigus.—This is rather a rare disease, and when chronic, coming out in successive crops, is very rebellious. I have cured several acute, and some tolerably chronic cases in from one to three weeks, by the weak alkaline wash, applied as in the case of eczema, combined with generous diet. Pustula. Impetigo.—This affection in all its forms is very common, and is best treated by the weak alkaline wash, exactly the same as in eczema In the chronic forms which attack the chin of men, constituting one ot the varieties of meutagra, the same treatment cures the most rebellious cases, if the moisture be constantly preserved. For this purpose the hair must be cautiously cut short with sharp scissors, and the razor carefully avoided. If the side of the cheek covered by the whisker be attacked, removal of the hair from thence also is essential to the treatment. A 50 786 DISEASES OF THE INTEGUMENTARY SYSTEM. bag or covering accurately adapted to the part affected must be made of gutta percha sheeting, and tied on with strings. This may be covered with a piece of black silk, to allow the individual to go about and carry on his usual occupations. In this way I have frequently seen chronic impetigo of the chin, of from eight to ten years' standing, which has re.-isted all kinds of ointments and heroic remedies, completely removed in a few weeks. But then the surface must be kept constantly moist, a circumstance requiring great care and determination on the part of the patient. When it becomes necessary to shave, flour and warm water, or paste, should be used, and not soap. Alkalies applied from time to time only, as in the form of wash or soap, always irritate, although, when employed continuously, they are soothing. Ecthyma is not a common disease, and usually presents itself con- joined with Eczema or Impetigo, and is treated successfully in the same manner as those diseases. The E. cachecticum requires, in addition to the alkaline wash locally, a generous diet. Aene is a disease always requiring constitutional rather than local remedies. Although not uncommon in private, it is rare in hospital practice. Careful regulation of the diet, abstinence from wine and sti- mulating articles of food, watering-places, baths, etc., etc., constitute the appropriate treatment. Rupia.—This disease I have never seen occur but in individuals who have been subjected to the influence of mercurial poisoning. Hydriodate of potassium and tonic remedies, with careful avoidance of mercury in all its forms, is the general treatment I have found most successful. If the pustules be few in number, the scabs may be removed by poulticing, and the sees treated locally with water dressing or red wash. But if they are numerous, great caution should be exercised in exposing so many ulcerated surfaces, and it is better to let the crusts remain. Papula. Lichen and Prurigo.—In both these affections, constant inunction with lard is as beneficial as constant moisture in the eczematous and impetiginous disorders. In the prurigo of aged persons, the Ung. Hyd. Precip. Alb. is a useful application, although the disease is not unfre- quently so rebellious as ouly to admit of palliation. The chronic papular diseases often constitute the despair of the physician. Squamae. Psoriasis, and that modification of it known as lepra, is a very common disease, and has been uniformly treated by me externally with pitch ointment. I have satisfied myself by careful trials that it is the pitch applied to the part that is the beneficial agent, as I have given pitch pills and infusion of pitch largely internally, without benefit. With the hope of obtaining a less disagreeable remedy, I have frequently tried creosote, and naphtha ointment, and washes, but also without benefit. Lastly, I have caused simple lard to be rubbed in for a lengthened time, but without doing the slightest good. The oil of cade is occasionally useful, especially in psoriasis of the scalp. Internally, I give five drops of Fowler's solution, and as many of the tr. cantharidis. THE TREATMENT OF SKIN DISEASES. 787 It is rare that the internal treatment alone produces any effect on a case of psoriasis of any standing. If a case resists this conjoined external and internal treatment, I have always found it incurable. Some years ago I carefully treated a series of cases internally with Donovan's solu- tion, without producing the slightest benefit. True Pityriasis frequently disappears of itself. In chronic cases the treatment by pitch is useful, and sometimes the application of the Ung. Zinci Oxyd. or Ung. Hyd. Precip. Alb. The form of pityriasis that is dependent on a vegetable fungus is identical with favus. (See Favus.) Ichthyosis.—I have treated several chronic cases of ichthyosis. But while in some cases the skin has become a little softer from a course of pitch treatment, no permanent cure was effected. Tuberculje. Lupus is the only kind of tubercular skin disease I have seen in the skin ward of the Infirmary, and that is pretty common. It is a constitutional disorder, and must be treated by cod-liver oil, and all those remedies useful for scrofula, of which it is a local manifestation. The external treatment is surgical, consisting of the occasional appli- cation of caustics, red lotion, water dressing, ointments, etc., according to the appearances of the sore. I agree with Hebra in thinking lupus and the radesyge of the Norwegians to be the same disease. 31 any years ago I found lupus of the legs and thighs to exist among the fisher- women of Newhaven, who assisted their husbands in hauling in their boats, or who were accustomed to wade for any length of time in salt water. Maculae. Lentiyo I have never found to be benefited by any kind of treatment, local or general. It is evidently connected with season and the in- tensity of the sun's rays, as it often disappears in winter and returns in summer. Ephelis and Navi are alike incurable. Bronzing from exposure to the sun, as in hot climates, frequently disappears on returning to a tem- perate latitude. Purpura is a constitutional disorder, for the most part allied to scurvy. It consists of an alteration of the blood, with tendency to disintegration of the coloured corpuscles and diffusion of haematozine. Under such circumstances, ecchymoses occur in the skin, sometimes confined to round spots varying in size, at others existing in patches. It is for the most part associated with weakness, and requires rest and time to permit ab- sorption of the extravasated blood, conjoined with tonics, anti-scorbu- tics, and generous diet. In sea scurvy, lemon juice and fresh vegetables are the true remedies. (See Scorbutus.) Scalp diseases must be treated according as they depend on eczema, impetigo, psoriasis, or favus, in all cases first removing the crusts with poultices, then keeping the head shaved, and, lastly, applying alkaline washes, pitch ointment, or oil, according to the directions formerly given. Ringworm is a disease I have never seen in Edinburgh, and 788 DISEASES OF THE INTEGUMENTARY SYSTEM. of what it consists I am ignorant. Some writers apparently consider it to be favus, and others a form of herpes. On two or three occasious I have seen a scaly disease of the scalp, in the form of a ring—that is lepra, which I have cured by pitch ointment, or oil of cade. Dr. Andrew Wood informed me some time ago, that he banished it from the llcriot's Hospital school of this city by condensing on the eruption the fumes of coarse brown paper, and thus causing an empyrcumatic oil, or kind of tar to fall upon the part. This at one time led me to suppose that it might be a scaly disease, and a form of lepra or psoriasis. On the whole, I am inclined to think it a form of favus, which has commonly been mistaken for a scaly disease of the scalp. (See Favus.) So-called Syphilitic diseases of the skin are, in my opinion, the va- rious disorders already alluded to, modified by occurring in individuals who have suffered for periods more or less long from the poisonous ac- tion of mercury. A longer time will be required for their cure, but the same remedies locally, conjoined with hydriodate of potassium in small doses, with bitter infusions, tonics, and a regulated diet, offer the best chance of success. The great difficulty in the treatment of skin diseases, generally con- sists in their having been mismanaged in the early stages—a circum- stance I attribute to the little care with which, until a recent period, clinical students have studied them. Many chronic cases of eczema are continually coming under my notice, which, in their acute forms, have been treated by citrine ointment, or other irritating applications, that almost invariably exasperate the disorder. I shall not easily forget the case of one gentleman, covered all over with acute eczema, who had suffered excessive torture from its having been mistaken for psoriasis, and rubbed for some time with pitch ointment. In the same way I have seen a simple herpes, which would have readily got well if left to itself, converted into an ulcerative sore by the use of mer- curial ointment. Nothing is more common than to confound chronic eczema of the scalp with favus, although the microscope furnishes us with the most exact means of diagnosis. I have seen one case in which a chronic eczema of the cheek was cut out by a surgeon, under the idea that the disease was malignant. I presume that acne must frequently have been mistaken for tubercular disease. In no other way can I ac- count for some very distressing cases, where the patients' faces have been painted over with butter of antimony. I need scarcely say, that the correct application of the remedies I have spoken of can oidy be se- cured by an accurate discrimination, in the first instance, of the diseases to which they are applicable. The general constitutional treatment in all these cases seldom demands aperient or lowering remedies except in young and robust individuals with febrile symptoms. In the great majority of cases, cod-liver oil, good diet, and tonics are required. In a few instances sedatives, both locally and internally, are necessary to overcome excessive itching or irritation. These the judicious practitioner will readily understand how to apply according to circumstances. Baths in all their various forms are useful in skin diseases, although, since I have applied a kind of con- stant local bath in the form of moist application, formerly alluded to (see Treatment of Eczema), they are comparatively seldom used by me DERMATOZOA. 789 in the Infirmary. The natural baths and mineral springs of watering places in Great Britain, France, and Germany, are undoubtedly benefi- cial in appropriate chronic cases. DERMATOZOA. The skin may be attacked by certain animal parasites. Of these the pediculi, or lice, are too well known to need description. But we may shortly allude to the Acarus scabiei, and the Entozoon folliculorum. Acarus Scabiei. This insect has been proved by the researches of M. Bourguignon* to be the undoubted cause of itch. The male is about a third smaller than the female. He has suckers on two of his hind feet, and possesses on the abdominal surface genital organs, all of which characters are absent in the female. She, on the other hand, in addition to her size, and the negative marks alluded to, is characterized by the three kinds of horny Fig. 459. spines which are scattered over the back. The suckers, or ambulacria, are organs of locomotion; the mandibles enable it to cut the epidermis, * Traite entomologique et pathologique de la gale de l'homme. 4to. Paris, 1852. Fig. 457. Dorsal surface of the female Acarus Scabiei. Fig. 458. Ventral surface of the same. Fig. 459. Ventral surface ofthe male Acarus.—(Bourguignon). 100 diam. 790 DISEASES OF THE INTEGUMENTARY SYSTEM. and extract fluid from the tissues, which passes through a delicate oeso- phagus, the internal termination of which is unknown, the body of the animal being apparently filled with an unorganized, very finely molecu- lar pulp. A short delicate tube may also sometimes be observed at the anus—a supposed rectum. No respiratory apparatus can be discovered, although the creature may be seen to swallow minute bubbles of air, which pass down the oesophagus, and, like the nutritive juices, diffuse themselves through the interior. At all events, animal juice and air are both necessary to the life of the Acarus. The disease called scabies has been conclusively shown by M. Bour- guignon to be entirely owing to the presence of the insect, and to be communicated from one person to another, eight times out of ten, by their sleeping together. The female seldom quits her burrow but at night, and if impregnated, not even then, unless disturbed mechanically, as by scratching. Once in motion, she crawls over the surface with great rapidity, and readily passes from one person to another, where the skins are in contact. Communication is not readily occasioned by holding the hands of those affected, or by coming in contact with them during the day. The disease cannot be communicated by inoculating with the serum of the vesicles, by the pus of the pustules, or by any principle contained in the dead body of the insect itself. Neither can the Acarus of one species of animal, as of the horse, or sheep, inhabit the body of a different one. Still the disease is not purely local, inasmuch as papular, vesicular, or pustular eruptions often occur in parts which the Acarus has not infested, so that they seem to originate from some cause inde- pendent of its mere presence. The Acarus has a predilection for youth and a tender skin, aud has a hatred of hair bulbs. Hence why it frequents young persons more commonly than old ones, and why in children it occurs indiscriminately all over the body, while in adults it is most often found between the fingers and toes, inside of the thighs and genital organs. Seventy times out of a hundred, scabies is confined to the hands, and in the other thirty, occurs also on the trunk and genitals. The only proof of the existence of itch, is the presence of the Acarus, and this is easily to be detected by a microscope adapted for the purpose by M. Bourguignon. It consists of a body with eye-piece and lenses magnifying seventy diame- ters linear, with a condensing lens, the whole placed on a moveable arm with several joints, attached to a firm stand. With this instrument the entire surface of the body may be explored, and the movements and doings of the insects observed with the utmost facility. The associated papules, vesicles, and pustules are, in the opinion of M. Bourguignon, in no way diagnostic. M. Biett made a series of experiments at the Hopital St. Louis, to determine what substance would cure itch in the shortest space of time. He employed forty-one different applications aud modes of treatment. The result was, that frictions with the following ointment occasioned recovery on the average in the smallest number of days :—Take of sublimed sulphur, two parts; of subcarbonate of potash, one part; and of lard, eight parts. M. Albin Grass endeavoured to ascertain what substances would most quickly destroy the Acarus just removed from its burrow. It survived DERMATOZOA. 791 three hours in water; two in olive oil; one in a solution of acetate of lead; four-fifths of an hour in warm water; twenty minutes in vinegar and an alkaline solution; twelve minutes in a solution of sulphuret of potash; nine minutes in turpeutine; and from four to six minutes in a solution of the hydriodate of potash. It survived sixteen hours in the vapour of sulphur under a watch glass; and one hour in the flowers of sulphur. According to these researches, therefore, hydriodate of potash would be the best remedy. He removed three living insects from a patient who had taken three sulphur baths, whereas, after a single application of Helmer- inch's ointment, that is, where sulphur and potash are combined, he fre- quently found them dead. M. Bourguignon, with his microscope watched with great care the effect of the frictions made at St. Louis with the sulphuro-alkaline oint- ment. After the first day, in which there had been two frictions aud a simple bath, the Acari were in no way disturbed. In two days, after four frictions, they were still active, but burrowed deep in their grooves. In three days they still lived, but were unusually flat; but their eggs could be hatched by artificial heat, and produced larvae, possessing great activ- ity. In four days the insects in the superficial parts were shrivelled up and dead; the deeper ones, though living, tres malades. Many of the eggs now aborted. In five days all the insects were dead; and in six even the eggs had lost their vitality. The eruptions, on the other baud, often remained stationary, and not unfrequently became worse from the irritation of the ointment and frictions, but after a time they disappear also. Hence it is common at St. Louis, after seven or eight days' fric- tion, to send out the patients though still covered with eruption, and in most cases they get well. About three in ten, however, return with the disease again established, a circumstance that Mons. B. attributes to the fact, that the frictions, which were only applied to the superior and inferior extremities, had not destroyed the insects which were present on the trunk. M. Bourguignon, on considering the structure of these Acari, and the facility with which a poisonous fluid could penetrate their delicate integu- ment, was led to make a series of observations to determine how long they would live after the application of various toxic solutions. He found those which possessed the most energetic action on these creatures were solutions of the ioduret of potassium and of the ioduret of sulphur, which killed them in eight minutes. A solution of the alcoholic extract of staphisagria was the next iu virulence, destroying the animals in fifteen minutes. The hands of an itch patient were immersed in a solu- tion of the two former for two hours, so as strongly to impregnate and colour the integuments. On examining the insects immediately after- wards, they were as lively as ever, but ou the next day they were all dead, and the eggs destroyed. The epidermis was greatly shrivelled, and in three days complete desquamation occurred, carrying with it Acari, grooves, aud eggs, and leaving the cutis raw and tender. The action ou the skin was evidently too strong. A bath of a solution of the alcoholic extract of staphisagria was then made, and immediately after a two hours' immersion of the hands, all the insects were found dead, and, with one exception, the eggs destroyed. So far from irritating the integument, this application at once caused the itching to cease, and 792 DISEASES OF THE INTEGUMENTARY SYSTEM. produced such calmative effects, that M. B. proposes it as a local remedy for inflammation. The eruptions also appeared to be rapidly cured by it. After various experiments, he adopted an ointment of the staphisa- o-ria as the most generally useful preparation, prepared as follows:—Re- cent grains of staphisagria in powder, 300 grammes; boiling lard, 500 grammes. Digest for 24 hours at the temperature of 100w in a sand- bath, and strain. Four days of friction with this ointment, instead of seven with sulphuro-alkaline ointment, not only destroys the insects and their eggs, but completely cures and prevents the integumentary irrita- tion and eruotions. Entozoon Folliculorum. This insect inhabits the sebaceous follicles of the skin and is very common in the face, more especially when the seat of acne. In the follicles of the nose they are present in the majority of living persons, and, accord- ing to Simon, are almost universal in dead bodies. He frequently found Fig. 460. Fig. 461. them living six days after the death of the individual in whom they were found. The animal measures from 1 135th to l-64th of an inch in length, and from 1155th to l-555th of an inch in breadth. It is com- posed of a head, a thorax, and abdomen. Fig. 460. Three follicles of the skin of the dog containing entozoa. 100 diam. Fig. 461. Cul-de-sac of a sehaceous follicle, containing three animalcules in differ- ent positions, and two eggs—(afler Gruby.) 350 diam. DERMATOZOA. 793 The head represents in f >rm a truncated cone, flattened from above downwards, and directed obliquely downwards of the trunk. The existence of an eye has not been determined. The head is furnished with two maxillary palpi, which admit of ex- tensive motion. The thorax is the broadest part of the animal, and is composed of four segments. In each of these, on each side, are two legs—eight in all. The abdomen varies in length, is annulated in structure, and admits of certain movements. Internally, Dr. Erasmus Wilson has traced out an alimentary canal, and its termination in an anus, together with a brownish mass which he considers to be the liver. No sexual differences have been dis- covered in them, and they possess no respira- tory organs. The animalcule is easily found by compress- in" with two fingers the skin we wish to ex- amine, until the sebaceous matter is squeezed out, in the form of a little worm. This matter should be placed in a drop of oil previously heated, then separated with needles, and ex- amined with a microscope magnifying '250 di- ameters. Their movements are slow, whilst the conformation of their articulations only per- mits them to move forwards and backwards, like lobsters. (Gruby.) They are nourished by the sebaceous secretion of the follicles. They most commonly occupy the excretory duct of the follicles, which are often dilated in the place where they are lodged. Their head is always directed towards the base of the gland. When there arc many together, they are placed back to back, and their feet are applied against the walls of the duct. When very numerous they are compressed closely together, aud are found deeper in the ducts. They rarely exist, however, at the base of the gland. In young persons they generally vary in number from two to four; iu an aged in- dividual, they may be from ten to twenty. (Gruby.) Though this entozoon may occasionally be associated with acne, it seldom gives rise to great inconvenience. According to Erasmus Wilson, the difficulty seems not to be to find these creatures, but to find any indi- vidual, with the exception of newly-born children, in whom they do not exist. Fig. 462. Hair and its follicle, in which may be seen the animalcules descending towards the root of the hair, and cul-de-sac of the follicles.—(Gruby.) 100 diam. 794 DISEASES OF THE INTEGUMENTARY SYSTEM. DEliMATOPHYTA. The growth of parasitic fungi on the surface of the skin, has now been observed under a variety of circumstances, and constitutes occa- sionally in man three forms of skin disease, whicii I believe to be essen- tially the same, viz —taenia favosa, a certain form of pityriasis of the scalp and of mentagra. The latter is very rare in this country; and I have never seen a case of it. All these disorders, however, may be classified under the head of favus, under which I shall consider them. Favus. Case CLXXVII.*—Favus of the Scalp in an Adult—Incurable. History.—Isabella Fergusson, set. 22, a somewhat stout servant girl, with fair skin, and scrofulous aspect, was admitted into the clinical ward of the Royal Infirmary, May 6, 1849. She states that there has been an eruption on her head for the last twelve years. Four months ago the catamenia ceased, since which time she has been subject to occasional headache, constipation, and slight dyspepsia. Symptoms on Admission.—Nearly the whole of the scalp is covered with a thick yellow friable crust, of uneven surface, and irregular margin, emitting a highly offen- sive odour, like cat's urine, and causing great itching and irritation. Up to the mid- dle of July she was treated with various internal remedies, which subdued the consti- pation and dyspepsia, and caused return of the catamenia. The crusts on the scalp were removed by poultices, and an ointment, composed of ammon. mur. 3 j ; and dug. sulphiiris z j> applied locally. Dr. Bennett first took charge ofthe case on the 14th of June. The head was then again covered with favus crusts, some isolated, others com- pressed together, and forming an elevated scab. A small portion examined under the microscope, presented the branches and sporules of the cryptogamic plant so character- istic of the disease. The crusts were again removed by poultices of linseed meal, the head shaved, and cod-liver oil ordered to be applied to the scalp morning and evening —the wlu.l'' to be covered with an oil-silk cap. This treatment was continued for six weeks, but on suspending it the favus crusts returned. During the months of August and September, iodine and pitch ointments were applied; portions of the scalp were even blistered, but without effect. Progress of the Case.—At the commencement of October, the scalp being at the time perfectly clean and closely shaved, all local treatment was suspended, and the reappearance of the disease carefully watched. In three days the entire surface pre- sented a scaly eruption, the epidermis being raised, cracked, and broken up over the whole scalp, which was exceedingly dry and harsh. The furfuraceous condition of the scalp continued, becoming more and more dense, until the fourteenth day, when there were first perceived minute bright sulphur-coloured spots in it. These, on being examined microscopically, were seen to be composed of fine molecular matter, mingled with epidermic scales, from which delicate branched tubes were ap- parently growing. The crusts were now once more removed by repeated poulticing, and cod-liver oil applied as formerly. The scalp continued free from erup- tion until the 20th [of November, when she was seized with febrile symptoms, which ushered in a very severe attack of typhus, that ran its usual course. She was not considered fully convalescent until the 8th of December. During this ' Reported by Mr. William Johnson, Clinical Clerk. DERMATOPHYTA. 795 ceriod no local application was made to the scalp, with the exception of the cold douche to alleviate the head symptoms, delirium and coma having been severe. The surface latterly once more became covered with furfuraceous scales ; and on the 1 \tli December the bright yellow minute spots again made their appearance. As her strength improved, the favus crusts increased in size and number, and the progress of this very singular disease was again very carefully watched. Each individual crust, at first the size of a small pin's head, gradually flattened out and became circular. Its centre was cupped and umbilicated, and many, which were more isolated than the rest grew until they measured a quarter of an inch in diameter. More generally, however they came in contact with others, and groups of twos, or threes, and some- times a dozen became compressed together and presented the hexagonal form of the honey-comb. Gradually the concavity disappeared. Each crust presented an external dark ring and an internal lighter centre, which became considerably elevated. The various groups became aggregated together, and she complained of great itching and irritation and it was evident that, if allowed to proceed further, the condition she presented on admission would be soon produced. The crusts were, therefore, again removed by poultices, cod-liver oil once more applied, and the scalp remained clean and free from irritation until 17th January, when the cure appearing to be hopeless she was dismissed. She was enjoined to continue the use of the oil, which, whilst applied, and covered with the oil-silk cap, had the power of preventing the formation of fresh crusts on the scalp. Case CLXXVIIL*—Favus of the Scalp of three years' standing—Cured. History.—Margaret Bryer, set. 12, of scrofulous and cachectic appearance, was admitted June 19th, 1849, with favus crusts on the scalp. The crusts are most numerous and dense on the crown of the head; but others, isolated or in small groups, are scattered over the temples, forehead, and occiput. The scalp is bald here and there in patches, varying in diameter from half an inch to an inch. On examining the crusts microscopically, they are seen to contain the cryptogamic branches and sporules pathognomonic of favus. The disease is of three years' standing, and is attributed to the use of a comb, belonging to another girl who had a sore head. The crusts have been several times removed by means of pitch plasters and a variety of ointments, but have always returned. Progress of the Case.—At first, the crusts were removed and the scalp kept moist by means of an alkaline lotion, which succeeded in removing the irritation. Early in July she was ordered § ss of cod-liver oil three times a day. The oil was also directed to be applied to the shaved scalp twice daily, which was to be kept constantly covered with an oil-silk cap. This treatment was persevered in until August 10th, when she was dismissed cured. This girl was re-admitted September 5th, and remained in the Infirmary five days, under observation. Up to this time the disease had not re-appeared, so that, when dismissed on the 10th, a permanent cure was undoubtedly produced. Cask CLXXIX.f—Favus caught in the Ward from Case CLXXVIL— Cured. History.—Margaret Cameron, sat 5, an ill-nourished cachectic-looking cnild— admitted July 23d, 1849, on account of an eruption ou the scalp. In some places * Reported by Dr. J. Smith, Clinical Clerk. f Reported by Mr. Alexander Struthers, Clinical Clerk. 796 DISEASES OF THE INTEGUMENTARY SYSTEM. the hair was matted together by a recent pmtular eruption; groups of impetiginous pustules and eczematous vesicles being scattered here and there. In others, when- the disease was more chronic, hard, nodulated, elevated masses, and friable crusts existed. The disease was eczema impetiginodes. Xo favus was present, as was proved by careful examination, and microscopic demonstrations of the scabs. Poultice* were ordered to the scalp, to remove the crusts ; and afterwards an alkaline wash, with cod- liver oil internally. Progress of the Case.—My colleagues taking charge of-the ward during the months of August and September, I lost sight of this patient; but on resuming duty in the beginning of October, I was surprised to find the child's head covered with favus crusts, with the branches and sporules fully developed, as proved by the micro- scope. It appeared that the girl was a great favourite with Isabella Fergusson (Case CLXXVIL), and frequently slept in her bed, and there can be little doubt she had caught favus from her. The child's general health, however, had greatly improved ; and the crusts were ordered to be removed by poultices, the head shaved, and cod-liver oil applied locally trcice daily, and an oil-silk cap to be worn constantly. This treatment was continued for seven weeks. At the end of that time all treatment was suspended, and the scalp watched daily. In fifteen days the head was covered with a slight furfuraceous desquamation ; but the hair was abundant. Another week elapsed without any return of favus ; and, her health being now good, she was discharged, December 6th. Case CLXXX.*—Favus of the Scalp of four years' standing, cured by a Sulphuric Acid Lotion. History.—Helen Goodall, vet. 1.3—admitted November 3d, 18.3.'l. She has been affected with favus of the scalp for four years, and frequently been in the Infirmary, and subjected to various kinds of treatment, under different physicians, without any permanent benefit. Ou admission, a great portion ofthe scalp was bald, from destruc- tion of the hair bulbs, but the other portions were covered with a prominent yellow friable crust, of mousy odour, crowded with pediculi. Oa tae 7th of November a lotion composed of one part of sulphurous acid and three parts of water, was constantly applied by means of lint saturated in it, and covered with an oil-skin cap. It was suspended December 23d, leaving the scalp partly bald, but quite clean. On the 15th of January, 1854, the disease had not returned. The scalp was then rubbed over with the oil of cade, twice daily, to remove the squamous eruption, and she was dismissed apparently quite cured, Pebruary 5th. Case CLXXXI.f—Limited Favus of the Cheek, cured by Cauterization with Nitrate of Silver. History.—James Scott, a;t. 15, a painter, applied for advice, January 27, 1850. He states that, a week ago, without any known cause, he observed a small spot about the size of a pin's head, over the external angle of tli3 left malar bone. Ou examina- tion, a circular reddened spot, about the size of a shilling, is seen over the external angle of the left malar bone, in the centre of which were several favus crusts, aggrega- ted together. These examined und^r the microscope, presented the branches and sporules pathognomonic of the disease. The whole was then well cauterized with nitrate of silver, and was cured at once. * Reported by Mr. P. \V\ Wallace, Clinical Clerk. t Reported by Mr. Hugh Balfour, Clinical Clerk. DERMATOPHYTA. 797 Commentary.—Of the five cases of favus now given, the first was that of an adult, and was of twelve years' standing. By means of poultices and excluding the air with oily applications, the scalp could easily be freed from the eruption, and kept so; but as soon as these means were discontinued, the disease returned. The second and third cases were permanently cured by the constant application of oil to the Bcalp for six or seven weeks. They were children of the ages of twelve and five years respectively. In the former the disease was of three years" standing; in the latter, it was altogether recent, and caught from another case in the ward. The fourth case was cured by using a Bulphurous acid lotion instead of oil—a practice recommended by Dr. Jenner, in consequence of the powerful effect possessed by this acid, in destroying vegetable growths. In the fifth case, the disease was limited, and was at once destroyed by means of caustic. It is rare that favus can be watched through its entire progress in the wards of a hospital— first, because the disease commonly lasts months—often years, and charitable institutions cannot support individuals so long ; and, secondly, because it always happens, that when urgent cases demand admission, and beds are required, these are just the parties who are discharged to make room for them. At the same time, the disease is so common in Edinburgh, that the wards are seldom free of one or more examples of it in various stages. Besides, by poulticing off the crusts, and allowing the eruption to come back, its commencement and progress may be studied in any individual case. Case CLXXXIL'—Parasitic Pityriasis—Incurable. History.—Charlotte Clerk, aet. 18—admitted June 20, 1857—a Hindoo girl from Bombay. She has had an eruption on her head ever since she can remember. On admission the hair was found clipped short; the scalp was bald in patches, especially over the crown of the head. The hair is filled with scales, easily detached, resembling desquamated epidermis. Towards the back of the head these scales are embedded in a diffused friable yellowish matter, which, on examination under the microscope, presents the thalli and sporules of favus. July 6th.—To determine more certainly the character ofthe disease, poultices have been applied to the head, the hair has been shaved, and the disease allowed to return. To-day, being the seventh since the head was clean, two bright yellow favus spots, each perforated by a hair, were observed. Tliese rapidly increased and amalgamated with others, never forming distinct favus crusts, but causing a scaly eruption over the Surface, together with a few pustules of impetigo. On removing the scales a friable yellow mass can be generally seen below, presenting on examination the vegetable structure of the Achorion Schcenleini. The sporules and thalli were unusually large and well developed. This girl was treated by constant oleaginous and other applications; was dismissed and re-entered the house; but when I last saw her iu December, 1857, the disease still existed as bad as ever. Commentary.—-This eruption presented to the naked eye all the appearance of pityriasis of the scalp. The only suspicious circumstance was the baldness. I had previously seen two similar cases, and was in • Reported by Mr. W. Guy, Clinical Clerk. 798 DISEASES OF THE INTEGUMENTARY SYSTEM. no way surprised to find that the disease was a parasitic one. All chronic scalp eruptions, especially if there be Alopteeia, should be ex- amined microscopically, in order to arrive at an exact diagnosis. Es- sentially the fungus is the same as that of favus, although it may pre- sent occasional modifications as to the size of the sporules and thalli. In the present case they were remarkably well developed and larger than usual; in one case I found all the sporules perfectly globular, and only half the size of the usual oval corpuscles. In this, as in Case CLXXVIL, all the remedies tried were of no avail. Uistorg of Favus as a Vegetable Parasite.—(Achorion Schamleini of Link.) The demonstration by Bassi* of the vegetable nature of the disease named muscardine in silk worms, which causes so great a mortality amongst those animals, opened up to pathologists a new field for obser- vation, and led to the discovery, that certain disorders in the higher animals, and even in man himself, were connected with the growth of parasitic plants of a low type. Schdulein,t of Berlin, was the first to detect them in favus crusts—an observation confirmed by Remak,t_ Fucbs, and Langenbeck.§ (Jruby|| gave a very perfect description of these vegetations in 1S-41, and made numerous researches as to their seat, origin, and mode of propagation. These were repeated by myself, and further extended in 1842.• In ls45 I succeeded in inoculating the disease in the human subject. Since then they have been made the subject of further investigation by Lebert,*2 Remak,t2 Robin,t/ and numerous other inquirers, to whose observations I shall have occasion to allude subsequently. Mode of Development and Sgmptoms of Favus. By most writers, amongst whom may be cited Willan, Bateman, Biett, and Bayer, favus is described as commencing in a pustule, which breaks and forms the peculiar scab. Others, such as Baudeloeque, Alibert, and Gibert, deny its pustular nature, and state that it commences in a crust. But numerous observations have satisfied me that the formation of pus- tules is not essential to the disease, although they are often present. Hence the mistake of those pathologists who classified favus amongst the pustulae. M. Gruby says that they are never present, which is equally erroneous, althougli they appear to be a secondary result, attri- * Del. Mai. del Segno Calcinaccio o Muscardino. Milano, 1837. \ Mailer's Archives. 1836. J Medicinische Zeitung. 1810. jj Comptes Rendus de la Polyclinique de Guttingen. || Comptes Rendus, torn. xiii. pp. 72 aud 309. 1841. If On Parasitic Vegetable Structures found Growing in Living Animals. Edin- burgh Philosophical Transactions, vol. xv. p. 277. 1S42. Monthlv Journal, June, 1842. *2 Physiologie Pathologique, torn. ii. 184.3. t2 Diagnostiche und Pathogenische Untersuchungen. 184.3. J2 Des Vegetaux qui croissent sur l'Homme, etc. 1847. DERMATOPHYTA. 799 butable to the irritation the disease produces in some individuals * On the other hand, I have never seen this affection produced, without hav- ing been preceded by desquamation of the cuticle, an observation which appears to me of some importance in explaining the origin of the disease as we shall subsequently see. Occasionally, also, the scales form a thick mass, and the favus matter is more disseminated, and does not form the distinct umbihcated crusts. This constitutes the parasitic pityriasis of some writers. After removing the favus crusts by poulticing, and then watching from day to day how the disease returns, it will be seen that the first morbid change is increased vascularity of the skin, accompanied with a desqua- mation ofthe cuticle; and that in a period varying from twelve to four- teen days, small spots of a bright yellow colour, like that of sulphur, may be detected. These gradually augment in size, but even at the earliest period may be observed, with a lens, to have a central depres- sion, through which a hair may generally be observed t» pass. The crust or capsule may enlarge to about the size of a shilling, and if it be isolated, still retain its rounded form. Usually, however, its edges come in contact with other capsules, and theu it loses its rounded shape, and assumes the hexagonal and honey-combed appearances described by authors. I consider, then, that the so-called Porrigo lupinosa, and Por- rigo favosa, constituting distinct forms or varieties of some writers, are merely different stages of the same disease, and dependent upon the greater or less aggregation of the crusts. On the first appearance of the capsule, its edges are somewhat depressed below the surface of the cuticle; but as it increases in size, the margins become more and more elevated and prominent, whilst a series of concentric rings or grooves may be observed in them. At first, also, the whole capsule appears of a homogeneous bright yellow, bu.t when further developed, its centre assumes a whiter colour. This arises from the aggregation of the spo- rules of the plant, whicii are more abundant in this situation. As the development proceeds, this central whitish yellow mass assumes a mealy, powdery con>istence, aud encroaches upon the edges of the capsule, whicii gradually disappear, whilst the upper concave form becomes con- vex, as Gruby pointed out. In general, an inflammatory ring is seen round the crust, which, as the capsule becomes elevated above the skin, enlarges, and assumes a deeper colour, indicative of the increased local irritation. At length the whole cracks or splits up ; all regular form is lost; a dense thick crust covers the scalp; an odour, like the urine of cat* or mice, is evolved; and in chronic cases, vermin deposit their eggs in the interstices, and crawl in large numbers over the surface. I have satisfied myself that occasionally the disease, instead of pre- senting distinct capsules round hair bulbs, becomes diffused under the epidermis, which then assumes the appearance of pityriasis, and not unfrequently of chronic eczema. A microscopic examination, however, will in such cases always detect groups of sporules and thalli more or less developed. In one instance I found the sporules smaller than usual, * This explanation of the origin of pustules and purulent matter, when present, has been adopted by Lebert, Remak, and Simon. 800 DISEASES OF THE INTEGUMENTARY SYSTEM. and perfectly globular instead of oval. In others I have seen the sporules three or four times larger than those of ordinary favus, with included nuclei, multiplying fissiparously. Hence the so-called para- sitic pityriasis of the scalp, I believe to be a modification of favus, and consider it a good rule, in all chronic eruptions on the head, to examine the crusts microscopically. The other local symptoms are merely those which result from the greater or less degree of irritation produced in different persons by the changes above referred to. At first, scarcely any uneasiness is felt; perhaps occasional slight itching of the part. As the disease progresses, however, the itching becomes more intolerable, and induces the patient to rub and scratch the scalp. By tliese means, several of the crusts are forcibly torn from their attachments, and considerable effusion of serous fluid and blood is produced. Sometimes inflammation is thus occasioned. Impetiginous pustules are frequently formed, or suppuration produced, terminating in ulceration, and the discharge of an ichorous fluid from beneath the" crusts. At an advanced stage of the disease, the peculiarly offensive odour exhaled is insupportable to those who surround the indi- vidual, and the ichorous discharge, vermin, and crusts, which cover the affected parts, present a most disgusting appearance. C (1 Fig. 463 Although the disease most commonly attacks the hairy scalp, it maj occur on the forehead, temples, cheeks, nose, chin, ears, shoulders, Fig. 463. a, Isolated crusts of Favus, presenting the lupine seed-like depression in different stages of growth (so-called Porrigo lupinosa); some are arranged in groups of twos and threes, b, A larger group of these crusts, somewhat compressed at the sides, like a honeycomb (Porrigo favosa), c, Another group which occurred on the shoulder of a young girl. No hairs passed through the centre of these crusts, d, Largeisolated crusts in an advanced stage of growth, the external ring is cracked, an I the friable centre is enlarged and elevated, e, Numerous crusts aggregated together, so as to form an irregular elevated mass. Traces of the original form may be observed in the cracked rings round the margin. (Natural size.) DERMATOPHYTA. 801 arms, abdomen, lumbar region, sacrum knees, and legs. Albert wives a plate in which it is figured iu all these situations. I have myself seeq it on the cheek, shoulders, back, arms, and inferior extremities, and in some of these situations I could detect no hairs perforating the capsules. (Fig. 463, c.) The constitutional symptoms are of the utmost importance, but, generally speaking, receive little attention from practitioners. In most of the individuals affected, who have come under my notice, the general health has been greatly deranged, and a scrofulous or cachectic constitu- tion more or less evident. In some the fades scrofulosa of authors has been well marked; in others there were engorgements of the lymphatic glands of the neck ; and in the only fatal case which has come under my observation, there were found tubercular depositions in the lungs, mesenteric glands, and other textures. Indeed, the generality of individuals who die labouring under favus, perish from phthisis, or other forms of tubercular disease. The beautiful plates published by Alibert, are in this respect far from being true to nature ; for whilst the capsules and crusts are accurately drawn, the individuals affected seem to be ideal personages, enjoying the most robust health, and possessing even the utmost beauty of form and feature. In the generality of cases, on the contrary, the patient is thin, the countenance is of a dirty yellow colour, and the whole aspect betrays depression of the vital powers. The appetite is often impaired, the alvine evacuations irregular, and the functions of digestion and nutrition are impeded. Numerous writers have observed the physical and mental development of the individual to be retarded ; and Alibert gives instances where the epoch of puberty was considerably delayed. By those not well accustomed to the diagnosis of skin diseases, favus has often been confounded with other eruptions of the scalp, more espe- cially eczema and impetigo, or the combination of tliese diseases known as the eczema impetiginodes. In none of these eruptions, however, do the yellow crusts or scales present traces of vegetations when examiued microscopically. This, therefore, furnishes the real diagnostic and pathognomonic character of the disease.* Occasionally, as ^has been stated, favus presents a scaly character. It has then been called Pity- riasis. On examination of the scurf, however, the epidermic scales will be found associated with the Achorion Schcenleini, in various stages of development. Causes. Alibert considered the disease hereditary, and gives cases confirma- tory of this view. x\s regards age, it is by far most common in children between the ages of three and twelve years. In infancy, and after * I am not aware that this peculiar disease has ever been observed in any of the lower animals. I may therefore mention, that I have seen it on the face of a common house mouse, in which animal the same cryptogamic vegetations were to be detected as in man. Dr. Carter has confirmed this observation in a com- munication he brought before the Royal Medical Society of this city, during the session 18.36-57. Prof. Glusre of Brussels has also described and figured the same fact (Bulletins de l'Academie Royale de Belgique. 2me. serie. Tom. iii. No. 12). 51 802 DISEASES OF THE INTEGUMENTARY SYSTEM. puberty, it is more rare, although sometimes present; and in a few instances it has been observed in persons advanced in years. In almost all the cases which have come under my notice, the individuals have been exposed to causes which depress the vital powers, and are well known excitants of tuberculous disease. Close questioning will usually elicit that they are of a scrofulous family; have been exposed for some time to infected or corrupted air; inhabited small rooms, or confined streets, or dwellings situated in unhealthy situations ; that the aliment has not been very nutritive, etc., etc. Hence why the disease is common in workhouses and jails, and most prevalent amongst the poorer classes of the population, and individuals who obtain a precarious subsistence. Almost every writer on the disease considers it to be contagious. Bateman, Guerseut, and others, speak of its spreading amongst school- boys, from the employment of the same towels, combs, caps, etc. Gibert has seen it propagated in the wards of St. Louis from the same cause. It has been observed, he says, two or three times to be conimuui- cated by young people kissing each other, when it has appeared in the chin or neighbourhood of the mouth. Mahon even pretends to have con- tracted favus incrustations on his fingers, from having neglected to wash them after dressing the heads of those affected. Alibert, in his early writings, also thought it to be contagious. In his later works, however, he evidently doubts it, says that much exaggeration has been made use of on this subject, and states that the amour propre of parents usually induces them to ascribe the origin of so disgusting a disease to external communication. He further observes, " Ales eleves ont souvent tente d'inoculer en notre presence, le produit de rincrustation faveuse, sous plusieurs formes, et en variant le procedes. Le plus souvent il n'est rien resulte, dans d'autres cas est survenue une inflammation passagere, qui s'est bientot evanouie—parfois une suppuration semblable qui pour- rait s'etablir par tout irritant mecanique, ou par l'insertion d'une sub- stance etrangere dans le tegument."* Gruby also, on discovering its vegetable nature, inoculated thirty phanerogamous plants, twenty-four silk-worms, six reptiles, four birds, aud eight mammifera, but only pro- duced the disease once, and then in a plant. The human arm was inoculated five times, but, independent of a slight inflammation and suppuration, no effect was produced. Sixteen years ago I inoculated myself and others many times with a view of determining whether favus was or was not contagious. But in none of these experiments, performed in various ways, and frequently repeated so as to avoid fallacy, could I succeed in causing the plant to germinate on parts different from those on which it was originally pro- duced. In other words, I could not communicate the disease to other individuals, or from one part of the same individual to another. At the time I did not consider these experiments (performed in 1841- 42) as decisive of the question, although they show that it is with great difficulty inoculation succeeds. Shortly after, Dr. llemak, of Berlin, communicated the disease to his own arm iu the following way :—He fastened portions of the crust upon the unbroken skin, by means of plaster. In fourteen days, a red spot, covered with epidermis, appeared, and in a few davsmn^ a dry yellow favus scab formed itself upon the Traite des Maladies de la Peau, fol. p. 443 DERMATOPHYTA. 803 spot," which, examined microscopically, presented the mycodermatous vegetations characteristic of favus.* Mentioning this fact to my poly- clinical class, at the Royal Dispensary, in the summer of 1845, one of the gentlemen in attendance volunteered to permit his arm to be inoculated. A boy, called John Bangh, aet. 8, labouring under the disease, was at the time the subject of lecture, and a portion of the crust, taken directly from this boy's head, was rubbed upon Mr. M.'s arm, so as to produce erythematous redness, and to raise the epidermis. Portions of the crust were then fastened on the part by strips of adhesive plaster. The results were regularly examined at the meetings of the class every Tuesday and Friday. The friction produced considerable soreness, and, in a few places, superficial suppuration. Three weeks, however, elapsed, and there was no appearance of favus. At this time, there still remained on the arm a superficial open sore about the size of a pea,"and Mr. M. suggested that a portion of the crust should be fastened directly on the sore. This was done, and the whole covered by a circular piece of adhesive plaster about the size of a crown piece. In a few days, the skin surrounding the inocu- lated part appeared red, indurated, and covered with epidermic scales. In ten days there were first perceived upon it minute bright yellow- coloured spots, which, on examination with a lens, were at once recog- nised to be spots of favus. On examination with the microscope, they were found to be composed of a minute granular matter, in which a few of the cryptogamic jointed tubes could be perceived. In three days more, the yellow spots assumed a distinct cupped shape, perforated by a hair; and in addition to tubes, numerous sporules could be detected. The arm was shown to Dr. Alison ; and all who witnessed the experiment being satisfied of its success, I advised Mr. M. to destroy each favus spot with nitrate of silver. With a view of making some further observations, however, he retained them for some time. The capsules were then squeezed out, and have not since returned. Mr. M. had light hair, blue eyes, a white and very delicate skin. There is every reason to believe that the strips of plaster employed in the first attempt shifted their posi- tion, and that the crust was only properly retained by the circular pieee of plaster employed in the second experiment. That the disease, therefore, is inoculable, and capable of being com- municated by contagion, there can be no doubt, a result which accords with the observations of most practitioners, and with numerous recorded facts. (Case CLXXIX.) It must also be evident that it does not readily spread to healthy persons, and that there must be either a pre- disposition to its existence, or that the peculiar matter of favus must be kept a long time in contact with the skin previously in a morbid condi- tion. Pathology. We have seen, when describing the symptoms and mode of develop- ment of the disease, that it is not essentially pustular, and that the pustules occasionally present are accidental. On the other hand, it has been shown that the peculiar favus crust is composed of a capsule of epidermic scales, lined by a finely granular mas° : that from this mass * Medicinische Zeitung, August 3, 1842. 804 DISEASES OF THE INTEGUMENTARY SYSTEM. millions of cryptogamic plants spring up and fructify; and that the piesence of tliese vegetations constitutes the pathognomonic character of the disease. In order to examine the natural position of these vegetations micro- scopically, it is necessary to make a thin section of the capsule, com- pletely through, embracing the outer layer of epidermis, amorphous mass, and light friable matter found in the centre. It will then be found, on pressing this slightly between glasses, and examining it with a magni- fying power of 300 diameters, that the cylindrical tubes (thalli) spring from the sides of the capsule, proceed inwards, give off branches dicho- tomously, which, when fully developed, contain, at their terminations (mycelia), a greater or smaller number of round or oval globules (spo- ridia). These tubes are from the T^ to gi^- of a millimetre in thick- ness, jointed at irregular intervals, and often contain molecules, varying from To^»n t0 ioVo °f a millimetre in diameter. The longitudinal diameter of the sporules is generally from -^^ to T^, and the transverse from -ji^ to Ti^ of a millimetre in diameter (Gruby). I have seen some of these, oval and round, twice the size of the others. The long diameter of the former measured A-g of a millimetre. The mycelia and sporules agglomerated in masses are always more abundant and highly developed in the centre of the crust. The thalli, on the other hand, are most numerous near the external layer. There may frequently be seen swell- ings on the sides of the jointed tubes, which are apparently commencing ramifications. On examining the hairs which pass through the favus crusts, it will often be found that they present their healthy structure. At other times, however, they evidently contain long, jointed branches, similar to those in the crust, running iu the long axis of the hair, which is exceed- ingly brittle. I have generally found these abundant in very chronic cases; and on adding water, the fluid may be seen running into these Fig. 464. Branches ofthe Achorion Schcenleini, in the early stage of development, growingvfrom a molecular matter, and mingled with epidermic scales, from a very minute Favus crust. Fig. 465. Fragments of the branches more highly developed, with numerous sporules and molecular matter, from the centre of an advanced Favus crust. 300 diam. DERMATOPHYTA. 805 tubes by imbibition, leaving here and there bubbles of air, more or less long. There can be very little doubt that the tubes and sporules, after a Fig. 466. time, completely fill up the hair follicle, and from thence enter the hair, causing atrophy of its bulb, and the baldness which follows the disease. The various steps of this process, however, I have been unable to follow, never having had an opportunity of observing favus in the dead scalp, and of making proper sections of the skin. Several writers on favus have treated its vegetable nature as a mere hypothesis. At first it was considered, as by Mr. Erichsen,* to be " founded merely upon the outward appearance, sufficiently strong, cer- tainly, which the cup-shaped crust of favus offers to lichens, or vegetations of a similar description." Subsequently favus was supposed to consist of a mass of cells ; and it was argued by Dr. Carpenter t that the vesicular organization is common to animals as well as plants; and hence "to speak of Porriyo favosa, or any similar disease, as produced by the growth of a vegetable within the animal body, appears to the author a very arbitrary assumption." Mr. Erasmus Wilson, in his work on "Diseases of the Skin" (p. 430), as well as in a special "Treatise on Ringworm," is also opposed to the idea of favus owing its essential characters to a vegetable growth. He considers that the peculiar branches and oval bodies previously described are mere modifications of epidermic cells, which in some cases he is of opinion may be transformed into pus cells—in others, into those observed in favus. The branches of the plant he calls " cellated stems," and the sporules, secondary cells; and argues, that mere resemblance to a vegetable formation is not sufficient to constitute a plant. He says, " The statement of the origin of the vegetable formations by roots implanted in the cortex of the crust is un- founded ; the secondary cells bear no analogy to sporules or seeds; and it is somewhat unreasonable to assign to an organism so simple as a ced the production of seeds, and reproduction thereby, when each cell w endowed with a separate life, and separate power of reproduction. % * Medical Gazette, December, 1851, p. 415. f Principles of Physiology, p. 453. X On Ringworm, 1817, p. 23. Fig. 466. o, A light hair containing branches of the Achorion Schenleim (magni- fied 300 diameters linear). The wood-cutter has made the branches too beaded. b, A darker coloured hair, containing branches of the plant. oUU diam. 806 DISEASES OF THE INTEGUMENTARY SYSTEM. Lastly, M. Cazenave,* although he acknowledges himself to be no histologist, says he has sought for the sporules many times, and believes himself authorized to conclude that their detection is not always so easy as is supposed (p. 225). Finally, he denies that favus is a vegetable parasite, and maintains it to be a peculiar secretion, originating in the sebaceous glands (p. 236). With the exception of Mr. Wilson, who appears carefully to have examined the favus crust, the opposition to the vegetable nature of this production seems to have originated in very imperfect notions as to its intimate structure on the one hand, and that of certain cryptogamic plants on the other. For if long hollow filaments, with partitions at intervals, containing molecules within their cells, springing from an unorganized granular mass, and giving off towards their extremities round oval bodies, or sporules, arranged in bead-like rows, be not vegetables, what are they ? The animal tissues present nothing similar, while numerous plants, long known to botanists, present the same identical structure. But not only must they be referred to the vegetable kingdom, but to a considerably elevated position among the cryptogamic plants. The protococcus nivalis and torula cerevisia, universally considered as plants, together with the sarcina ventriculi, described by Goodsir, are immeasurably beneath them in complexity of structure; and many of the mucores or moulds growing in damp places are, as I have satisfied myself \>y repeated examination, much more simple in their organism. Any one who looks over the cryptogamia of Greville will at once detect the strong analogy between the structures found in favus and the penicilium glaucum of Link, the aspergilfus penicillatus, acrosporium monilioides, sporotorium minutum, nostoc caruleum, and other plants therein figured. Indeed, it seems to me surprising how the vegetable nature of these creatures can for a moment be doubted by any one who has personally examined them, especially under powers of from six to eight hundred diameters linear. In considering whether the structures described, and now by every one acknowledged to exist in the favus crusts, really belong to the vegetable kingdom, we should remember that they are not the only formations of this kind which have been found to grow parasitically in living animals. Iu my original paper,f I described others growing in phthisical cavities, in the sordes on the gums and teeth of typhus patients; and pointed out that they had been observed in the living tissues of mollusca, insects, reptiles, fishes, birds, and mammiferous animals. These observations have subsequently been confirmed by numerous pathologists and natu- ralists. Lastly, we cannot overlook the opinion of botanists themselves concerning this question. The most eminent mycologists, so far as I am aware, have no doubt of the vegetable nature of favus. Dr. Greville. to whom I exhibited them, was quite satisfied of the fact. Brongniart, according to Gruby, and Mes.-rs. Link and Klotzsch, to whom they were shown by Remak, expressed a similar opinion. Brongniart considers them to belong to the genus Mycoderma of Persoon. J. M tiller places them among the genus Oidium; but both Link and Klotzsch consider' that they ought to constitute a distinct genus. The former, in consequence, has given it the name of Achorion (from achor, the old term for favus), * Traite des Maladies du Cuir Chevelu, 1850. t Edin. Philosophical Trans. 1842. DERMATOPHYTA. 807 and added to it the designation of the discoverer, Schonlein. The fol- lowing is his description of the plant:— "Achorion Scheenlcini nobis orbiculare, flavum, coriaceum, cuti humanae praesertim capitis in.vdens; rhizopodion molle, pellucidum, floceosum floccis tenuissums, vix articulatis, ramosissimis, anastomoticis (?) •* mycelium floccis crassioribus, subramosis, distincte articulatis, articulis inaequalibus irregulanbus in spondia abeuntibus ; sporidia rotunda, ovalia vel irrejularia in mo vel pluribus lateribus germinantia?'1 The mode of development from sporules has now been determined with considerable exactitude. Remak made small grooves on the cut sur- face of a fresh apple; placed portions of the favus crust in them; then laid the apple, with the cut surface turned upwards, in moist sand; and covered the whole with a glass bell. Under these circumstances, he found that the sporules developed themselves, and he examined them frequently up to the sixth day, when the surface of the apple became of a brown colour, and was covered with a rapid growth of Penicilium glaucum, or otlier kind of mould, among which the structure peculiar to favus could no longer be traced. These observations, however, showed that the sporules of the Achorion undergo development in the same manner as those in other cryptogamic plants. That is, the membrane whicii surrounds them throws out one or more prolongations, which are converted into tubes; and these, in turn, present, generally towards their extremities, a number of sporules, which at length are pushed out, Fig. 467 Fisr. 469. or are disintegrated, and so become free. Figs. 467 and 468 represent the changes observed in the sporules germinating on the surface of the apple; and Fig. 469 shows the thalli, mycelia, and sporules, seen in the crusts, produced by inoculation, on Remak's arm. The method of reproduction and formation of sporules may be observed with great facility in any well-developed favus crust, especially under powers varying from 500 to 800 diameters linear. Thalli, with variable-sized cells, may be observed branching at the extremities, with * I have never seen any anastomosis. Fig. 467. Sporules developing on the surface of an apple, after three days. Fig. 468. The same, after four days. Fig 469. The same more fully developed on the human arm, after inoculation. a, Thalli, with pale walls; b, containing sporules (mycalia); c, mycelium separated from the thallus; d, sporules separated from the mycelium—[after Remak). 300 diam 808 DISEASES OF THE INTEGUMENTARY SYSTEM. sporules forming within them. These are conjoined with separated mycelia, containing well-developed sporules, many of which are also free, as in the figure below. It follows, therefore, that all the circumstances connected with the development and mode of reproduction of the Achorion Schcenleini have been fully ascertained. The seat of favus has been much disputed by authors. By some it has been located in the piliferous bulbs or follicles (Duncan, Baude- locquc, Rayer), by others in the sebaceous glands (Sauvages, Underwood, Murray, Mahon, and lately by Cazenave), and a third party in the reti- cular tissue of the skin (Bateman, Gallot, Thomson). According to Gruby the plants grow in the cells of the epidermis, the true skin is compressed, not destroyed, and the bulbs and roots of the hairs and sebaceous follicles are only secondarily affected. I have made observations to determine the correctness of this state- ment, and have found that the whole inferior surface of the capsule is formed of epidermic scales, thickly matted together. These are lined by finely molecular matter from which the plants appear to spring, and which unites the branches and sporules together in a mass. Superiorly, however, the epidermic scales are not so dense ; and I have always found them more or less broken up, and not continuous. This observation is valuable, as indicating the probable mode in which these plants, or the sporules producing them, are deposited on the scalp. It will be seen that the appearance of the peculiar porrigo capsule was invariably pre- ceded by a desquamation of the cuticle, that is, a separation or splitting up of the numerous external epidermic scales which constitute its outer- most layer. Hence it is more probable that the sporules or matters from which the vegetations are developed, insinuate themselves between the Fig. 470. Thalli, mycelia, and sporidia, of the Achorion Schcenleini, showing the mode of reproduction. 800 diam. DERMATOPHYTA. 809 crevices, and under the portion of epidermis thus partially separated than that they spring up originally below, or in the thickness of the cuticle. Hie chemical constitution of the matter originally exuded is supposed by M. Cazenave to be allied to fat, but it appears to me to be more pro- bably albuminous, and allied to the molecular character of all broken down or disintegrated organic material in which fungi grow. We have seen that^ previous to the return of favus crusts, the head is always covered with broken-up epidermis, more or less disintegrated. Experi- ments have shown that the plants will not grow on the healthy skin, and that inoculation succeeds only in places where pustules have pre- viously been formed. It is also exceedingly probable that, when favus is communicated from one person to another, the part affected (generally the scalp) has been the seat of some other eruption (Case CLXXIX.), or is not particularly clean. Mr. Erichsen considers, " That the matter of favus is a modification of tubercle—that it is a tubercular disease of the skin. By tubercular I do not mean a disease like lupus, characterised by small firm tumours, but a disease, the nature of which consists in the deposition of that hete- rologous formation called tubercle." This view of the nature of favus I have long held; and it was distinctly stated by me, when treating of the pathology of scrofula, in a work published in 1841.* The favus crust, however, is not constituted wholly of tubercular matter. The peculiar exudation only constitutes the soil from which the mycodermatous vege- tations spring, as I shall now endeavour to show. Gruby describes the mycodermata of favus as springing from an amor- phous mass, of which the periphery of the capsule is composed. This mass undoubtedly exists, and, according to my observations, is composed of a finely molecular matter, identical in structure with certain forms of tubercle, or recently coagulated exudation. The cheesy matter, for instance, so frequently found on the secreting surface of serous membranes, and in tubercular cavities and other structures in chronic cases of tuber- culosis, or general tendency to tubercular deposition, presents this cha- racter. Every pathologist who has minutely examined tubercle recog- nises a granular form in which there is no trace of nucleus or cell, and which, therefore, we are warranted in considering as unorganised. I have myself repeatedly examined this tubercular matter, and been unable to detect any difference between it and the mass in which the vegetations of favus appear to grow. Chemical analysis of this form of tubercle demontrates it to be composed principally of albumen, with a minute proportion of earthy salts; sometimes there is combined with it a small quantity of fibrin or gelatine. If this general result be compared with the analysis, by Thenard, of favus matter, the identity between it and tubercle must appear highly probable. He found in 100 parts—coagu- lated albumen, 70; gelatine, 17; phosphate of lime, 5; water and loss, 8 parts. Thus the evidence furnished by morphology and chemistry- agrees in determining the molecular matter found in the crusts of favus and in tubercle to be analogous. * Treatise on the Oleum Jecoris Aselli, p. 94. 810 DISEASES OF THE INTEGUMENTARY SYSTEM. Remak found that, although the sporules underwent developmental changes on the cut surface of an apple, as well as in animal fluids to whicii sugar had been added, no such changes took place in spring or dis- tilled water, in the serum of blood, solution of albumen, pus, muscle, substance of brain, cut pieces of skin, ov animal fat. In these cases the animal tissues, as well as the portions of favus crust, became gradually disintegrated, and infusorial formations commenced. Hence the Acho- rion grows under the same circumstances only as all other moulds. Putrefaction of animal or vegetable substances is unfavourable to its pro- duction; but that peculiar acid change which occurs in milk or paste, ex- posed to the air for some days, and in which growths of mould and con- fervae are favoured, is also beneficial to the development of favus. Hence why inoculation in healthy tissues fails, and why certain exudations in peculiar states of the constitution, or disintegrated matters which have undergone particular chemical changes, probably from acid secretions of the skin, are necessary to the production of the disease. I believe, therefore, that the pathology of favus is best understood by considering it essentially to be a form of abnormal nutrition, with exudation of a matter analogous to, if not identical with, that of tubercle, which constitutes a soil for the germination of cryptogamic plants, the presence of which is pathognomonic of the disease. Hence is explained the frequency of its occurrence in scrofulous persons, and among cachec- tic or ill-fed children: the impossibility of inoculating the disease in healthy tissues, or the necessity for there being scaly, pustular, or vesi- cular eruptions on the integuments, previous to contagion. But as ex- periments have proved the possibility of inoculation in healthy persons, it follows that the material in which the vegetations grow, may at the commencement, in a molecular exudation, be formed primarily or secon- darily. That is, there may be want of vital power from the first, as occurs in scrofulous cases, or there may have been production of cell forms, such as those of pus or epidermis, which, when disintegrated and reduced to a like molecular and granular material secondarily, constitute the necessary ground from whicii the parasite derives its nourishment. and in which it grows. Treatment. Almost every species of treatment has been had recourse to, in order to remove this disagreeable and intractable disease; and there can be no doubt, that cases have recovered under the use of all and' each of the methods recommended. In some instances, favus wears itself out, or rather, as the development of the frame proceeds, and the constitutional strength improves, the conditions necessary for its production and main- tenance are removed, and it consequently disappears. In every case, however, it must be our object to get rid of the disease permanently as soon as possible, and this is only to be done by removing the pathologi- cal conditions on which it depends. The notion that it originates in the bulbs of the hair caused an attempt to remove the disease by eradicating the structures with which it was supposed to be connected. Hence the barbarous and cruel treat- DERMATOPHYTA. 811 ment by means of the Calotte. This consisted in spreading a very ad- hesive plaster inside a cap, which closely fitted the shaven scalp. The hair was then allowed to grow and insinuate itself amongst the sub- stance of the plaster—when the whole was forcibly torn off. In this way, portions of the scalp were sometimes separated—at others, pieces of the plaster remained firmly attached, and gave great trouble. A modification of this plan consisted in covering the head with the plaster in strips, which were removed separately from before backwards, and from behind forwards, so as to tear out the hairs. Even this plan failed. The practice I saw adopted in Berlin, in 1841, consisted in plucking out the hairs individually with a pair of pincers; but this tedious and painful method, also, was found to be of little service. In Paris, the above kinds of practice have generally been put aside for the milder empiric treatment of the freres Mahon. Between the years 1807 and 1813, 439 girls and 469 boys, affected with favus, were cured by them at the Bureau Central des Hopitaux, and the mean duration of the treatment was 56 applications. These applications are generally made every other day, so that the average length of treatment by this much boasted and successful method is three months and a-half. I have endeavoured to show, however, that in many cases it is a con- stitutional disease, and dependent upon the causes which induce scrofu- lous diseases in general. The treatment, therefore, in such ought to be constitutional, and directed to removing the tendency to tubercular exu- dation, on which the malady depends. No doubt, however, a local treatment in this, as in all other disorders which are at the same time general and local, is of the utmost service. I consider, then, that the chief indications of treatment are—1st, To remove the constitutional derangement; and, 2dly, To employ such topical applications as tend to prevent the development of vegetable life. This line of practice mav be thought similar to that recommended long ago by Lorry, who advises, 1st, A modification of the fluids and solids of the economy by a general treatment; "Ally, A vigorous attack upon the local disease by topical applications, capable of removing the crusts, causing the skin to suppurate deeply and substituting a solid cicatrix for the morbid ulceration of the hairy scalp. For the most part, however, brought forward be correct, and it is in its nature allied to tubercular affections, a treatment exactly opposite ought to be pursued. Ihe de- velopment of vegetable life may also be prevented by the_application ot much milder remedies than the escharotics, or irritating ointments usually employed. , , , We have previouslv seen that tuberculosis is caused and kept up by some fault in the digestive process; that the blood _ is secondarily affected, and its albuminous constituents proportionately increased ; that the albumen at length becomes effused into the different structures ot the economy, causing the various forms of tubercular disease ; and lastly, as the albumen in the blood becomes excessive, and its effusion into the textures increases, the fatty constituents of the frame diminish It ha, been shown, by numerous facts, that under such circumstances the inter- 812 DISEASES OF THE INTEGUMENTARY SYSTEM. nal and external exhibition of cod-liver oil has been attended with the most marked advantage, aud often been made the means of cure when all other remedies have failed. The action of the oil appears to be the same in favus as in other forms of scrofulous disease, and its use should be combined with appropriate diet and exercise, and with reference to the same indications and contra-indications. The local treatment I have employed for several years, is directed, in conformity with the pathological views previously detailed, to the exclu- sion of atmospheric air, so as to prevent vegetable growth. For this purpose, I direct, in the first instance, that the affected scalp should be poulticed for several days, until the favus crusts are thoroughly softened, and fall off. Then the head is to be carefully shaved, after which it will be found to present a shining clear surface. Lastly, cod-liver oil should be applied with a soft brush, or dossil of lint, over the affected surface morning and night, and the head covered with an oil-silk cap to prevent evaporation, and further exclude the atmospheric air. Every now and then, as the oil accumulates and becomes inspissated, it should be removed by gently washing it with soft soap and water. It is very pos- sible common lard, or any other oil, would do as well as cod-liver oil. In one case I found a sulphurous acid lotion succeed. I have found the average duration of this treatment to be six weeks, which contrasts very favourably with the results of MM. Mahon's prac- tice at the Hupital St. Louis. Some cases seem to be incurable, and these are most frequent among adults; but even in them, so long as the scalp is kept moist with oil, and the air is excluded, the eruption will not return (Case CLXXVIL). In young subjects, in whom general as well as local treatment is admissible, and in whom a scrofulous disposi- tion is manifest, the prognosis is more favourable, and the disease may be permanently eradicated (Cases CLXXVIII. to CLXXX.). Whenever favus is recent and of limited extent, it may at once be destroyed by cauterization with nitrate of silver (Case CLXXXL). Lebert is of opinion that poultices and oily applications soften the favi, and distribute the sporules over the skin. He, therefore, insists on removing the crusts dry, by means of a small spatula, sewing needles, or other instruments. He says that nothing is more easy than to detach them entire; for, although pushed into the skin, they are not held there by any adhesion. But I think it will be found that, however dexterous a person may be in removing the crusts, that the majority are held finny by the scalp, by means of the hair which perforates them, and that tearing these out is very painful. Besides, the crusts are easily broken, and the time and trouble required, even when they are thinly scattered, renders this plan impracticable in hospitals. When densely matted together, it, of course, cannot be done. I believe, then, that repeated poulticing is by far the best and most efficient method of freeing the skin from eruption, whilst it has the extra advantage of doing so without irritation, and thereby diminishing the tendency to the formation of im- petiginous pustules. SECTION X. DISEASES OF THE BLOOD. The diseases of the blood have strongly engaged the attention of modern pathologists, who, putting aside the vague speculations which the ancients held regarding this important fluid, have sought to inves- tigate the subject by the aid of facts derived from chemical, micro- scopical, and clinical researches. The general results of these have been sketched, pp. 102 to 105. The alterations of the blood give rise to many of the most important disorders which affect the body, besides being necessarily associated more or less with every morbid change connected with alterations of nutrition. It is the principal idiopathic or essential forms of blood disease which will be treated of in this place. LEUCOCYTHEMIA. On the 19th of March, 1845,1 examined the body of a man, who died under the care of Professor Christison, in the Royal Infirmary, labouring under hypertrophy of the spleen and liver, and whose blood was crowded with corpuscles which exactly resembled those of pus. This case was the first of the kind in which a careful histological examination of the blood was made, and in which the remarkable morbid condition then discovered, was separated from ordinary pyaemia, and shown to be unconnected with any form of inflammation. It was published in the Edinburgh Med. and Surg. Journal, October 1st, 1845, vol. lxiv., p. 413. Dr. Cragie, who was present at the dissection, recognised its similarity to one he had had under his care four years previously, the blood of which had been examined microscopically by Dr. John Reid, who found " that it contained globules of purulent matter and lymph." An account of it appeared in the same number ofthe Edinburgh Journal for October, 1845. Six weeks after these cases had been published, Professor Vir- chow of Berlin gave the history of another, in the second number for 814 DISEASES OF THE BLOOD. November, 1 S45, of Froriep's '• Notizen " (No. 780), under the name of " Leukhemia," or white blood. On the 31st of December, 1845, a man was received into St. George's Hospital, London, in whom Dr. Fuller detected, both before and after death, the increased number of colourless corpuscles in the blood. This man, like the other individuals, had great hypertrophy of the spleen. A notice of the case is inserted in the " Lancet," for July, 1S46. Since then several similar cases have been met with, in which this morbid condition of the blood has been deter- mind to exist, by an accurate examination with the microscope ; and a reference to the records of medicine has shown the previous occurrence of like cases. In these last, the blood, with two exceptions, was not physically proved to contain an unusual number of colourless corpuscles, although now on looking back upon the facts whicii are mentioned in regard to them, we can have little doubt that such was the case. The exceptional cases occurred to M. Barth in 1839, and Dr. Cragiein 1841. In the first, M. Donne found one-half the corpuscles in the blood to be " mucous globules," and in the second, Dr. John Reid found that the blood " contained globules of purulent matter and lymph." * The term " Leukhemia," or white blood, given to this disease by Virchow, is faulty, because, in the first place, as was correctly stated by Dr. Parkes, the blood is not white, but' presents its usual red tinge when drawn from the arm. The colourless clots occasionally observed after death will certainly not warrant the application of this term to the blood generally, as they are frequently present without the morbid condition under consideration. Besides, the same name (white blood) has been given with more propriety to the fatty blood, examined by Drs. Traill, Christison, and others, whicii presents a milky, opalescent appearance. At the meeting of the Academy of .Medicine in Paris, ou January 29th, 1856, the members were naturally enough led into great confusion in consequence of not keeping this distinction in view. What ought to be expressed is, that the blood abounds in. colourless corpuscles, and this is done by the term Leucocythemia—from Aewos, white; kvtos, cell; and alp.a, blood—literally, white cell blood, which expresses the simple fact, or pathological state, and involves no theory. Throughout England and France this name has been universally adopted. Case CLXXXIII.f—Leucocythemia discovered after death—Hypertrophy ofthe Spleen, Liver, and Lymphatic Glands—Absence of Phlebitis and of Purulent Collections in any part of the Body. History.—John Monteith, aged 28, a slater—admitted into the clinical ward of the Royal Infirmary, February 27, 1845, under the care of Dr. Christison. He is of * Gazette Hebdomadaire, March 21, 1856, and Edin. Med. and Surf. Journal, October, 1845. f This case occurred in the clinical ward of Professor Christison, who treated it. The body after death was most carefully inspected by me as pathologist to the Royal Infirmary, and parts were removed for careful subsequent examination, and for pre- servation, the appearances being altogether of a kind quite new to me. The case, for reasons which will appear in the sequel, is here given verbatim, as it was origi- nally published in the Edinburgh Journal for 1st October, 1845. LEUCOCYTHEMIA. 815 dark complexion, usually healthy and temperate ; states that twenty months ago he was affected with great li.-tlessness on exertion, which has continued to this time. In June last he noticed a tumour in the left side of the abdomen, which gradually increased in size till four months since, when it became stationary. It was never painful till last week, after the application of three blisters to it; since then, several other small tumours have appeared in his neck, axilla?, and groins, at first attended with a sharp pain, which has now, however, disappeared from all of them. Before he noticed the tumour, he had frequently vomiting in the morning. The bowels are usually consti- pated, appetite good, is not subject to indigestion, has had no vomiting since he noticed the tumour ; he has used chiefly purgative medicines, especially croton oil; employed friction with a liniment, and had the tumour blistered. Symptoms on Admission.—On cdmission, there is a large tumour, extending from the ribs to the groin, and from the spinal column to the umbilicus, lying on the left side. It is painful on pressure near its upper part only. Percussion is dull over the tumour; pulse 90 ; states that for three months past he has not lost in strength. There is slight cedema of the legs. To have two pills of iodide of iron morning and evening. Progress of the Case.—March 1st.—Urine of yesterday somewhat turbid when just passed, natural in colour, acid to litmus; sp. gr. 1013. Sediment presents cubic crystals under the microscope, disappears almost entirely on the addition of aqua potassse, but is unaffected by nitric acid. The filtered urine is not affected by aqua potassa?, and yields only a slight white haze when boiled. March 9th.—(Edema of legs increased. They have been bandaged with flannel rollers R^ Potassce Carbonatis, l'i', Spiritus jEtheris Nitriei, 3iv; Aqiue Mentha;, § iij; Aquas fon fix, 3 ij. M. Sumat unciam ter in die. March 10th.—Tormina and considerable diarrhoea; urine not increased. Habeat haustum ex Olei Ricini 3 ss statim ; et cxactis quatuor horis Opii, gr. ii. March 13th.—Attacked this morning with heat of skin; thirst; pulse 110, full, very compressible. The diarrhoea, which had been checked, returned yesterday; none this morning after taking an opium pill. Urine 100 ounces. Omittantur medi- camenta. Sumat statim Pulveris Ipecacuanhas et Opii, gr. x, et repetatur dosis singulis semihoris ad tertiam vicem. March 14th.—Xo sweating from the powders; diarrhoea still rather troublesome ; pulse 100, softer; tongue dry and brown ; febrile expression of countenance, resembling that of typhus, ty Aqua; Acetatis Ammonias 3vi; Solutionis Morphia;, 3i; Aquasfontis, 3" iij ; Syrupi, ?j. Sumat unciam quarta qudque hord. Habeat decoctum hordei pro potu. March 15th.— Died suddenly in the morning. Sectio Cadaveris.—March 19 (four days after death). Externally, the body presented a considerable prominence ofthe ensiform cartilage and false ribs' on both sides. The abdomen was contracted; considerable dulness on percussion on left side, which had previously been marked out by a line formed with nitrate of silver. No ascites nor cedema of the limbs. Blood.—The blood throughout the body was much changed. In the right cavities of the heart, pulmonary artery, venae cava, vena azygos, external and internal iliac veins, and many of the smaller veins leading into them, it was firmly coagulated, and formed a mould of their size and form internally. In the cavities of the heart and vena? cava?, the blood, when removed, was seen to have separated into a red or inferior, and a yellow or superior, portion. The red portion was of a brick-red colour ; it did not present the dark purple smooth and glossy appearance of a Healthy coagulum, hut was dull and somewhat granular on section, and when squeezed readily broke down 816 DISEASES OF THE BLOOD. into a o-rumous pulp. The yellow portion was of a light yellow colour, opaque and dull, in no way resembling the gela- tinous appearance of a healthy de- colorised clot. When squeezed out of the veins, as was sometimes acci- dentally done where they were divided, it resembled thick creamy pus. In some portions of the veins, the clot was wholly formed of red coagulum. In others it was divided into red and yellow. In a few places the yellow formed only a streak or superficial layer upon the Fil'. 4T1. red, or covered the latter with spots of various sizes. Whether this coagulum existed in all the veins, could only have been ascertained by a complete dissection of the body. It was seen, however, that the femoral veins, after passing under Poupart's ligament, were empty and perfectly healthy, as far down as the Sartorius muscle. The external and internal iliac veins, as well as the pelvic vein.-, were full and distended. The azygos, both axillary and jugular veins, were full, also the longitudinal, the lateral, and other sinuses at the base of the cranium, and veins ramifying on the surface of the brain. In this last situation some of the veins appeared as if full of pus, whilst others were gorged with a dark coagulum —(See Fig. 473). In the aorta and external arteries were a few small clots, resem- bling those found in the veins. These vessels, however, were comparatively empty. The basilar artery at the base ofthe brain was distended with a yellow clot. Vessels.—The arteries and veins themselves were perfectly healthy. Although carefully looked for, in no place could thickening or increased vascularity be observed. Nowhere was the clot adherent to the vessels, but, on the contrary, it readily slipt out when an accidental puncture was made in them. Head.—On removing the dura mater, the veins which empty themselves into the longitudinal sinus were considerably engorged, especially posteriorly. Some were filled with the red, and others with the yellow clot previously described. Others, ngain, were half filled with red and half with yellow coagulum, the passage ofthe one into the other being clearly perceived. Both hemispheres, with the longitudinal sinus and fidx in situ, were removed by a section across the brain, as low down as the division of the cranium would permit. The brain was then discovered to be very soft uniformly,—a circumstance accounted for by the time which had elapsed since death. The part removed was put aside, in order to be preserved and hardened in spirit. The lateral ventricles were found healthy, contained no serum, and the choroid plexus was perfectly normal. At the base of the brain the Fig. 471. Portion of clot from the vena cava, showing the divisions into red and white coagula. Half the real size. Fig. 472. Posterior surface of the aorta and vena cava. An incision has been made in the latter, to show that it is not thickened or diseased, as well as to expose colour- less coagula even in the most depending portions of the clot. Half the real size. LEUCOCYTHEMIA. 817 basilar artery was seen distended with the yellow coagulum, as were also a few ofthe arteries, hut to a very slight extent. The substance of the brain itself was throu-mont healthy. All the sinuses at the base ofthe cranium gorged with the red coa^Ium Fig. 478. Chest.—A few chronic adhesions united the pleura; on both sides, which were easily torn through. Both lungs were slightly engorged posteriorly and inferiorly. The anterior margin of the left lung emphysematous, but to no great extent. On section, the yellow coagulum of the blood was observed to occupy all the ramifications of the pulmonary artery. In some places it was so consistent as to be drawn out, exhibiting an arborescent form; in others, it was more soft, and exuded from the cut surface like thick pus. Heart somewhat enlarged ; weighed, when freed from coa°u- lum, eleven and a half ounces. Its texture was healthy; the valves normal. The ri°ht auricle much distended, and gorged with a firm coagulum, the upper third of which was found composed of the yellow, and the two inferior thirds of the red clot formerly described. The right ventricle and pulmonary artery were similarly distended; portions of the clot closely embraced the columnae carneae, but were in no place adherent. The coronary arteries and veins were normal. Abdomen.—On the interior surface of the diaphragm there existed a firm, almost cartilaginous, deposit, about a Une in thickness, of a white colour, oval form, two inches long by one and a half broad, with irregular margins, which were composed of several rounded tubercular bodies, the size of a small pea, and of a fibrous struc- ture. The liver enormously enlarged from simple hypertrophy. Its structure throughout healthy. Gall-bladder enlarged, and distended with a clear pale yellow Fig. 473. Appearance of the upper surface of the hemispheres after removing the dura mater, showing the remarkably white appearance of the coagula in the veins and longitudinal sinus. Half the real size. 52 818 DISEASES OF THE BLOOD. • bile. The whole weighed ten pounds twelve ounces. The spleen also enormously enlarged from simple hypertrophy. It was of a spindle shape, largest in the centre, tapering towards the extremities. It weighed seven pounds twelve ounces. It measured in length fourteen inches; in breadth, at its widest part, seven inches; and iu thickness, four and a half inches. Towards its anterior surface was a yellow firm exudation, about an inch deep, and three inches long. The peritoneum, also covering a portion of its anterior surface, was thickened, opaque, and dense over the space about the size of the hand. Both kidneys healthy. The stomach and intestines healthy throughout. About four inches from the anus the superior hemorrhoidal veins were distended on both sides external to the rectum. They formed two chains of tumours about three inches long, consisting, on the one side, of three swellings as large as a walnut; on the other, of one swelling somewhat larger. They were filled with a red coagulum, broken down into a grumous mass. The lymphatic glands were everywhere much enlarged. In the groin they formed a large cluster, some being nearly the size of a small hen's- egs, and several being that of a walnut. The axillary glands were similarly affected. The bronchial glands were not only enlarged, but of a dark purple colour, and in some places black from pigmentary deposit. The mesenteric glands were of a whitish colour, some as large as an almond nut. A cluster of these surrounded and pressed upon the ductus communis choledochus. The lumbar glands were of a greenish-yellow colour, also enlarged, forming a chain on each side, and in front of the abdominal aorta, more especially at its bifurcation into the iliacs. No collection of pus could be found in any ofthe tissues. Fig. 474. Microscopic Examination.—The yellow coagulum of the blood was composed of coagulated fibrin in filaments, intermixed with numerous colourless corpuscles, Fig. 474. Colourless corpuscles, mingled with a few coloured ones, from the white clot ofthe blood in Case CLXXXIII. Fig. 475. The same bodies mingled, with a larger number of yellow blood cor- puscles in the red clot. Fig. 476. Change produced on the colourless corpuscles on the addition of acetic acid, the yellow corpuscles being dissolved. Fig. 477. Cells in the fluid squeezed from the lymphatic glands, after the addition of acetic acid. Fig. 478. Blood-vessels giving off a capillary from the pia mater; the latter is seen filled with colourless corpuscles; the former partly with colourless, mingled with coloured corpuscles. 250 diam. LEUCOCYTHEMIA. 819 • which could be readily squeezed out from it when pressed between glasses. Where the yellow coagulum was unusually soft, the corpuscles were more numerous, and the fibrin was broken down into a diffluent mass, partly molecular and granular, partly composed of the debris of the filaments broken into pieces of various len. tions with regard to number ^& and size of the colourless cor- Fig. 4S2. Fig. 4S8. puscles were found to exist, as have just been referred to in blood drawn fresh from the finger. It was always observable, however, that they were most numerous in the clot; and when they existed in any number, as in Case CLXXXIIL, they communicated to the colourless coagulum a peculiar dull, whitish look, and rendered it more friable under pressure. When less numerous, por- tions of the colourless coagulum from the heart and large vessels might be seen to present a dull cream colour, easily distinguishable from the gelatinous and fibrous appearance of a healthy clot, and such altered portions always contained a large number of the colourless bodies. The blood has been carefully examined chemically in several cases, from which it would appear that there is generally an excess of the fibrin and diminution of the corpuscles. The former ranges from 3 to 7 parts, and the latter from 100 to 49 parts in a thousand. In a well-recorded case by Dr. Wallace of Greenock, the blood was analysed by Dr. W. Fig. 482. Colourless corpuscles slightly increased in number. Fig. 483. The same after the addition of acetic acid. 250 diam. LEUCOCYTHEMIA. 829 Robertson, and ascertained to contain in 1000 parts only 1-5 of fibrin, and 79* of corpuscles.* The organs which have been found most uniformly diseased are the spleen, the liver, and lymphatic glands. The spleen, in the great ma- jority of cases, has been enlarged, varying in weight from one to above nine pounds. The texture of the organ varied in different cases—in some Deing of unusual density, in others it was natural, and in a third class was more or less pulpy. In a few cases it contained yellowish masses, apparently a form of desposit, but in reality a degenerated tissue. In most cases the cell and nuclear elements of the pulp were increased in amount, while the fibrous portion of the organ was apparently normal. Mere enlargement of the spleen, however, is not necessarily connected with leucocythemia, as I have met with many cases where it has been greatly hypertrophied without appreciable alteration of the blood. It has appeared to me that in such instances the enlargement is more owing to congestion and fibrous hypertrophy, than to increase in cell elements. Next to the spleen, the liver is most commonly found diseased in leuco- cythemia. In the majority of cases it is simply hypertrophied, and in a few, cirrhosed in various stages, or cancerous. The lymphatic glands are, also, frequently enlarged. In most cases they are soft, presenting on section a granular whitish appearance, and yielding a copious turbid juice on pressure. In a few cases they were indurated, loaded with cal- careous deposits, or infiltrated with cancerous or tubercular exudation. The solitarg and aggregated glands of Peyer have also been found by- 'i^M pertrophied in a few cases. The thyroid body was cancerous in one case, and evidently gave rise to the g^ leucocythemia (Case CLII.) ; and ^> in certaiu cases of bronchocele, in •&>££ which the blood was examined by Flg> 4S4- Drs. Holland and Neale, a similar condition was observed. Dr. Addison has also shown, in two of his cases of disease of the supra-renal capsules, that the blood was leucocythemic. Other lesions which have been occasionally found in cases of leucocythemia are evidently accidental, and in no way connected with that morbid state of the blood which we are now considering. , Relation existing between the Colourless and Coloured Corpuscles of the Blood.—Many physiologists have maintained that the coloured corpus- cles are formed from the colourless ones; and among those who hod this opinion, some have supposed that the latter bodies are directly transformed into the former (Pagetf). Others, again contend that, whilst such maybe the case in fishes, reptiles, and birds, in mammals the coloured disc is merely the liberated nucleus of the colourless cell (Wharton Jones J). From the observations I have made on the blood * Glasgow Journal. April 1855 ,„.,,„ . , aa ?.Q i Lond. Phil. Trans., 1846. f Kirke's Physiology, pp. 68, 09. \ im . _____ Fig. 4847 Colourless corpuscles increased in number and of small size. Kg. 485. The same after the addition of acetic acid. -m «*««■ 830 DISEASES OF THE BLOOD. corpuscles in cases of leucocythemia, the latter appears to me to be the more correct opinion. The mode of transformation of the nucleus of the colourless cell into the flattened, biconcave, coloured disc, has not yet been described; but from the appearances I have observed, it would seem to take place in the following manner :—The colourless cell may frequently be seen, on the addition of acetic acid, to have a single round nucleus. But more commonly the nucleus is divided into two, each half having a distinct depression, presenting a shadowed spot in its centre. Occasionally, before the division takes place, the nucleus becomes oval, and sometimes is elongated, more or less bent, and even of a horse-shoe form. Not unfrequently the nucleus is divided into three or four granules, each having the central shadowed spot. All the appearances here figured have been frequently observed, and I have placed them in the presumed order of development. ©@®®(D®(D @©(Di)©®i) Fig. 4S6 On one occasion the colourless bodies in the blood were of two distinct sizes. The smaller were.evidently free nuclei, such as could be observed within the larger. (See Figs. 492 and 493.) On examining these latter, after the addition of acetic acid, all the appearances represented in the accompanying figure were observable, and these I have again placed in a b Fig 457. the presumed order or development. On examining the lymphatic glands in this case, they were^observed to contain the first body figured (a) in great numbers, associated with a few of the second one (b). On several occasions the blood, when crowded with colourless cor- puscles, was removed from the arm by venesection ; and it was observed, that after standing twenty-four hours these variously-shaped nuclei had become of a straw colour, and exactly resembled the coloured discs in tint. It was immediately apparent that they had imbibed the colouring matter of the blood, leaving the cell which surrounded them perfectly transparent, (See Fig. 481, p. 822.) With a view of still further determining the transitional changes in the colourless cells, I performed the following experiment:—A rabbit was killed three hours after having eaten a meal. The thorax was ra- pidly opened, and a ligature placed round the pulmonary artery, to pre- Fig. 486. Colourless blood-cells observed in leucocythemia, showing the different appearances of the nuclei, placed in the presumed order of their development. Fig. 487. Presumed development of the nucleus in colourless blood-cells, in another case of leucocythemia 500 diam. LEUCOCYTHEMIA. 831 vent the corpuscles coming from the thoracic duct passing into the lungs. The abdomen was then pressed gently for a few moments, to favour the flow of chyle, and then a ligature placed round the large vessels, and the heart removed by cutting above it. On examining the blood in the right ventricle, it presented an unusually large number of colourless cells, the nuclei of which, on the addition of acetic acid, exhibited all the transi- tion stages figured Fig. 486. On examining the blood in the left ven- tricle, the colourless cells were found normal in amount. This experi- ment was repeated with the same results. I am therefore of opinion, with Valentin, Wharton Jones, and others, that the coloured blood corpuscles in mammals are free nuclei. But I do not consider, with the latter observer, that these nuclei iu mammals should necessarily proceed so far in development as to be surrounded with a cell-wall,—in other words, the coloured disc is not always a fur- ther phase in the evolution of the colourless cell. On the contrary, I believe that the vast majority of the coloured blood discs simply reach the nuclear stage of growth before they join the circulation. Many of them, however, do proceed beyond this point in development, and may be seen to have cell-walls around them. Under such circumstances, the nuclei increase endogenously by a process of fissiparous division, in the manner formerly described, circulate in the blood within colourless cells, and on the solution of the cell-wall, also become coloured blood discs. I have further examined the blood of birds, reptiles, and fishes, and have been enabled to observe transitional forms between the colourless and coloured cell, with even greater facility than I could in man. Indeed, the attention once directed to this point, scarcely a demonstration of blood can be made in these animals without seeing abundant evidence that the latter is a transformation from the former. In them, however, the colourless cell, at first ® © O © @ round, enlarges gradually, becoming oval, and colour Fig. 4ss is added to it. The nuclei, also, after the addition of acetic acid, may be observed in these animals to be undergoing fissiparous multiplication within the cells. Thus all the appearances, _ n * n e TT „, , V a on j-i l. fr 1.1 ° ° v « O Haddock. Dig. 489, may readily be seen. Hence the _ ~ same mode of endogenous development © © vi r^ (§ 0 ilirkey- may take place in the blood-cells of all the -./»*(. t>s» Frog. vertebrated tribes of animals, the difference ' y^ B®° being, that whilst in birds, reptiles, and Fig. 489. fishes, the corpuscles retain the form of nucleated cells, in mammals we find the majority of them to be free nuclei. Fig. 488. Cells of various sizes, colourless and coloured, observed in the blood of a haddock, frog, and turkey, placed in the order of their supposed development. The three first bodies figured in each line are colourless. Fig. 489. The nuclei of the blood-cells of the haddock, frog, and turkey, as seen after the addition of acetic acid. 45u dmrn- 832 DISEASES OF THE BLOOD. Origin of the Blood Corpuscles.—Hewson was the first who distinctly stated that the blood corpuscles were derived from the lymphatic glands, yet few have adopted his opinions. Even Cruickshank, who wrote on the lymphatic system immediately after him, and was one of his contem- poraries, says of the lymphatic fluid in which these corpuscles swim, " that we do not know the use of this fluid."* The correctness of Hew- son's views is not even clearly admitted by his recent commentator, Mr. Gulliver,f and has been denied by most physiologists in this country; and although Nasse, Wagner, Miiller, and a few others, have contended that the lymph corpuscles in the blood are the same as those found in the lymphatic vessels, the mode of their origin and their functional importance is not even alluded to. On examining the chyle in the lacteals ramifying below the serous ' coat of the intestine, it is found to consist of a multitude of minute fatty molecules, floating in a fluid (see Fig. 43X, p. 686). These dimin- ish in number as the chyle progresses towards the thoracic duct, in which it is found to contain a number of free nuclei, mingled with a few others which are surrounded by a delicate cell-wall. The free nuclei may frequently be observed in mammals to present the same size and bi-concave discoid form of the coloured blood corpuscles. (Fig. 438, a.) Moreover, on the addition of water, they in like manner become globular, and, after the fluid has been allowed to evaporate a little, assume a puckered or crenatcd appearance. They only differ in their want of colour, and in not being par- ■'("f:A- v'o.:;'> ■..-.-. tially soluble on the addition of "" ' ^ '*' q ^ Q> acetic acid. (Figs. 438, a; 490, O) q (S) ' Q- and 491.) On cutting into a . > ; • O -. • and examining the juice which O "C^J ° "■ '■&.' maybe squeezed from it, it will x ■&).'■■',. f ■ -:- C be found to contain numerous '-•--:-;•,.:••••- free nuciej an(j nucleated cells. Fis- 490. Fig. 491. These are evidently the same bodies as are found in the lymph and chyle, and those found in the latter closely resemble the colourless cells of the blood. The nucleus of these corpuscles also may frequently be observed to have undergone the fissiparous division formerly described, and to exhibit various stages of this process, in chyle taken from the thoracic duct. The opinion, therefore, held by many physiologists, that the colourless cells of the blood, and those of chyle or lymph, are the same, and consequently that in the highest class of animals they are not formed in the blood itself, but before they are mixed with that fluid, seems to be well founded. * The Anatomy of the Absorbing Vessels of the Human Body. London, 4to, 1786. P. 73. f The Works of William Hewson, F.R.S., edited by George Gulliver, F.R.S.L. Printed for the Sydenham Society. Note, p. 281. Fig. 490. Fluid chyle, mingled with water, taken from the thoracic duct of a cat three hours after it had been fed on milk. Fig. 491. The same after the addition of acetic acid. 250 diam. LEUCOCYTHEMIA. 833 According to Henle, the molecules of the chyle unite together in order to form the nuelei, which are afterwards surrounded by an envelope.* These, he thinks, are delayed, and become more fully developed in the lymphatic glands, t Nasse| also states, that he has seen aggregations of the chyle molecules and granular bodies, formed before they reach the lymphatic glands. On the otlier hand, it is certain that both nuclei and cells are most abundant in the glands themselves, and the cases of leucocythemia prove, that excess of colourless cells in the blood is not dependent upon an increase in the amount of chyle molecules, but is coincident with the enlargement of the spleen and other glandular organs. It is to these, therefore, we must attribute the principal influence in the formation of the colourless cells, and to them evidently we must look for the origin of the blood- corpuscles. Hewson considered the lymphatic glandular system to consist of the spleen, thymus, and lymphatic glands. He believed that particles were produced in these organs which ultimately became the blood- corpuscles, aud that the spleen especially served to secrete the colour- ing matter which surrounded them. This doctrine, though supported to a greater or less extent by some German authors, has been repudi- ated by all British physiologists up to this time. Mr. Simon § declares it to be impossible that the globules of the thymus can enter the lymphatic or blood-vessels, on account of the limitary membrane within which they are enclosed. But that they do find their way into those vessels was shown by Hewson and Sir Astley Cooper,|| who found them there; and that the colourless corpuscles of the spleen and lymphatic glands enter the blood in large numbers, is proved by what occurs in leucocythemia, and by the great preponderance of these bodies at all times in splenic and portal blood. There are other glands which must be associated with those just mentioned as part of the lymphatic system, such as the thyroid body and supra-renal capsules. The pituitary and pineal glands have also been referred to the same class of organs by Oesterlen. 1 \\ ithout entering into lengthy anatomical details of each, it may be said that all these organs resemble one another in the following particulars :— 1. They consist of a fibrous stroma, enclosing spaces lined by a structureless membrane, which spaces are filled with colourless mole- cules, nuclei, and cells, in all stages of development. 2. The corpuscles of all these glands resemble one another,—the nuclei corresponding in size to the coloured blood-discs of mammals, and the cells corresponding to the colourless corpuscles of the blood. The very slight differences which do exist are at once explained by vari- ations in the degree of development. 3. They have no excretory ducts, so that if the corpuscles formed in * Anatomie Generale, par Jourdain. Tom. i. p. 455. f Anatomie Generale, par Jourdain. Tom. ii. p. 103. X ^\'agner's Handworterbuch. Arts. Chylus and Lymphe. § On the Thymus Gland. P. 91. I Anatomy of the Thymus Gland. Pp. 15 and 43. • Beitrage zur Physiologie des gesunden und krankeu Orgamsmus. Jena, 1843. 53 834 DISEASES OF THE BLOOD. them are to leave the organs in which they originate, it can only be by the lymphatics or veins. Now, it is certain that the blood of the splenic and portal veins, even in health, is always richer in colourless corpuscles than that of the sys- temic circulation.* It is also well known that in young animals the blood contains a larger number of these bodies than it does in their adult condition,—that is, when all these glands, including the thymus thyroid, and supra-renal capsules, are fully developed and in a state of activity. In leucocythemia, we observe that when these glands are hyper- trophied and their corpuscular elements are multiplied, the colourless cor- puscles of the blood are increased in number. Two very carefully made observations, however, appear to me sufficient in themselves to determine the connection of these lymphatic glands with the cells of the blood. Thus in Case CLIL, where the thyroid body was enlarged, its cells and their included nuclei were considerably smaller than usual, and it was ascertained that the colour- less bodies in the blood and ^ ©* their nuclei were smaller also. (Figs. 439 and 440, p. 697, ) In one 8 (g>) and Fig. 484, p. 820. (@ ) '.— ease it was seen D colourless corpuscles in the blood were of two distinct sizes, the smaller correspond- ing with the nuclei of the larger ones, and the lympha- Fi?-49S- Fig. 493. tjc glan(Js were found to be crowded with corpuscles also of two distinct sizes, exactly corresponding to those in the blood. (Figs. 492 and 493.) From these facts we can have little doubt that the colourless corpuscles are formed in the lym- phatic glands, and from thence find their way into the blood. By what channel they effect this, whether by the lymphatics, the veins, or by both, it is very difficult to determine. The limitary mem- brane which surrounds the saccular glands is exceedingly delicate; indeed, so much so, that its existence has been denied by some observers. When distended, therefore, it may easily break, and the contents be poured into the pulp, surrounding stroma, or blood-vessels. Dr. Saudersf has shown that the Malpighian sacs of the spleen are traversed by very large vessels, and Mr. Gray has attempted to demonstrate an intimate relation between the former and the splenic veins.| But it must be acknowledged, that notwithstanding the certainty which exists as to the connection between the closed lymphatic glands and the blood-vessels, and the passage of corpuscles from one to the other, the method by * This well known fact has been confirmed by the careful observations of Funke. —HenWs Zeitschrift, 1851, p. 172. \ Report of Physiological Society of Edinburgh for January 31st, 1852. Monthly Journal for February, 1852. \ On the Spleen, pp. 233-4. 1854. Fig. 492. Numerous naked nuclei ofthe colourless corpuscles ofthe blood. Fig. 493. The same after the addition of acetic acid. 250 diam. LEUCOCYTHEMIA. 835 which this is accomplished has not yet been satisfactorily shown. I cannot help thinking, however, that there must be a direct venous com- munication. Of late years physiologists have been in the habit of calling these glands the blood glands, although nothing more definite has been deter- mined with regard to them than that they are in some way subservient to nutrition, especially during an early period of life. But if I have been successful in establishing that the corpuscular elements found in these organs are transformed into those of the blood, it will follow that the lymphatic glands secrete the blood corpuscles in the same manner as the testes secrete the spermatozoa, the mammae the globules ofthe milk, or the salivary and gastric glands the cells of the saliva and gastric juice. With regard to the exact mode in which the corpuscles are formed in the glands, two theories exist, both of which are dependent upon numerous facts aud observations closely connected with the origin of all vital structures, and indeed of organization itself. One is, that they are thrown off, in the form of epithelium, from the membrane which sur- rounds them; the other, that they originate in an organic fluid, by the production of molecules, the successive development and aggregation of which constitute the higher formations.* I have long been of opinion that the latter theory is the more consistent with known facts, and cer- tainly all that I have seen during repeated investigations into the struc- ture of the various lymphatic glands, is in harmony with it. Nowhere have I seen the nuclei and cells of these glands attached to, or appa- rently given off from, a membrane, still less from supposed fixed germs, but everywhere pervading a molecular fluid within the closed sacs. But, however produced, whether from molecules or fixed germs, it is here they are formed, aud are subsequently thrown into the torrent of the circula- tion—there, colour is added to them, and they become blood corpuscles. Multitudes of free nuclei in this way join the blood, and are at once converted into coloured blood discs.f The cells, which in health are comparatively few in number, circulate for a time as colourless corpuscles, but after a certain period their walls dissolve, when their included nuclei also become coloured discs. Iu leucocythemia the colourless cells are increased, whilst the free nuclei are diminished in number. The conse- quence is, that the former are developed at the expense of the latter, and as they do not become coloured on reaching the lungs, the forma- tion of red blood is more or less checked. In the three inferior verte- brate tribes, the entire cell becomes oval, and assumes colour. All that is known of the development of the blood corpuscles, on the one hand, and of the blood glands on the other, supports the theory now brought forward. The primitive production of blood in the embryo * Report of Physiological Society of Edinburgh for January 31st, 1352. Monthly Journal for April 1852. „ , . . , . + In making this statement, I am aware of the possibility of these nuclei being surrounded by a cell-wall so fine as not to be detected by the best instruments. Uut having confirmed the observations made originally with Oberhaeuser s microscope, by means of an excellent lens by Ross, of one-eighth of an inch focus, with the most care- ful attention to the management of the light, it is my conviction that the great major- ity of these bodies possess no cell-walls. 83C DISEASES OF THE BLOOD. occurs in the interior of cells in the vascular layer of the germinal mem- brane, which cells are afterwards transformed into vessels. At this period the colourless cells are very abundant, and their nuclei may be seen to undergo the fissiparous mode of multiplication formerly described ■ the cells themselves also in this foetal condition, multiply by division.* In the invertebrate tribes, there are no lymphatic vessels or glands. In fact there is only one circulation, which has been shown by Milne Edwards to consist of a series of tubes, analogous to arteries or veins, which communicate by means of lacunae that surround viscera. But the circulating fluid contains two distinct kinds of corpuscles, which Mr. Wharton Jones has shown to be different phases of each other, and to correspond with the colourless and coloured corpuscles of fishes, rep- tiles, and birds. In fishes a lymphatic system exists separately, and in them we first observe a pituitary body, supra-renal capsules, and a spleen. In reptiles there are added the thymus and thyroid glands, and in both these classes of animals the communications between the blood-vessels and lymphatics are numerous and direct. In birds we first observe, in addition, glands on the lymphatics of the neck, but not on the lacteals, and there are two thoracic ducts. In the mammalia, the highest develop- ment of the lymphatic glandular system exists, including mesenteric and lymphatic glands, a spleen, thymus, thyroid, piueal and pituitary bodies, and supra-renal capsules. Thus we observe a correspondence between the amount of corpuscular elements in the blood, and the extent and complexity of the lymphatic glandular system. The corpuscles are comparatively few and colourless in most of the invertebrata, and in such animals, as stated by Wagner, should be considered analogous to those of lymph. They become more numerous and coloured, with the appearance of a spleen and supra-renal capsules, in fishes. Both in fishes and reptiles, however, the colourless cells are numerous. In birds the coloured cells are smaller, but still nucleated; and in animals the coloured bodies arc free nuclei, and are even much more abundant. Again, it has been supposed that the coloured cannot be formed from the colourless bodies of the chyle,—1st, Because the former can be seen of all sizes in the blood itself; -d, Because, on examining the blood of foetal animals, no intermediate stages of growth can be seen between them ; and 3d, Because, on the addition of acetic acid, while the coloured bodies are nearly dissolved, the naked nuclei of the chyle are not, and hence, it is said, they are of different chemical composition. With regard to the first argument, derived from variations in the size of the coloured particles, it may be said that, granting the fact, nuclei may also be observed both free and within cells, of all sizes, so that they cor- respond perfectly with the coloured corpuscles of the blood. Besides, in different cases of leucocythemia, although the colourless cells have been seen to be smaller, of the same size, somewhat larger, and even twice as large as the coloured bodies, their nuclei may always be observed to correspond exactly with the different phases of the latter. With regard to the second argument, advanced by those who have not suc- ceeded iu detecting transition forms in embryonal blood, I am persuaded that this arises from the circumstance, that attention is directed to the * These changes are well figured by Fahrner.—De Globulorum Sanguinis, &c. Turici, 1845. LEUCOCYTHEMIA. 837 colourless cells, instead of to their nuclei. For my own part, I have never failed to observe all the changes previously described, not only in foetal, but even iu adult blood. As to the third objection, in reference to dissimilarity of chemical composition, it must be remembered that when the chyle corpuscles enter the circulation by the left jugular or sub-clavian vein, they pass immediately through the pulmonary artery into the lungs, come in contact with oxygen, and undergo chemical changes, with which we are as yet unacquainted. Some physiologists have supposed that colour is added to them before they join the pul- monary circulation, because yellow corpuscles have been seen in the upper extremity of the thoracic duct. In all such observations, how- ever they have been necessarily exposed to the atmosphere; and I have frequently confirmed the observation of Emmert, viz., that the coagulum of chyle, at first colourless, becomes pinkish-red in contact with air. Ou this point I offer no opinion, believing that neither chemistry nor physiology has as yet communicated to us any exact information with regard to when or how baematin is produced. But whatever the changes may be wbich occur in the lymph corpuscles on their passage iuto the lungs, to those organs we must attribute the alteration in their chemical constitution, as they are colourless and insoluble in the lym- phatic glands and in chyle, but coloured aud partially soluble in the tor- rent of the circulation. Moleschott,* having found the colourless cells increase in the blood of the frog after excision of the liver, supposes that it is in the latter organ colour is added to the blood. In man we have seen that the structural diseases of the liver are frequently associated with enlarge- ment of the spleen in leucocythemia. but in other cases the liver has been quite natural even in very severe examples of the blood disease. Besides, it is difficult to understand how chemically so important a func- tion should be performed by this organ. Ultimate destination of the blood-corpuscles.—There may frequently be observed in the spleen of all animals, groups of blood-corpuscles, sur- rounded by an albuminous deposit closely resembling a ^-n ^ cell-wall. This fact has been differently interpreted, r* K-J ^, Gerlach is of opinion that they are new blood-corpuscles (gj /jg ^°jN forming within a mother cellf—whilst Kolliker^ and Ecker§ maintain that they are old ones, which, having f^% /^* fulfilled their functions in the circulation, go to the V^ ^JJ spleen, and are there dissolved. These large cells con- Fi,-. 49t. taming several coloured nuclei, I believe to be cells of the lymphatic glands* which under special circumstances, assume power of increased development, with endogenous multiplication of nuclei. lliey are common not only in the spleen, but in the mesenteric and other lym- • Midler's Archives. Hept. 1, 1853. t Handbuch der Allgemeine und Speciellen Gewebelehre, etc., s. orf. t Mikroskopische Anatomie, etc. 2 Band, s. 282. § Wagner's Handworterbuch. Art. Blukgefassdrusen. IV 494. Cells with single and multiple nuclei; many of the latter i^colour and form exactly resemble blood globules. From the human spleen. -o\) d,a,n. 838 DISEASES OF THE BLOOD. phatic glands, especially wdien hypertrophied from neighbouring irrita- tion, the result of inflammatory or cancerous exudations, and especially in typhoid fever. A similar increased power of development may occa- sionally be observed in the epithelial cells of the pulmonary air vesicles in certain kinds of pneumonia ; in those covering the choroid plexus in hydrocephalus; in those of the epidermis in epithelial cancer; and in pus. On the other hand, that extravasated blood-corpuscles may assem- ble together in groups, and subsequently be surrounded by an albumin- ous deposit closely resembling a cell-wall, is a fact of great pathological importance.* It is true the}' closely resemble the lymph cells, with mul- tiplying nuclei, but may, I think, be separated from them by possessing more colour. I have seen them not only in the spleen, but in other glands, and especially in the brain, following spontaneous and artificial sanguineous extravasations (see Figs. 292, 293, p. 214). But surely it will not be maintained that the normal function of the organs in which these accidental formations occur, is to dissolve the blood-corpuscles. Besides, from the numerous facts whicii have been referred to, I trust it has been made apparent that the spleen is much more probably a blood- forming than a bjood-destroying gland. The view which seems to me most consistent with facts is, that the blood-corpuscles are dissolved in the liquor sanguinis, and with the effete matter absorbed from the tissues by the lymphatics, constitute blood fibrin. (See p. 103.) From the various facts which have been stated, I think we may conclude :— 1. That the blood-corpuscles of vertebrate animals are originally formed in the lymphatic glandular system, and that the great majority of them, on joining the circulation, become coloured in a manner that is as yet unexplained. Hence the blood-corpuscles may be considered as a secretion from the lymphatic glands, although in the higher animals that secretion only becomes fully formed after it has received colour by exposure to oxygen in the lungs. 2. That, in mammalia, the lymphatic glandular system is composed of the spleen, thymus, thyroid, supra-renal, pituitary, pineal, and lymphatic glands. 3. That, in fishes, reptiles, and birds, the coloured blood-corpuscles are nucleated cells, originating in tliese glands; but that, in mammals, they are free nuclei, sometimes derived as such from the glands; at others, developed within colourless cells. 4. That, in certain hypertrophies of the lymphatic glands in man, their cell elements arc multiplied to an unusual extent, and under such circumstances find their way into the blood, and constitute an increase in the number of its colourless cells. A corresponding diminution in the formation of free nuclei, and consequently of coloured corpuscles, must also occur. This is leucocythemia. Since the above views were published by me in 1851, they have been confirmed by observations of various kinds. Thus Hollandf aud * See Dr. Sanderson on the Metamorphosis of Coloured Blood Corpuscles, etc. Monthly Journal for September and December, 1851. f Journal of Microscopical Science, vol. i. p. 176. LEUCOCYTHEMIA. 839 Ncale* Ivave shown that in many cases of bronchocele the blood is leucocythemic. In the only two cases of supra-renal disease described by Addison in which the blood was examined, the colourless cells were increased in number. In a case of dysentery, with thickening of the mucous membrane of the small intestine, I found leucocythemia. (Case LXXV.)t Attempts have been made to divide leucocythemia into varieties. Thus, Virchow speaks of a splenic and a lymphatic variety. But in this manner we might make further distinctions of a thyroid, a supra- renal an intestinal, and a mesenteric variety, according as disease in these organs occasioned the blood lesion. Nay more, we might speak of an hypertrophic, a tubercular, a cancerous, a dysenteric, and an anaemic form, according as we found the blood glands simply increased in size, loaded with tubercle or cancer, or associated with dysentery or anaemia. These distinctions I believe to be of no advantage, either in a scientific or practical point of view. The different blood glands contain elements which, when locally increased in number, find their way into the blood, to constitute leucocythemia. They form one system * Medical Times and Gazette, vol. viii. p. 430. + The first eleven of the following cases of Leucocythemia have been under my care since the publication of my work in 1852. To these Dr. Haldane has kindly added seven others, the bodies of which he has examined in the Pathological Theatre ofthe Royal Infirmary since November 1853—making eighteen in all. I might have swelled the list greatly by adding numerous cases obligingly communicated to me by professional friends:— 1. Tho. Christie 24Wm. Baillie. S. Pat'ck Flood i. Jn. Gatt'ney. 5. Chas. Kennie 6. J. M-Arthur, T. Eliz. Pollock 56 8. Wm. Dods. 23 9. T. Crease. |2S 10. Eliz. Barker. 117 11. Janet Young 50 12. John Youngj27 13. G. Harper. 160 14. Ber. Collins. 35 15. D. Cookfteld. 16. J. M'Gregor. IT. Jer. Brown. IS. John Short. Advanced. Not Advanced. ;8 lb. 10 oz. Well mark'd Dis- Moderate. ,6 lb. 14 oz. Well mark'd 4 lb. 7 oz. Moderate. 3 lb. 5 oz. Advanced. Not Slight. 31b. 2oz. i Moderate. :2 lb. 8 oz Slight. 2 lb. 7 oz Moderate. 2 lb. Well mark'd Natural. Advanced. | Do. Well mark'd 5 lb. 10 oz. Slight. 6 lb. 8 oz Do. 5 lb. 11 oz Advanced. 5 lb. 9 oz i Well mark'd 4 lb. examined alter death. 2 lb. 4 oz. Little enlarged. missed from the house, and did 22 oz. Twice nat'l size, 2 lb. 14 oz. Enlarged. 6 oz. Highly tubercu- lar. examined after death. 5 oz. Greatly enlarged Spleen. Abdominal Glands. 6oz. Natural. Natural. 14 oz. dense. Mucous coat of ileum thickened. Enlarged. Not mentioned. Not mentioned. Sib with deposit Little enlarged. 27 oz." Not enlarged. 22 oz. deposit. 16 oz. 3 lb. 13 oz. Little enlarged. Much enlarged. Enlarged. 8 oz. dense. Not enlarged. Tubercular peri- tonitis. Cancer in various organs. Cancer in lung. Tubercular peri- tonitis. Aneurism—Waxy Kidneys. Glanders? Cere- bral hemor- rhage. Tubercle in lungs —Pneumonia. Bright's disease. Melisna. Acute tuberculo- sis. Bright's disease. t The blood in this case, when subsequently under the care of Dr. H|||iday D^S was an- alysed by Mr. Kemp, who found-water, S64-67 ; albumen, 71 2o, nbun, a so , coipu^ , 840 DISEASES OF THE BLOOD. of organs, and any kind of disease in them may structurally affect the blood. "What appears to me, however, now a desideratum in research, is to determine why, in some cases, the blood should, and in others should not, be, leucocythemic, when these glands are diseased ; and why simple anaemia, as was first shown by Remak, should increase the number of colourless cells in the blood.? In one case examined by me in the autumn of 1S5'_\ and the characteristic blood in which I had the pleasure of showing to Dr. Hannover of Copenhagen and to Dr. Sharpey of London, I unexpectedly ascertained that the microscopic examination cleared up a doubtful diagnosis. It was the case of a woman concern- ing whom a difference of opinion existed between two distinguished obstetricians, the one declaring a tumour in the left flank to be splenic, and the other that it was ovarian. I showed it to be splenic, by demon- strating that the blood was crowded with colourless cells. With regard to treatment, nothing that I have yet tried has appeared to be of the slightest service in well-marked cases of leucocythemia associated with distinct glandular enlargements. Iron, quinine, chloride of potassium, hydriodate of potash, and a variety of medicines given internally, with tincture of iodine applied externally, have been of no avail. The chief indications in advanced cases, however, will be found to be furnished by accidental complications, the most common of which are diarrhoea and epistaxis, which require astringents, combined with tonics, nutrients, and stimulants, to support the vital powers. Discovery of Leucocythemia. Professor Kolliker of Wurtzburg (in Month. Joum. of Med. Science, Oct. 1854), laid before the English medical public the history of the di>covery of Leucocythemia as it is understood in Germany, from the representations of Professor Virchow. The following is my reply:— It is said by Professor Kolliker that the first observatians on this subject occur in the year 1845, and take their origin from a case of disease by Dr. Cragie. Now, the fact is, that Dr. Cragie's case occurred in 1841 ; and it is admitted by Dr. Cragie himself that it would not have been published even four years afterwards but for the occurrence of mine. He says, " I kept it unpublished from the period at which it took place; and it is published at this time, chiefly because the occurrence of a case in many, if not in all, respects similar to another physician in the same hospital, led me to anticipate similar results, and went far to confirm my conclusions deduced from the first case."—Edin. Mid. and Surg. Joum., vol. lxiv. p. 402. Professor Kolliker takes great pains to show that Dr. Cragie and myself held the same opinions as to these cases, and that in mine, which followed bis, "nothing further was elucidated." On the other hand, he says Professor Virchow was the first to point, out that " no signs of inflammation in the veins were anywhere dis- coverable," etc. Now, exactly the contrary of this is the fact. Dr. Cragie put forth two possibilities as to the cause of the blood disorder. 1st, He says, " It is barely possible' that some inflammatory action had taken place in the tributary or constituent veins of the mesenteric trunks; and that the purulent matter and lymph thus formed had been conveyed into their interior with the blood, and thence into the vena cava, heart, and vessels of the brain." 2d, He says, " Another opinion occurred to me, however, as more probable, and which various circumstances in the case induced me to regard as the most correct. Considering that the spleen had been for some time, that is, for several weeks, in a state of chronic inflammation, and taking into account the large vessels with which this organ is connected to otlier organs, it appeared to me that this inflammatory process, which had been continuing LEUCOCYTHEMIA. 841 so long without abating, subsiding, or being subdued, was at length beginning to give rise to the formation of lymph and purulent matter, and that these substances, as they were formed, were immediately taken into the veins, and thus circulating with the blood, gave rise to the peculiar assemblage of symptoms which the patient presented during the few days preceding his death." (P. 409.) From these extract- it must be clear that Dr. Craigie considered the blood disease as secondary, and dependent on the absorption of pus from an inflammatory lesion either in the mesen- teric veins or spleen. The view taken up by myself was wholly different, viz., that the blood disease was primary, originating in that fluid itself, altogether independent of local inflam- mation, and especially unconnected with inflammation of the veins. This will appear from the following extracts from my paper:—"In the present state of our knowledge, tben, as regards this subject, the following case seems to me particularly valuable, as it will serve to demonstrate the existence of true pus formed universally within the vascular system, independent of any local purulent collection from which it cou'd be derived." (Pp. 413, 414.) And again, "Pus has long been considered as one, if not the most characterise; proof of preceding acute inflammation. But in the case before us, what part was recently inflamed ? There was none. Piorry and others have spoken of an inflammation of the blood, a true hematitis; and certainly il* we can imagine such a lesion, the present must be an instance of it. But it would require no laboured argument to show, that such a view is entirely opposed to all we knov of the phenomena of inflammation:'1 (P. 421.) From these passages it must he clear that I then separated the state of the blood from preexisting inflammation in any of the tissues, which had not been done by any preceding author. I espe- cially distinguished it from pyasmia as it was then generally understood. Thereby I established a new blood-disease—one of a primary nature. I carefully described all the facts which Virchow has only subsequently confirmed. I spent three entire days investigating the histological character of all the tissues in the body, and in demonstrating the important fact, that the colourless corpuscles in the blood, which I minutely described, were unconnected with inflammation. Notwithstanding all this, Professor Virchow has pertinaciously endeavoured to persuade his countrymen that I regarded the case as one of ordinary pyaemia or purulent absorption; and Professor°Kolliker, in his communication, says of tliese laborious researches, that ■'nothing further was elucidated'beyond what had previously been determined by Craigie and Reid. Here, it should be observed, that Dr. Craigie was no histologist, and had never employed the microscope in the investigation of disease. To argue, then, that the discovery of this condition of the blood—a discovery altogether dependent on histo- logical research—was made by him, seems absurd in the extreme. But it maybe maintained that this part of the inquiry was carried out by Dr. John Reid, because he stated in the register, kept by him as pathologist of the Infirmary, that the blood "contained globules of purulent matter and lymph." The few words now quoted constitute literally the whole of Dr. Reid's observations on the matter. They would have been buried*in oblivion, if I mvself had not found them in the register of dissec- tions, pointed them out to Dr. Craigie, and indicated their importance. I have frequently couversed with Dr. Reid himself on the subject, who had forgotten the circumstance of having examined the blood microscopically in Dr. Craigie s case, or of having made a note of it. Certainly he paid no more attention to it, or in any way thought it more important than a host of other notes he made, which still exist in the pathological register, and in which some future controversialist^ may doubt.ess find many similar discoveries, as yet unknown. At all events, it is certain tnat neither Dr. Craigie nor Dr. Reid ever imagined to themselves that the globules ot purulent matter and lymph "seen by the latter, originated independent of purulent absorption, or ever dreamed of claiming for themselves the discovery of leucocythemia. Who then did make it* Certainly not Virchow, who with Kolliker, in order to ' prcciate the value of mv observations, claims it for these gentlemen And ii noni ry i less corpuscles in the blood, independent of inflammation. -the white appearance of the blood (white blood), its independence ot inflammation and its separation from all previously known pathological conditions—were minutely described by me iu the paper ofthe first of October, 1845, and their accuracy has been 842 DISEASES OF THE BLOOD. everywhere confirmed. (See Case CLXXXIII.) Surely this description of facts never before published, and of their connection with a new blood-disease, constitutes the discovery. On the other hand Virehow's short and comparatively imperfect histo- logical description of a case of white blood (the white appearance of the blood being the chief point he dwelt upon) was printed in the second number for the following November, although from the admission of Professor Kolliker, as to the practice which pravails in Germany, the actual period of its publication may have been much later. Hence all that can be claimed for Virchow amounts to this, that be puts forth an opinion regarding these facts different from mine, but the possibility of which I clearly indicated. For having described the peculiarities of the blood—the white coagulum, its structural characters, the colourless corpuscles, the relation to the red ones, and the absence of the inflammatory appearances in every tissue, not except- ing the veins—the questions remained, What are these corpuscles ? How are they produced? In reply, I remarked that " with regard to the colourless corpuscles of the blood we know of no instance where they existed in the amount, or ever presented the appearance described." From this passage Professor Kolliker draws the inference that I denied that these bodies were the colourless corpuscles of the blood. But I need scarcely point out that the passage does not fairly bear that construction. On the other hand, it clearly shows that the possibility of their being these colourless corpuscles was fully entertained. At that time the whole subject was histologically new; and having shown that the cells observed closely resembled those of pus in their structural and chemical characters, I said so, and concluded they were pus corpuscles. But having also demonstrated that they could not have been derived from any inflamed tissue, it only remained to be concluded that these bodies were formed in the blood system itself, constituting a primary suppuration of the blood. Here, I contend, was the real discovery, which was at that time quite new, and remains up to this hour, in my belief, a correct generalization. Whilst Professor Kolliker seems to attach no importance whatever to my careful histological examination of the blood and of the tissues, and wholly disregards the fact I was at so much pains to establish, that the colourless corpuscles I described were not dependent on inflammation, he thinks it of the greatest importance that Virchow should have stated that these corpuscles were not those of pus. To me it has always seemed of little importance by what name these bodies were designated, so long as the facts regarding them were described with exactitude. It cannot be denied that I first discovered and described them, and pointed out their origin in the blood itself. What histological difference there can be between pus cells independent of inflammation, originating spontaneously in the blood, and the colourless corpuscles of that fluid, I am at a loss to imagine. Yet this is the only distinction which Vir- chow made. But what are pus corpuscles but cells presenting certain physical characters originating in an exuded blood-plasma? and what are the colourless corpuscles ofthe blood but similar cells originating in a plasma contained in the blood glands? I have yet to learn that there is any true histological difference between them ; I believe still that the only distinction is, that the same corpuscles originate in blood-plasma, sometimes outside, and sometimes within the blood-system. If so, the controversy raised by Virchow, and maintained by Kidliker, is wholly one of words. Here I may mention, that, acting on the persuasion that the two kinds of corpuscles, hitherto separated, are really identical, I opposed the generalization of Mr. Henry Lee, whicii set forth that pus brought in contact with living blood caused its coagulation. In conjunction with the late Professor Barlow of the Veterinary College, I injected considerable quantities of pus into the veins of an ass, in order to determine this point. I thus increased the colourless cells in the blood of the animal without producing any coagulation or inflammation whatever.—(Monthly Journal, January and March, 1853, pp. 80, and 272, 273.) Moreover, it may be questioned, and indeed it has been questioned in a communication which I received from Pro- fessor Gluge of Brussels, and in an article by Dr. Radcliffe [Half-Yearly Abstract of Medical Sciences, vol. xvi. p. 295), whether this distinction can have any real foun- dation. Rokitansky still maintains that the colourless corpuscles of the blood in leucocythemia are truly those of pus, and Vidal, after a series of observations directed to this very point, has come to the conclusion that the colourless corpuscles of the blood, those of pus and those of mucus, are the same [Gazette Hebdomadaire, Avril 11th, 185G). If so, the pretended discovery of Virchow sinks into nothing, as it ia not founded on fact, but simply on opinion. As to the subsequent progress of this inquiry, I have only to express my astonish- LEUCOCYTHEMIA. 843 ment at the statement made by Professor Kolliker, that in 1851, in the Monthly Jour- nal, and that in 1852, in my separate work, I made no allusion to my former views and did not take the slightest notice of the labours of Virchow. It is most untrue. My views regarding this disease have always been the same, but never such a= Virchow and Kolliker have represented them ; and so far from denying the labours of the for- mer pathologist, I have fully set them forth, and quoted all his facts and observations. I always have and still continue to estimate highly the value of the facts he has con- tributed in connection with this important subject. But what he has accomplished does not entitle him to the original discovery of leucocythemia, or to the merit of 15 Pevrier, 1856. X Gazette Medicale de Paris, 5 Avril, 1856. 844 DISEASES OF THE BLOOD. his and my cases appeared about the same time. As if six weeks were not more than a sufficient period for the Edin. Med. and Surg. Journal to reach Berlin, and to be placed on the library table of the Royal Library there, where it might have been seen by such readers of English medical literature, as Virchow undoubtedly is, long before the latter published his note, in the 2d number for November of Froriep's No- tizen. Schnepf (who is evidently unacquainted with my writings, and has only seen the short resume I presented to the Biological Society of Paris in 18/51, at the request of my friend M. Lebert) represents Virchow's case as occurring in March, and mine in October, 1845. That is, he gives to Virchow's case the date at which mine was investigated in Edinburgh, five months before the latter occurred! The real dates are as follows : Observed. Published. 1st Case...Prof. Bennett...March 19th, 1845...October 1st, 1845. 2d Case...Prof. Virchow...August 1st, 1845...Novem. 2d week, 1815. . 3d Case...Dr. Fuller.......Decern.31st, 1845...July, 1846. Dr. Craigie's case must obviously be placed amongst those that occurred long before the discovery of leucocythemia was made, although on looking back upon it one can ' have no doubt that it was an example of the disease similar to a very excellent one published by Duplay, in the Archives Gen. de Medecine, 2d series, vol. xxxvi. p. 223, 1834 ; or the one which occurred to M. Barth in 1836, hut was only published in 1856 by Vidal, when the subject was fully known. In a recent work, " Die Cellular Pathologie," 1858, Professor Virchow for the first time admits (p. 170) that my first case occurred, not about the same time, but "some months" before his. He continues, however, to assert that my conclusion as to the cells being formed in and not outside the blood, and therefore being a suppuration of that fluid, was not original, but was based on the views of Piorry as to hematitis, al- though, in the words previously quoted, I expressly repudiated that doctrine. But Virchow himself now says (p. 140 op. cit.) that pus corpuscles and the colourless cells of the blood cannot be distinguished from one another. " If found outside the blood, we can with certainty conclude that they are pus; if this is not the case, they belong to the elements of the blood." Further, as a proof of the impropriety of the word leukhemia, he now speaks of this morbid state under the name of leucocytosis! Hence after twelve years' misrepresentation of my discovery and views, he thus (indirectly) acknowledges my priority in observation, as well as the correctness of all the facts and opinions I originally put forth. CHLOROSIS AND ANJEMIA. Case CLXXXVL*—Chlorosis and Anwtnia—Cured. History.—Lilias Ross, set. 19, servant in a hotel—admitted October 13th, 1856. She states that menstruation commenced in her sixteenth year, and continued to recur regularly till about a year ago. It then ceased, and she experienced debility, palpita- tion with pain under the left breast, defective appetite, and discomfort after meals. On leaving oft work for six weeks, her health was restored and the catamenia returned. She again went into service, and in four months the symptoms came back. She dates the present indisposition from the last menstrual period, four weeks ago. Symptoms ox Admission.—She seems in every respect well formed, not ema- ciated, but the skin is blanched, and of a slight greenish waxy tint. Over the chest and mammas are a few patches of pityriasis versicolor, of a faint yellowish tint. She complains of occasional palpitation. On examination, the heart's impulse is in its normal position, and is at present of natural force. There is a soft but distinct blow- ing murmur with the first sound, loud at the base of the organ, and audible in the * Reported by Mr. John Glen, Clinical Clerk. CHLOROSIS AND ANEMIA. 845 course of the aorta and large arteries. Over the carotids above the clavicle, a loud double blowing is audible, which, on pressure with the stethoscope, becomes a continuous hnmming-top sound. Pulse 100, soft. Tongue pale and flabby, appetite defective, food causes a painful sense of weight with distension in the stomach, no vomiting or flatulence, occasional sense of constriction in the throat, bowels costive, havino- for some weeks been opened only by laxatives. She has frequent giddiness, rarely head- ache, often darkness before the eyes, no spinal irritation, but great weakness over the loins, and such a sense of fatigue, with heaviness in the limbs, that she has great diffi- culty in walking. The catamenia have not appeared at the usual period on this last occasion. They have never been profuse or accompanied by pain. Urine healthy. Re-pitory system normal. R Pil. Rluri Comp. xij. Two to be taken every third night. fy Ferri Citratis, Zy, Syrupi Aurantii, et Tr. Aurantii, aa, 5j; Infus.' Ca- lumb z lv- M-- Vne table-spoonful to be taken three times a day. Progress ofthe Case.— OeUber 25th.—Is improved in strength, and can walk about the ward. The heart's palpitations are easily excited. Sometimes the murmur over the carotids in the neck is of a hoarse double character, at others continuous and very loud. To encourage a return of the catamenia, four leeches ordered to be applied to the vulva, followed by a warm hip-bath. Nivember 10th.—Is gaining strength slowly on the whole, but experiences alternations in this respect—palpitations and pain under left mamma being sometimes severe, at others absent. The soft blowing murmur at base of heart has disappeared, but the humming-top sound over cervical vessels continues. November 25th.—Blowing murmur at base of heart occasionally returns only after exertion. Sounds in neck le*s intense. No catamenia, although pediluvia, mustard poultices to the feet, and otlier means have been employed at the supposed menstrual period. December 10th.—Has continued to take the chalybeate mixture all this time, and is now strong and vigorous. A faint sound only is audible over the vessels in the neck, after exertion. Appearance healthy, appetite good, bow- els regular, no headache, nor nervous pain. With the exception of amenorrhcea, may- be said to be quite well. Advised to go to the country for a little. Dismissed. Commentary.—This was a well-marked case of anaemia and chlorosis, cured by iron, tonics, aud rest. Such cases, in young women, are exceedingly common in the female wards of the Infirmary, especially auioug the class of servants. Great discussion has occurred as to the cause of the murmurs in the heart and large blood-vessels, some maiutainiug their seat to be the arteries, others the veins. The argu- ments of Dr. Ogier Ward, who first maintained the seat of the anaemic murmur to be iu the jugular vein, arc generally considered to be well founded. They are—1st, The continuous murmur is often co-existent with distinct carotid impulse, which alternates with repose ; 2d, It may be interrupted by pressing the vein above the stethoscope; 3d, The two murmurs may be occasionally heard by employing a small-ended stetho- scope, and shifting it slightly to the right or left; 4th, It is increased by any cause which accelerates the flow of blood through the jugular vein, as during the act of inspiration, and when in the upright posture— it is diminished when there is an impediment to the venous circulation, as during expiration, the recumbent posture, and when the veins are swollen or turgid. Andral endeavoured to show that the constancy of the murmur is proportionate to the diminution of corpuscles, and that it became continuous if the blood globules fell below 80 parts in 1000. But Dr. Davies has pointed out that the murmur is not peculiar to 846 DISEASES OF THE BLOOD. anaemic persons, but often exists in individuals of robust health. He attributes it to friction on the inner surface of the veins, which is more or less audible according to the readiness with which their parietes take up vibrations, and the facility witb whicii the latter are conducted to the outer surface of the body. Hence their frequency in children and young persons, aud in the quick ventricular contraction with thin blood of the chlorotic girl, and, on the otlier hand, their absence during the slower circulation, and thickened condition of the tissues in adult and aged persons. At the same time there can be little doubt that the interrupted blowing at the base of the heart, over the aorta and carotids which is synchronous with the impulse, is often arterial and not venous. Indeed, the separation of anaemic arterial and venous murmurs is fre- quently a matter of excessive difficulty. Sometimes also, as has been well pointed out by Stokes, they are associated with organic disease, whicii adds to the complexity, aud occasions still greater difficulty in forming a correct diagnosis. The coloured corpuscles of the blood may be increased or diminished in quantity, constituting Polycythamia and Oligocythamia (Von-el). These changes may be absolute or relative. In the former case, the corpuscles are uniformly inoreased or diminished throughout the body generally; in the latter, this depends upon the amount of water which, by being less or more, alters the proportion of the corpuscles to the other constituents of the blood. Becquerel drew a distinction between anaemia and chlorosis, which, on the whole, is well founded. Thus, anaemia is caused by a variety of circumstances which impoverish the blood, such as long-continued hemorrhage, exhaustive discharges, star- vation, chronic diseases, certain poisons, etc.; chlorosis is induced by obscure causes connected with the nervous system, generally originating in disturbed uterine functions. In anaemia, the alteration of the blood is constant and pathognomonic ; in chlorosis, it is only one of the pheno- mena, and not always present. In both diseases the physical signs may be alike, but in anaemia the functional sound is more often in the arteries, in chlorosis in the veins. In anaemia there is constant relation between intensity of symptoms and poverty of the blood. This is not the case iu chlorosis. The duration and progress of anaemia is depen- dent on the causes which produce it, but chlorosis is very variable, and no such evident connection is visible. The treatment of anaemia has two indications—1st, To suppress the exhausting causes which occasion it; and, 'idly, By means of wine, proper nutrients, and regulated ex- ercise, to improve the quality of the blood. In chlorosis, iron is the chief remedy, which should be conjoined with efforts to regulate the menstrual function. ICHOR^MIA OR PYAEMIA. 847 ICHOE^EMIA or (so-called) PYAEMIA. Case CLXXXVIL*—Acute Articular Rheumatism—Multiple Abscesses in the Joints, in the Muscles, within the Cranium, etc. History.—James Lockie, oet. 17, a rope-spinner—admitted December 1, 1854. Ten days ago, when spinning ropes in the open air, he was exposed to more than usual cold and wet. Next day rigors and other febrile symptoms appeared, followed by pain, redness and swelling of the right elbow joints. During the four following davs the right wrist and ankle joints were also affected, together with both knee joints. Four days before admission the heart's action became very violent, and leeches were applied to the precordial region. The pain and swelling of the joints have continued since. Symptoms on Admission.—On admission he complained of great pain in the right wrist, ankle, and left shoulder joints, which were swollen, immovable, doughy to the feel, tender to the touch, with the integuments over them erythematous. From the left shoulder joint, the swelling extended into the axilla and down the inside of the arm. Pulse 130, full and strong; heart's impulse violent, but no blowing murmur. The tongue coated with brown in the centre and white at the edges; no appetite; great thirst; skin hot and dry; urine turbid from excess of lithates; bowels open ; no headache, and the other functions normal. Fiat vcnesectio ad r xiv. R Potassa; XHratis z SSS Aquae 3 vj solve. 3 ss to be taken in half a tumblerful of Hater every four hours—warm saturnine lotions to the inflamed joints. Progress of the Case.—December 2d.—Little change, pulse 120, more soft, blood not buffed, but it was drawn from a small orifice.. Dec. 4th.—Pain in all the joints greatly diminished ; the swelling, however, continues. A blister has formed over the external malleolus of right ankle—complains of soreness in the heels. Pulse 100, of good strength. No blowing murmur with the heart's sounds. Took ;j °f castor oil last night (the bowels having been constipated), which has acted copiously. Tongue dry, and covered with a brown fur. Febrile symptoms continue, with pro- fuse diaphoresis. On the Oth December the blister over the malleolus of right ankle burst, and gave issue to a quantity of pus. Distinct fluctuation existed over the right wrist and dorsum of the hand, which was opened by an incision, and also gave exit to a considerable quantity of pus. To omit the nitrate of potash. On the 8th, com- plained of pain in the back of the neck, and a bed sore was seen to be forming over the sacrum. To be placed on the water bed. From this time the pulse, which ranged from 110 to 140, lost its fulness, and became much more weak; the skin assumed a dirty yellowish or tawny hue, the typhoid febrile symptoms continued, with dry tongue aud sordes, and numerous abscesses formed in the joints and various parts of the body, several of which, as soon as they became soft, were opened. A very large abscess formed over the occiput, which was opened on the lS^A, and another over the manubrium of the sternum, extending up the left side of the neck, which was opened on the 24lh. The skin over the heels, trochanter of the right hip, and the sacrum, sloughed, notwithstanding every care taken to prevent it. On the 26th, the whole of the right lower extremity was swollen, cedematous, and white, resembling in aspect phlegmasia dolens; there was laborious breathing, and great prostration. Low muttering delirium, and involuntary evacuations supervened, and he sank on the morn- ing of the 27th. The treatment had latterly been directed by generous diet and stimuli, to support his strength, relieve pressure on depending parts, and to dressing his sores. * Reported by Mr. A. \V. Moore, Clinical Clerk. 848 DISEASES OF THE BLOOD. Scctio Cadaveris.—Seventy-two hours after death. Body greatly emaciated ; a fistulous opening, the size of a shilling, existed imme- diately in front of the left sterno-clavicular articulation. Other sores, varying in size from half an inch to three inches in diameter, and laying bare the hones, existed over the right elbow, ankle, both hip joints, right knee, and sacrum. Head.—The integument covering the occiput was separated from the skull, infiltrated with putrid pus, a great quantity of which had been evacuated by openings, previously made. On removing the calvarium, an abscess, containing thick yellow pus, existed between the bone and dura mater, about the centre of the occipital bone. The bone externally was somewhat carious, but internally it was healthy. Xo commu- nication could be traced between the external and internal abscesses. Brain healthy. Chest.—On removing the heart and aorta, a fluctuating oval swelling, about J inch in its long diameter, was situated outside the aorta, about an inch from the aortic valves, which was distended with yellow purulent matter. The posterior por- tions of both inferior lobes of the lungs were condensed. On section they presented a reddish purple colour, the air vesicles filled with a soft sanguineous exudation and readily sinking in water. Heart healthy. Abdomkx.—Kidneys slightly enlarged—one section presenting a whitish mottled appearance, without great atrophy of the secreting, or encroachment on the tubular substance. Other abdominal organs healthy. Joints.—The left sterno-clavicular articulation was carious and disarticulated, with matter burrowing to considerable depths in the surrounding soft textures. The right shoulder, left elbow, right wrist, both hip joints, both knees, and both ankle joints, were filled with dirty purulent looking matter, which, in several instances, more especially in the left elbow and hip joints, had infiltrated itself more than half way down the fore arm and thigh. The various articular cartilages presented all stages of abrasion, softening, and ulceration, whilst the osseous textures below exhibited a carious and blackened necrosed condition. The base of the ulcer over the sacrum con- sisted of necrosed bone, and over the right elbow, right hip, and knee joints, bone was exposed and necrosed. The Veins were carefully examined, especially in the right inguinal region, and with the sinuses at the base of the brain, were everywhere found healthy, aud free from coagula; indeed, the blood was everywhere unusually fluid—even in the heart presenting small, dark, and soft coagula. Microscopic Examination.—The pus consisted of molecular and granular matter with debris of disintegrated pus cells, with the exception of the abscess within the cranium, the pus of whicii was normal. The cartilage covering the joints was in some places healthy, but in others its cells were enlarged, filled with secondary cells, and not unfrequently with fatty granules. Around the articulations of the joints were laminae of chronic exudation, consisting of dense amorphous matter, principally composed of minute molecules. The blood was carefully examined, and everywhere found normal. Commentary.—This was a case of what is frequently called pyaemia, a disease which is not uncommon as the result of mechanical injuries, or suppurative diseases. I believe it to be very rare, however, as a conse- quence of attacks of acute rheumatism, such as the symptoms aud the history of this case prove it to have been. The lad was healthy and in ICHOR^EMIA OR PYEMIA. 849 pursuit of his ordinary occupation when, after exposure to cold and wet, he was seized with the usual symptoms of rheumatic fever, including vio- lent action of the heart, and on this supervened suppuration in almost all the joints, with numerous abscesses, accompanied by a low typhoid fever, under the effects of whicii he sank. Dr. Watson has recorded two cases singularly like it, but in them the constitutional disease was preceded by otorrhcea and abscess in the ear,* to which he theoretically ascribes the origin of the disease. In the present case there was no primary abscess, no evidence of a pre-existing collection of pus before the attack of rheumatism, and I think there can be little doubt that the constitu- tional state of the blood, whatever it may have been, was dependent on the abscesses which resulted from the acute inflammation of the joints. This morbid condition, so much dreaded by surgeons and obstetri- cians, in which typhoid fever comes on after severe accidents or parturi- tion accompanied with purulent infiltration, or multiple abscesses, in one or more organs, has received different explanations. The various observations and experiments performed with a view of elucidating this subject in modern times have led to the four following theories :— 1. That this condition is owing to an admixture of the blood with pus (pyohemia of Piorry), and that the pus corpuscles being larger than the coloured ones of blood, are arrested in the minute capillaries, and give rise to secondary abscesses. 2. That it is owing to the presence of some irritating body, which not being able to escape from the economy, pro- duces capillary phlebitis. 3. That it is dependent on a property pos- sessed by pus of coagulating the blood. 4. That it is caused by the presence of a peculiar poison which contaminates the system. All these views have been maintained with much ingenuity, and they are all supported by experimental and clinical researches. A knowledge of the circumstances previously detailed concerning leucocythemia will enable us to criticise these doctrines from a new point of view. 1. With regard to the first theory, it must, I think, be granted by all those who have examined the blood in leucocythemia, or will study the figures I have given illustrative of that disease, that no difference what- ever can be detected between the colourless cells of the blood and those of pus. Their general appearance, size, structure, and behaviour, on the addition of re-agents, are identical,—indeed so much so, that m the first case I observed in 1845,1 could not resist the conclusion that the blood was crowded with pus cells. It follows, that all explanations of puru- lent infection founded upon the mechanical impaction of these bodies in the minute capillaries must be erroneous. Some of these colourless corpuscles have been observed much larger than ordinary pus corpuscles. In one instance, many of them were twice as large ; and although this may in some measure be owing to endosmosis of serum, there can be little doubt that they must have exceeded the usual size of pus cells. In Case CLXXXIII., also, it was observed that several of the colourless cells were larger than the average, and yet the circulation went ou, and every drop of the patient's blood contained hundreds of these bodies The first theory, then, is no longer tenable. * Practice of Physic, vol. i. p. 381, 4th edition. 54 850 DISEASES OF THE BLOOD. Neither does there seem to be anything peculiar in the nature of good and laudable pus, which necessarily leads it to poison the blood ■ for it is a matter of common observation, that large abscesses are ab- sorbed and eliminated without occasioning so-called purulent infection. In all such cases, the pus corpuscles must, in the first instance, be disin- tegrated and reduced to a fluid condition ; still the matter or substance of which they were composed passes into the blood. Hence, while leucocythemia proves that corpuscles, identical in form, size, structure, and chemical composition with those of pus, may float in the blood and circulate innocuously, the well-known fact of the absorption of abscesses demonstrates that pus, when healthy, does not possess any poison- ous properties. If, then, the fever and other marked symptoms are owing to the absorption of pus, it must be of pus possessing properties wholly different from those of what is called good or laudable pus. '2. The second explanation was advanced by Cruveilhier, who, on injecting mercury, ink, and other substances into the blood of a living animal, found that abscesses were formed wherever these accumulated. From hence it follows, that the impaction of certain substances in the tissues may induce local inflammations, and lead to abscesses; but that such is not the necessary result of admixture of pus with the blood, is proved not only by the previous observations, but by numerous experi- ments of Lebert* and Sediilot,f in which the animals recovered. 3. The third doctrine was advanced by Mr. Henry Lee,| and resulted from observing that when pus was mingled with recently-drawn blood, it coagulated more rapidly and more firmly than under ordinary circum- stances. This observation he connected with the well-known fact, that phlebitis was often associated with coagula causing obstruction of the veins. Now it is worthy of remark, that in decided cases of leucocy- . themia the blood is more highly coagulable than when drawn from the arm, and after death it often presents firm coagula, filling the vessels, as in Case CLXXXIII. Figs. 471 to 473 illustrate these colourless coa- gula, as observed in different parts of the body. The same occurred in Case CLXXXIV. ; and yet, during the life of the patient, the blood, loaded with the colourless corpuscles, rolled through the vessels without impediment or the formation of coagula. It does not follow, then, that because dead pus is mingled with recently-drawn blood about to coagu- late, that therefore it should induce coagulation of living blood in the vessels of an animal. Indeed, numerous experiments by Lebert and Sedillot show that such does not take place; for although in some cases death followed, in others the animals lived, and the pus corpuscles were dissolved.§ Hence, although the fact to a certaiu extent must be admit- ted, that when pus is mingled with blood the coagulum formed is more firm, it by no means follows that it produces coagulation of living blood, and is the cause of phlebitis or purulent infection. * Physiologie Pathologique, torn i. p. 313. f De l'lnfection Purulente, p. 73, et seq. X On the Origin of Inflammation of the Veins. London, 1850. § In 1852, to determine this point more definitely, I performed, with the late Professor Barlow ofthe Veterinary College, the following experiments:— Experiment 1.—The saphena vein of an ass was exposed, and a tube introduced confined by a ligature. Fresh and healthy pus was then slowly injected upwards towards the heart, from a syringe holding an ounce. A slight obstruction was uow perceived, and the vein above the liga- ICH0R2EMIA OR PYEMIA. 851 4. The fourth theory seems to have been maintained by A. Boyer* and Bonnet,! who believed good pus to be innocuous, and the bad effects occasionally produced to depend on its becoming putrid, or being other- wise altered. This view was also more or less supported by DarcettJ and Berard,§ who, in order to explain the undoubted effects of putrid substances when injected into the veins, separated pyohemia from puru- lent infection. But as pus corpuscles do not alone cause the symptoms, it is certainly more probable that, in all cases, there must be a toxic prin- ciple associated with pus when it proves mortal. Dr. Millington|| has shown, in repeating Mr. Lee's experiments, that putrid fluids prevent coagulation of the blood, and that the coagulum caused by the addition of pus is more perfect the fresher the purulent matter is. This fact is opposed to the idea, that multiple abscesses are induced by the coagula- tion, but corresponds with what is observed after death in cases of puru- lent infection. When, therefore, we consider the typhoid nature of the symptoms so similar to that of certain animal poisons; the multiple abscesses so analogous to what occurs in glanders, plague, syphilis, variola, etc.; and the undoubted fact, that the blood may be loaded with corpuscles in every respect identical with pus cells, without causing ture could be seen to be somewhat swollen. This swelling, on being felt, was very soft; nnd on pressing the vein from below upwards, the mixed blood and pus were readily pushed before the finger, when all obstruction to the passage of pus from the syringe was removed. The syringe was again filled, and another ounce of pus injecied, without occasioning any further local effects. The animal was then allowed to get up, and exhibited no change in its normal condition whatever. Experiment 2.—The same ass was the subject of this experiment a fortnight later, having been perfectly well in the interval. Six inches ofthe jugular vein in the neck were carefully dissected ' and exposed; and a minute aperture was then made in the upper end ofthe exposed vein, and the bent tube of the syringe introduced without a ligature. The coats of the vein were so transparent that the flowing blood could be seen through them. An ounce of fresh and perfectly healthy pus was then slowly injected downwards towards the heart, and, owing to the transparency of the vein, the yellow opaque fluid was seen to join the blood, to continue a few moments running side by side with the crimson current, until at length the vein became full of pus. On removing the syringe to obtain a fresh supply, the blood from above could be seen to join the pus, to continue side by side with that fluid, presenting a streaked red and white appearance, without any coagula- tion, until all tlie pus was carried forwards and downwards towards the heart, and the vein was again full of blood. Another syringeful of pus was then injected, which could once more be seen first to flow with the blood, then, as its quantity increased, to take the place of the blood, and then, on the svringe being exhausted, to receive blood from above; the two mixing together, and con- tinuing their course" without coagulating, until once more the vein contained nothing but blood. The wound was now closed, and the animal allowed to rise, which he did without apparent suffer- ing. He presented no unusual symptoms whatever during the next four days, when he was killed, and the parts carefully dissected. The vein was pervious, presented no thickening, nor cording or abscesses, and the external wound was nearly healed. This experiment appeared to be so decisive, and so clearly opposed to the idea that the contact or mixture of pus and blood necessarily induced coagulation in a living animal, that it was thought unnecessary to repeat it. With regard to the slight coagulability apparently occasioned in the first experiment, it was attributed to injecting contrary to gravity, whereby the mixed pus and blood were allowed to fall backwards and remain stationary, while the ligature prevented any flow of blood from being continned. No such phenomenon was observed in the second experiment, where no ligature was employed, and where the effect of gravity was avoided by injecting downwards. In a communication, however, received from Dr. Henry Lee, I was informed tuat no ligature was employed by him. . The second experiment was in its nature the same as the seventh and eighth experiments ot Dr. Henry Lee, and yet none of the appearances observed by that gentleman resulted. There was no fulness or cording ofthe vein, no acceleration of respiration or constitutional symptoms; and alter death no coagulation ofthe blood, no obliteration of the vein, nor local inflammation. \\ hat are the circumstances which occasioned this difference, I am not prepared to say; but the positive fact of having introduced the pus on two separate occasions, as recorded in Experiment I, ot Hav- ing seen the pus mix with the blood and the blood with the pus, through the transparent vein, without producins coagulation, is sufficient to negative the general proposition, that whenever pus is mingled with blood in a living animal, coagulation ofthe latter fluid is the invariable result. * Gazette Med. de Paris, p. 193. 1834. t Ibid. p. 5i)3. 1837. Both cited by Sedillot, Op. cit. p. 55. J These Inaugurale. Paris, 18-12. § Dictiounaire de Med , torn. 26. 1842. || Monthly Journal. November, 1851. P. 486. 852 DISEASES OF THE BLOOD. these symptom.-;, the irresistible conclusion is, that these effects are not owing to pus in the blood, but to an animal poison. This view has been opposed on the ground that fresh pus, to all appearance healthy and without odour, has yet caused the death of ani- mals. But what sensible property distinguishes the pus of the vaccine from the small-pox pustule, and cither of tliese from healthy pus ? And yet how different their effects when introduced into the blood ! The subject of animal poisons is certainly obscure ; but it is more in accord- ance with our actual knowledge to attribute purulent infection to such a cause, than to consider it as the consequence of the mere mixture of pus with the blood, or a so-called pyohemia. This doctrine, which was first clearly put forth in my work on " Leu- cocythemia" in 1<^5:2, seems now to be generally adopted, and the con- dition of the blood has been called septicaemia (Vogel), and ichorhaernia (Virchow). The so-called pus-corpuscles, which some observers have thought they saw in the blood, are identical with the colourless cells of that fluid, and if in excess, constitute white cell blood. Virchow himself, who has claimed so much for simply denying that leucocythemia can be pyaemia, is obliged to admit, when writing on the latter subject* that the diagnosis between pus and the colourless cells of the blood is very difficult, and frequently impossible. In truth these bodies are the same, and in the majority of cases, what has been called pyaemia is not depend- ent on pus cells mingling with the blood, but on a matter derived from some kinds of pus, which poisons the blood, and occasions the secondary phenomena. GrLUCOH^EMIA. Case CLXXXVIII.f—Diabetes Mellitus. History.—Allan M'Clermont, set. 32, labourer—admitted 7th June, 1852. About three weeks ago, on recovering from a general rheumatic attack, he found himself much reduced in strength, and somewhat emaciated. He experienced great thirst, and passed a large quantity of urine. These symptoms have rapidly increased. Symptoms on Admission.—On admission, tongue moist and clean, appetite in- creased, thirst excessive, bowels rather costive, skin dry, urine very pale, and slightly turbid. On heating a portion of the urine with an equal portion of Aq. Potassae, a deep brown colour is produced. He has passed during the last 24 hours, 380 oz., spec. grav. 1030, having drunk 460 oz. of water in that time. Other functions performed normally. His weight was 11 stone 8 lbs. Ordered pills of Aloes and Ipeeacuan, and a mixture of Inf. Quassias and Tr. Aurantii. Progress of the Case.—On the 10th June, he was ordered the following diet: 3 cakes made of bran, butter, and milk, weighing half a pound; 3 eggs; 4 oz. steak or breakfast, 12 for dinner, 4 for supper; 1 cabbage ; 3 bottles of soda water; 8 oz. of lime water; 3 oz. of wine. To have a warm bath every third night. On 15th June the amount of urine passed was diminished to 120 oz. in the day, of density 103G, and he drank during that time 150 oz. His weight was 11 stone. On the 22d, he was ordered 4 oz. of steak additional, and another bran cake. From this * Gesammelte Abhandlungen. P. 653. f Reported by Mr. J. L. Brown, Clinical Clerk. GLUCOH.EMIA. 853 time the amount of urine fluctuated from 160 to 190 oz. daily; but on the 5th July, it was reduced to 150 oz., spec. grav. 1034, and his drink was 167 oz. He then weighed 11 stone 2 lbs.; but being wearied of the treatment, he insisted on going out on the 6th. Case CLXXXIX*—Diabetes Mellitus—Phthisis Pulmonalis—Vomica on Right Side—Death. History.—Robert Fallow, a tailor, ast. 24—admitted into the clinical ward, July 8th, 1851. Last December, while in America, was attacked with bilious fever, which continued ten weeks. Shortly afterwards, he observed that the quantity of urine he passed was greatly increased, and that his thirst was excessive. Cough appeared six weeks ago, followed by purulent expectoration; and the skin, which had previously been remarkably dry, was now covered with copious sweat during the night. Svmitoms ox Admission.—Percussion elicits no decided difference of sound on either side of the chest, but there is a much greater degree of resistance under the right clavicle than under the left. On auscultation, cavernous respiration is very distinct under the right clavicle, but the sounds are dry. The vocal resonance, also, is greatly increased in the same situation, and has somewhat of a metallic character. Under the left clavicle, inspiration is harsh, and expiration prolonged. On the left side, posteriorly and inferiorly, the inspiration is everywhere harsh, with occasional cooing rales and prolongation of the expiration. The expectoration is copious, mucopurulent, and of a brownish tint, without distinct traces of blood. Cough severe. Tongue furred and dry, coated near the base. Appetite good. Thirst insatiable. Sour-sweet taste in the mouth. Pulse 108, small and weak. Has voided 70 oz. of urine during the last twelve hours. The addition of liq. potassae, followed by heat, throws down a reddish-brown sediment. Skin soft and moist. Progress of the Case.—On the 11th of July, gurgling was heard under the right clavicle. On the 20^//, there was complete loss of appetite, and repugnance to food. The urine varied since last report, from 170 to 230 oz. voided in the 24 hours. Profuse sweating at night. Mucous rales heard over the whole anterior surface of chest on the right side. Vocal resonance still metallic under right clavicle, with cracked-pot sound on percussion. August 4th.—The amount of urine passed now varies from 100 to 150 oz. during the 24 hours. Weakness and emaciation have greatly increased; sweating and loss of appetite continue. Died at 7 p.m. As to treatment he was ordered a diet, consisting at first of eggs, boiled meat, and stale bread and milk; pills of opium and hyoscyamus at night, and cod-liver oil internally. An expectorant mixture, afterwards combined with antispasmodics, was ordered to relieve the cough. Permission to examine the body could not be obtained. Commentary.—Phthisis pulmonalis is a very common complication of diabetes in persons under 30—a circumstance which appears to me to support the pathological views formerly given, as to the great importance which should be attached to derangement of the nutritive functions, as a cause of the tubercular disease. An animal and oleaginous diet is indi- cated in both disorders; which, however, when present in the same indi- vidual, may easily be supposed to constitute a hopeless form of malady. • Reported by Mr. W. M. Calder, Clinical Clerk. 854 DISEASES OF THE BLOOD. The excretion of sugar in large quantities by the kidney has for a lengthened period excited the attention of pathologists, and given rise to abundant speculation. It having been shown by Mr. Macgregor of Glasgow, that sugar was formed in the stomach from the digestion of food, while that principle was subsequently detected in the blood by the same observer, as well as by Ambrosiani, Maitland and Percy—the view of Uollo was, on the whole, considered the correct one, and the treat- ment he proposed has been, in its main features, followed by subsequent practitioners. This theory supposed that the sugar formed in the stomach and alimentary canal, from the starchy and saccharine principles of the food, instead of being rapidly converted into other compounds, as Prout supposed, was absorbed into the blood, and excreted by the kid- neys. The treatment based upon this theory was, therefore, directed to keeping up nutrition from substances which were thought incapable of beino- converted into sugar; aud it is worthy of remark, that such treat- ment does often greatly diminish the excretion of sugar, without, how- ever, suppressing it, and also ameliorates the other symptoms. Dr. Gray of Glasgow was induced to give rennet in teaspoonful doses after each meal, and published three cases, in two of which it occasioned an appa- rent cure. (Monthly Journal, January, 1853.) He argued, that if out of the body rennet converts a solution of sugar into lactic acid, it may have a similar effect upon a solution of sugar within the body; and bearing in mind that lactic acid is found in the juice of flesh, and, accord- ing to Liebig, is a supporter of the respiratory process, he considered that if sugar, formed in the body of a diabetic patient, could be con- verted by the rennet into lactic acid, it would be burned in the lungs; and that if a larger quantity was formed than could be consumed in this way, that portion would be excreted by the kidneys. In consequence of this ingenious theory, and the facts in its support adduced by Dr. Gray, rennet was tried in several cases admitted into the Royal Infirmary of Edinburgh, but without success. The researches of M. Bernard have given rise to other views as to the origin of diabetes. He admits that sugar may be formed in the process of digestion, and that a certain amount of it may, as a result of absorp- tion from the alimentary canal, find its way into the blood. But he has demonstrated that, in dogs fed entirely on animal food, sugar may exist in the liver and in the blood of the hepatic vein, while it is absent in the portal vein. Moreover, he has shown that sugar is a normal secretion of the liver of all animals, from man down so low in the scale of beings as the mollusca; and that, moreover, it is secreted by the liver of the foetus. He has proved, experimentally, that this secreting function is increased, and diabetes produced, by irritating the eighth pair of nerves at their origin in the fourth ventricle; while, on the other hand, section of these nerves destroys its formation. I have seen M. Bernard perform these experiments, aud have repeated them myself in this city, and have no doubt as to the accuracy of these results. That sugar does not exist normally in urine aud in blood drawn from the arm, is explained by its rapid decomposition in a state of health, and its excretion by the lungs. But when it is so increased in quantity that the lungs cannot excrete the whole of it, the remainder passes off by the kidneys, and hence diabetes. M. Bernard has also ascertained, that although section of the pneumo- GLUCOH^MIA. 855 gastric nerves destroys the formation of sugar in the liver, it is restored by artificially irritating their central cut extremities; and that diabetes is produced exactly in the same manner as by irritating their origins in the brain. He was therefore led to conclude, that the nervous°action necessary for the secretion of sugar does not originate in the brain, to be transmitted directly along the pneumogastrics", but indirectly and by reflex action; the vagi being incident nerves, the medulla oblongata the centre, and the spinal cord, communicating with the solar gangTion, the excident channel. Following out this theory, he found that whenever the respiratory function is violently stimulated, sugar appears in the urine; and that, whenever aether or chloroform is rjiven, a temporary diabetes is occasioned. He further supposes, that in the same way that the lungs thus act by reflex nervous influence on the liver, so increased action of the liver acts upon the kidney; consequently, that the sugar produced in excess by one organ is excreted by the other. Hence may probably be explained the occasional temporary presence of sugar in the urine, independent of the disease known as diabetes. Continuing his researches, M. Bernard has arrived at the conclusion, that the liver does not secrete sugar directly, but rather a substance which presents all the physical and chemical properties of hydrated starch, and which is transformed into sugar by the aid of a ferment. This substance he has at length succeeded in separating from the liver. The ferment he presumes to exist in the blood, so that the starchy substance formed by the vital action of the liver undergoes a chemical transformation into sugar when it comes into contact with the blood. The sugar, thus formed in the blood, on arriving at the lungs, is in its turn decomposed by the oxygen of the air, and disappears. Hence the liver and the lungs are so far opposed to one another in function, that the one produces the substauce out of which sugar is formed, whilst the other decomposes the sugar which in health exists in that part of the circulation only that lies between the liver and lungs. It follows that the occurrence of sugar in the circulation generally, and its presence in the urine, is probably dependent not so much upon excess of hepatic, as upon diminution of pulmonary action. It is certain that the great ma- jority of diabetic patients die phthisical. These more recent views of Bernard point to the importance of the / observations made by Virchow, Busk, Carter, and others, as to the exis- tence and even wide diffusion of starch corpuscles throughout the animal economy (Carter), and should stimulate organic chemists to ascertain whether some chemical change in the lung may not be the true cause of diabetes. In the meantime, the researches of M. Bernard explain why Hollo's treatment diminishes the excretion of sugar, by cutting off all that enters the blood through the alimentary canal. According to Traube, the intensity of the secretion of sugar varies at different times of the day, and under different circumstances. Thus it is greatly increased after meals, and is least during the night. At the commencement of the disease, it is principally derived from the food; in the latter stage, it is largely formed by the organism. Hence why treatment directed to the stomach does not cure, because it fails to affect the hepatic organ. Bernard's observations appear to me also capable of throwing light 856 DISEASES OF THE BLOOD. on the good effects of opium—effects which are universally recognised —from its power of diminishing nervous irritability. No other practi- cal results, however, are as yet derivable from them, unless the well- known symptom of dryness of the skin be connected with the cause of the disorder, in which case diaphoretics, though they have often been used with great benefit, would be more strongly indicated. Perhaps, also, exercise and a cold atmosphere, whicii increase the oxygenating power of the lungs, might be of some avail. Further researches are required on these points, and it is to be hoped that practitioners, no longer exclusively directing their attention to the digestive organs, may, by new efforts, ultimately be enabled to control this singular disorder. The diet ordered in Case CCVII. is one whicii admits of very slight formation of sugar in the alimentary canal, and, together with opiates and the occasional use of the warm bath, constitutes the best treatment which has hitherto been adopted. Its good effects were well manifested, although it proves, in conjunction with the confinement of an hospital, very irksome to the patient. CONTINUED FEVER. A stage of fever may be said to exist when we find the pulse accele- rated, the skin hot, the tongue furred, unusual thirst, and headache. These symptoms are commonly preceded by a period of indisposition varying in extent and severity, the febrile attack being marked by a rigor or sensation of cold. This rigor, though not invariably well cha- racterised, is the symptom from which, when present, we date the com- mencement of the fever. Although fever may in one sense always be said to exist when the above group of symptoms is present, such fever may be idiopathic and essential, or symptomatic of some local lesion. It is to the former condition that the term fever is universally applied. Some pathologists, indeed, have endeavoured to show that there is no such thing as idio- pathic or essential fever, although they have differed among themselves as to the lesion of which it is symptomatic. Intermittent fever has been supposed to be symptomatic of diseased spleen, and remittent fever of intestinal derangement. With regard to continued fever, some have spoken of cerebral, others of intestinal or abdominal typhus. Another class have supposed, from the occasional appearance of an eruption on the skin, that it is allied to the exanthemata. If, however, you carefully watch the Edinburgh continued fever, you will easily satisfy yourselves that it frequently occurs independent of any of these lesions. Did we indeed adopt these views, we might, as Dr. Christison has pointed out, with more plausibility, maintain the existence of a pulmo- nary typhus, as we observe the lungs to be much more commonly affected in this city than any other organ in the body during fever. 1 agree, therefore, with those who consider continued fever as an essential disease, dependent on some unknown constitution of the blood, and occasionally accompanied or followed by various local lesions of the CONTINUED FEVEE. 857 cranial, thoracic, or abdominal viscera, and with various eruptions on the skin. Although this may be considered as the correct general view of con- tinued fever, it cannot be denied that it assumes various forms, which have been described in different ways by authors in this and foreign countries. Considerable confusion has consequently arisen, as to whether fevers observed in different places, and at various times, were identical or dissimilar in their nature ; and whether the varieties they presented were only attributable to the concomitant lesions which might be present. Any one who studies fever first in this city, and afterwards in Paris, will soon convince himself that there are at least two predominant kinds of fever ;—the one called by us typhus, the other called by the French typhoid,—that is, resembling typhus. Again, those who have studied fever in Edinburgh for the last fourteen years consecutively, are aware that every now and then a form of the disease is prevalent, which runs a short course, but has a tendency to relapse at pretty regular periods. Lastly, there is in fever, as in most other diseases, a kind which is very slight, and soon ceases—a so-called febricula.* Every practical physician is acquainted with these forms of fever; but whether they constitute varieties of the disease, which can be at all times separated, which have a distinct and invariable course, the one not being protective of the other, and so on, are points that are by no means determined. . Dr. Jenner, in a very elaborate series of papers inserted in the "Monthly Journal" during 1849-50, has endeavoured to show that febricula, relapsing fever, typhoid and typhus fevers, are four distinct diseases. He considers them, to use his own language, " as distinct from each other as are measles, scarlet fever, and small-pox, the poison of the one being, by no combination of circumstances, capable ot pro- * The variable amount and extension of fever at different times may ^gathered from the following table, showing the number of cases which have entered the Royal Infirmary of this city during the present century, which I extract from a paper lately published by Dr. Christison.—(Edinburgh Med. Journal, Jan. I808.) Table showing the Annual Number of Fever Cases in the Eoyal Infirmary since the beginning of the century. 12 Months to Dec. 1800, 329 " " 1801, 161 " 1802, 156 " 1803, 232 " 1S04, 32:! " 1805, 175 " 1S06, 95 " 180T, 110 " '; 1S0S, 111 " 1809, 186 '• 1S10, 143 " " 1811, 96 " " 1812, 103 " " 1813, 75 " 1814, 87 " 1815, 96 " 1816, 105 « " 1817, 485 « ISIS, 1546 " 1819, lll^S 12 Months to Dec. 1820, " 1821, " " 1822. « " 1S23, " 1S24, " 1825, 9 Months to Oct. 1826, 12 Months to Oct. 1827, « 182S, " 1829, » 1830, « « 1831, « 1832, " 1833, " 1S34, " 1S35, " 1S36, " 1837, « 1S3S, 858 DISEASES OF THE BLOOD. ducing, inducing, or exciting the others." He gives the following characters which, according to him, serve to distinguish these four kinds of fever. " Febricula.—A disease attended by chilliness, alternating with sense of heat, headache, white tongue, confined bowels, high-coloured scanty urine, hot and dry skin, and frequent pulse, terminating in from two to seven days, and having for its cause excess, exposure, over-fatigue, etc. —i. e., the cause of febricula is not specific. " Relapsing Fever-.—A disease arising from a specific cause, attended by rigors and chilliness, headache, vomiting, white tongue, epigastric tenderness, confined bowels, enlarged liver and spleen, high-coloured urine, frequent pulse, hot skin, and occasionally by jaundice, and termi- nating in apparent convalescence in from five to eight days; in a week a relapse—/'. e., a repetition of the symptoms present during the primary attack. ' After death, spleen and liver are found considerably enlarged; absence of marked congestion of internal organs.' " Typhoid Fever.—A disease arising from a specific cause, attended by rigors, chilliness, headache, successive crops of rose spots, frequent pulse, sonorous rale, diarrhoea, fulness, resonance and tenderness of the abdomen, gurgling in the right iliac fossa, increased splenic dulness, delirium, dry and brown tongue, and prostration, and terminating by the thirtieth day. After death, enlargement of the mesenteric glands, disease of Peyer's patches, enlargement of the spleen, disseminated ulcerations, disseminated inflammations. " Typhus Fever.—A disease arising from a specific cause, attended by rigors, chilliness, headache, mulberry rash, frequent pulse, delirium, dry brown tongue, and prostration, and terminating by the twenty-first day. After death, disseminated and extreme congestions ; in young per- sons, enlargement ofthe spleen."—(Medical Times—Twentieth Paper) Dr. Dundas of Liverpool has advanced another doctrine, entirely opposed to that of Dr. Jenner. His views on the subject of fever are essentially these :—Not only are there no specific differences between the various kinds of continued fever, but there are none between con- tinued, intermittent, and remittent fevers. All these disorders, according to Dr. Dundas, are essentially one disease, and may all be cured by one remedy, viz., quinine. Given in doses of ten grains, repeated at intervals of two hours, until five or six doses had been taken, he says that it arrested or-cut short a continued, as it did an intermittent fever. These statements, deliberately brought forward, and still maintained, by Dr. Dundas, who, in Brazil and in this country, has had abundant oppor- tunities of carrying out the practice, supported, moreover, by confirma- tory cases, published by different medical men in Liverpool, determined me to give this practice a fair trial. During the months of November, December, and January 1851--, I treated nineteen cases of continued fever in the clinical wards, of which four were febricula, one relapsing, three typhoid, and eleven typhus fever. In a disease so common as fever, I have thought it necessary to condense the facts as much as possible, from the lengthy and accurate reports taken in the hospital books. All these cases, however, were examined with the utmost care, and all the phenomena noted, especially in reference to the two doctrines I have placed before you,—viz., those CONTINUED FEVER. 859 of Dr. Jenner and of Dr. Dundas. Further, to avoid repetition, I have Bimply stated th«,t the quinine treatment was employed; but in every case this treatment was practised exactly in the manner recommended by the last named physician. The effects we observed to be produced by the quinine I shall notice afterwards. Febricula. Case CXC*—Margaret Divine, set. 42—admitted 26th Nov. 1851. Was attacked with rigors on the 23d, after complaining for two days before of headache and general debility. On admission complained of pain in the limbs, and general dull pains over the body. Had no appetite, but great thirst, with a dry furred tongue ; she is very subject to pyrosis; skin was hot and dry, pulse 80, strong; a slight murmur accom- panied the first sound of the heart. I£. Sol. Acetat Ammon. §i; Vini Antimon. §ij ; Aqum, % iij. M. To take one table-spoonful every four hours. November 28th.—Better to-day; pulse 72; a sediment filling one-fourth of the glass is deposited in the urine ; still general dull pain of surface. 29th.—The general pains are gone. She feels quite well, and wishes to rise ; she was now convalescent, but owing to weakness, was-not dismissed until the 15th of December. Case CXCL*—Susan Rennie, wife of labourer, aet. 49—admitted 15th December 1851. On the 11th, was seized with severe rigors, followed by pain in the lower part of the back and the limbs ; with frequent alternations of shivering and perspiration during the day; there was severe headache, with loss of appetite and oppressive thirst. On admission, the tongue was slightly furred ; she had constant nausea, and vomited nearly everything she took; the skin was hot, but moist; there was no erup tion on her person; she had a short cough, with trifling expectoration. Pulse 76, small. She continued in this state till December 19th, when, after sweating and a lengthened sleep, the fever left her, and she became convalescent, and was dismissed January 1. The treatment consisted of salines, anodynes, and stimulants. Case CXCII.f—Thomas Stevens, set. 21, servant of a cowfeeder—admitted Novem- ber 24, 1851. On the afternoon of the 23d, while engaged in his usual work, he was seized with severe rigors, headache, and pain in the back; he passed a sleepless and uneasy night, and on attempting to resume work next day, found himself quite un- able to do so, from return of the rigors, and aggravation of the headache. Had not been exposed, so far as he knew, to contagion. Had been already a patient in the house several tim3s, having suffered from fever on three different occasions. On ad- mission, the tongue was moist and clean, and the appetite was not much impaired, but he had very oppressive thirst. Bowels had been irregular some time before admission. On examination of the chest, slight bronchitis of the left side was found to be present, and the sputum was thick, viscid, and muco-purulent. Skin was very dry and hot, he complained of pain in the head, principally in the frontal region, and of a throbbing character. Pulse, 72, of good strength. He was ordered a full dose of castor oil, which produced copious evacuations from the bowels ; and fohowing mixture :—R> Vini Antimonii I ss ; Sol. Mur. Morph. 3 i; Aquas, I vss. Take J ss every second hour. He continued to complain of headache and general restlessness, and the pulse kept about 80, very full and strong, till the evening of the 25th, when he began to perspire a httle ; aud on the forenoon ofthe 26th, he had profuse sweating. On the * Reported by Mr. J. L. Brown, Clinical Clerk. f Reported by Mr. W. M. Calder, Clinical Clerk. 860 DISEASES OF THE BLOOD. 30th, the antimonial solution was stopped; he improved rapidly, and was dismissed quite well, on the 8th of December. Case CXCTII.*—Andrew Downan, ret. 11, tobacco-boy—admitted January 14th, 1852. On the 11th was attacked by violent headache, lost all appetite for food, hut felt exceedingly thirsty ; his skin felt very hot, and he complained of general lani; CXCIV.*—Edward Anderson, a Swede, vet. 25, hawker—admitted Dec. 15th, 1851. Seized with rigors on the 8th; had great pain in the head, back, and over the body generally, and felt languid and depressed, though he was not com- pelled to take to bed till the 14th. On admission, tongue thickly coated; no appetite; much thirst ; bowels constipated ; slight pain of head ; pulse 70, of natural strength; skin hot, but moist, presenting a well-marked eruption of small roundish and oval spots of a rose red tint, slightly raised above the surface of the skin, entirely dis- appearing under pressure; widely scattered, but most abundant on the thorax. December 10th.—Slept badly; pulse 75, natural strength; sweating a good deal; much thirst, but total disinclination for food; spots more numerous. To have an effervescing draught and six ounces of wine; also half an ounce of the following mixture at bedtime:—Tinct. Hyoscyam!, 3i; Tinct. Kino, 3y; Aq. § ij. Con- tinued to improve daily after this date; and had no feverish accession while he remained in the ward. Was dismissed on the 29th at his own desire, as he was anxious to resume his occupation, though still rather weak. The several systems were carefully examined before dismissal, and found normal. * Reported by Mr. \V. M. Calder, Clinical Clerk. CONTINUED FEVER. 861 He was re-admitted on the 5th of January, 1852. Had resumed his work, hut on the 1st inst., 24 days after the first rigor in the former attack, was again seized with shivering, and felt pain all over the body, but especially complained of pain in the throat, and difficulty of swallowing. There was also considerable dyspneea. On ad- mission, tongue dry and coated ; mucous membrane of fauces and pharynx much con- gested, and covered with a thin layer of pus; bowels constipated ; slight pain over abdomen generally, but especially in the right iliac region ; voice husky and indistinct; much cough of a convulsive character; little expectoration; no abnormal physical signs on examining the chest; pulse 110, full and hard; skin hot and flushed; and over the abdomen there were a few scattered spots of the same shape, and rose-red tint as before. Vini Antimon. ^i; Aq. 3 vj. M. ? i to be taken every second hour. January 6th.—Pain on pressure in iliac region increased; had little sleep ; puke 90, full, but softer. Acetate of Ammonia, with Morphia—six leeches to right iliac region. January 8th.—(8th day, or 32d from first attack), sweating a little last night; no change in urine ; no pain on pressure over the abdomen. January Oth.—Eruption very distinct, and continuing well marked for 24 hours, after which it gradually faded. January 12lh.—(36th day) more feverish to-day, and complains of more pain in the throat; pulse 120, sharp and vibratory; urine natural. After this date he began to improve gradually, and was quite convalescent on February 1 st. Commentary.—I have called the above a case of relapsing fever, simply because after the febrile state, counting from the first rigor, had continued for full seven days, there was complete recovery ushered in by diaphoresis. So well was this man, that he insisted on going out and resuming his occupation as a hawker. On the 24th day, however, he was again seized with all the symptoms of the primary attack, including. on both occasions, a distinct exanthematous eruption of rose-coloured, lenticular, elevated spots. I am aware it may be contended that this was a case of typhoid fever. Dr. Jenner would probably so consider it on account ofthe eruption, the iliac tenderness, and its termination about the 30th day. But if the circumstance of a complete recovery and a distinct relapse, is to be considered as a sufficient cause for distinguishing a fever, it is scarcely to be conceived that these occurrences could ever be better characterised than in the above case. There is this difference, that the relapse occurred on the 24th, and not on the 14th day. This, however, 1 have seen frequently happen in the epidemic of relapsing fever which occurred in this city during 1843. Though most common ou the 14th day, this period was passed over, and the first relapse occurred on the 21st or 21th day. One or more relapses are not unfrequent, and it would appear as if the period of the first had been passed over. Dr. Christison has pointed out that this form of fever is identical with inflammatory fever, or the synocha of Cullen, and in his article on Fever in the Library of Aledicine, he has shown their similitude, especially as he had observed it in the Edinburgh Epidemic of 1817 to 1S20, and 182G-27. During the great epidemic of 1843-44, I had abundant opportunities of studying it, not only in others, but in my own case, having been attacked a fortnight after my appointment as Physician to the fever hospital. On that occasion, Dr. Christison, who attended me, at once pronounced the disease to be the synocha, which he had seen twenty years previously, and confidently predicted the relapse, which 862 DISEASES OF THE BLOOD. occurred on the fourteenth day, when I imagined myself to be convalescent. That remarkable epidemic has been carefully described in the writings of Alison, Craigie, Cormack, Halliday, Douglas, Wardell, and others. TYPHOID FEVER TREATED BY QUININE. Case CXCV.*—Miles Murray, cet. 25, labourer—admitted November 7, 1851. First seized with rigors on the evening of the 2d, followed by strongly marked febrile symptoms. No contagion. On admission, features livid and anxious; skin dry and hot; no eruption. Severe frontal headache ; pain in the back, and over the whole body. Slight " subsultus tendinum." Tongue moist, but furred; no appetite, but excessive thirst. Pulse 84, full, but soft, occasionally intermittent. Short dry cough, and slight dulness on right side of chest ; no unusual rales. Ordered an antimonial mixture ; six leeches to be applied to the head. November 8th.—Slept well during the night; no delirium. Skin still dry and hot; no eruption; tongue more dry than yesterday. Pulse 82, full, but soft. Ordered quinine, in ten-grain powders, every second hour. Nov. 9th, Vespere (7th day).—He has taken the pow- ders regularly since ordered; no marked effect produced except on the pulse, which has come down eight or ten beats after each powder, its strength also being much reduced; there has been much sweating to-day. Still severe headache; no delirium. Urine passed this afternoon exhibits, under the microscope, amorphous lithates; but the deposit, on standing, is inconsiderable. Nov. 11th.—Has taken in all 205 grains of the quinine. Slight tingling in the ears this morning, but only transient. Is dull and stupid to-day. Countenance has still a worn and exhausted aspect. Slight cough, and a few scattered sibilant rales on auscultation. Pulse 76, small, and soft. Suspend the quinine. Wine four oz., mixture with the sp. aether, nitr. and sol. ammon. acetat. Nov. 19th.—Drowsiness increased since last report, but without any other marked change. No delirium. Nov. 20th (18th day). —Urine to-day loaded with lithates. Countenance rather livid. Skin not very hot; thirst moderate. No eruption has appeared. Nov. 21st (19th day).—Feverish symptoms returned. No decided delirium, but much drowsiness, and total indifference to what is going on around him Pulse 80, full and soft. Nov. 23d, Vespere (21st day).—Complains to-day of uneasy symptoms in epigastrium, with much nausea. Had slight vomiting in the afternoon. Nov. 24th.—Had an emetic ordered last night, which produced copious vomiting ; nausea and pain in epigastrium relieved, followed by profuse sweating. Nov. 30th (28th day).—Has had consider- able diarrhoea during the last four days; checked by the lead and opium pills, and tanuin. Slight delirium to-day; skin hot and dry, pulse 96, full, regular; cough more troublesome ; bronchitic rales abundant all over the chest. December 1st.—Much sweating to-day; strength greatly prostrated; cough oppressive, and expectoration brought up with extreme, difficulty; fceces and urine passed in bed. Has four oz. wine daily, and an expectorant mixture. Dec. 6th.—Weakness increasing; almost constant sweating, but no further change. Four oz. of brandy in addition to the wine. Dec. 7th (35th day).—Was more restless than usual last night, but there is now no delirium. A bed-sore is threatening over the trochanter of the right femur. Pulse 102, small and weak. Dec. 10th.—Cough occurring in paroxysms; weakness increasing. Dec. 12th (40th day).—Pulse to-day 130, small and vibratory; skin cool and moist; appetite little better. R Quinae Disulph. gr. iv; Fiant pulv. tales, .vj. One every three hours. After taking four of the powders, * Reported by Mr. W. M. Calder, Clinical Clerk. CONTINUED FEVER. 863 the pulse fell to 102, small and jerking. Quinine stopped, and brandy and wine resumed. Next day (41st of fever), he began to shiver about 3 p.m., and presented all the phenomena of a paroxysm of ague, the skin continuing pungently hot for about three hours, but without sweating. In the evening the skin was comparatively cool, and the patient felt languid and drowsy. He was ordered to resume the quinine, five grains every three hours. Dec. 14th (42d day).—No return of shivering, or febrile symptoms. After this date he began to improve steadily; and, with the exception of slight sore throat, and return of short dry cough for a few days, had not a bad symptom during the remainder of his stay in the house. He was dismissed perfectly well on the 19th of January, having been 73 days in the ward, and 80 days having elapsed since the occurrence of the first rigor. Commentary.—This case was observed and recorded with the greatest care, and I had no difficulty in considering it to be a case of typhoid fever, unusually prolonged, perhaps on account of the pulmonary com- plication. There were several distinct exacerbations, coming on with marked rigors, at intervals of seven days, followed by increased febrile symptoms. At one period this man's life was despaired of, the profuse sweatings, the diarrhoea, extreme prostration, with partial pneumonia, and general bronchitis, constituted symptoms of a most alarming charac- ter, through which, however, with the assistance of stimuli, liberally administered, he eventually safely struggled. This also was the first case of fever in which the quinine treatment was tried. It so happened, that having ordered six doses, of ten grains each, to be administered, and not seeing him on the following day, the drug was by accident con- tinued consecutively for eighteen doses, at intervals of two hours each. At the end of that time, no effect having been produced on the fever, it was continued in five grain doses, so that in all he took 205 grains of quinine. Notwithstanding, not only did the fever march on, but, as we have seen, the most alarming prostration was induced. No eruption could be detected during the whole progress of the disease, though daily looked for with the utmost care. Case CXCVI.*—Marianne Howison, set. 11—admitted January 16, 1851. Rigors appeared on the 10th, followed by febrile symptoms. Mother and sister had died immediately before of fever. On admission, pulse 130, full and strong ; intense bead- ache ; tongue dry and brown ; complete anorexia, and great thirst; skin hot, no eruption. On the 17th, the treatment with ten-grain doses of quinine was ordered. l$th.—F\ve powders were given; and the report to-day is: headache gone; pulse 94, soft; skin moist and cool; tongue moist and red. On the 19*A, restlessness and heat of skin returned. On the 24th, fever was as intense as when she was admitted. 25th.—Diarrhoea. 27^.—Considerable abdominal pain on pressing right iliac region ; six leeches applied; § vi of wine. 31st.—Diarrhoea, which had formerly continued only twenty-four hours, has been present continuously for the last three days. February 1st.— Pulse weak; sordes on lips and tongue; intellect confused; no diarrhoea Feb. 3d.—Pulse weak and irregular, 140 ; is insensible. Feb. 4th.— Very- restless during the night; still insensible; pulse 150, small and jerking; slight haemorrhage from the gums. Died at seven p.m. Sectio Cadaveris.—Fifty-six hours after death. The mucous surface of the lower third of the small intestine was scattered over * Reported by G. A. Douglas, Clinical Clerk. 864 DISEASES OF THE BLOOD. with round and oval elevations, becoming more crowded together near the ccecum. The former were of the size aud form of a split pea, the latter varied from the size of sixpence to that of an almond. In the lower portion, some of the elevated patches were softened and sloughing, and in one or two places the sloughs had separated, forming ulcerations. The upper third of the large intestines presented also numerous round papular elevations, similar to those in the smaller intestines—the whole exhi- biting the various well-known changes of typhoid elevations and ulcerations in a characteristic manner—the peritoneum corresponding to some of the ulcerations un- usually congested, hut there was no peritonitis. Some of the mesenteric glands en- larged and softened; other organs healthy. Commentary.—This was a well-marked case of typhoid fever, which was fatal on the twenty-fifth day; and on dissection, the intestinal lesion, characteristic of the disease, was discovered. Here also the quinine treatment was tried, with the effect of at first moderating some of the symptoms, although on the following day they returned with increased intensity. As in the last case, no eruption could be discovered on this girl, though carefully looked for. It is further worthy of observation, that the mother and sister had died of a similar disease. The contagious nature of this form of fever is still doubtful, as many in; ist that the intestinal lesion is dependent on purely endemic causes. Case CXCVII.*—John Anderson, set. 21, sailor—admitted 29th December, 1851. On the 4th of December, having been exposed to cold during his passage from Elsinore, he was seized with rigors, diarrhoea, and thirst, which continued severa] days. From this condition he was gradually recovering when the ship entered the harbour of Leith on the 24th. That night he was again attacked with rigors, great thirst, and diarrhoea, followed on the 27th by intense sudden pain in the abdomen, vomiting, and constipation. On admission the features were shrunk and hard; skin cold and clammy; tongue red and furred; severe griping pain in the abdomen, which is shrunk ; no tympanitis ; bowels costive ; scanty urine ; no head- ache ; pulse 126, feeble and vibrating. Twenty-four leeches were applied to the abdo- men; one opium pill every two hours. Dec. 30.—Unrelieved; mind wandering; bowels freely opened without relief; pulse very rapid, and almost imperceptible. Died at one p.m. Sectio Cadaveris.—Twenty-three hours after death. Peritoneum purple, congested, having flakes of lymph upon the surface. It con- tained several ounces of dirty turbid yellow fluid, having a slight fcecal odour. Stomach and duodenum normal. About the middle of the jejunum a small ulcer one-half of an inch by one-eighth in size, penetrating all "the coats of the intestine ; edges pale and not raised. Mucous membrane of the lower part of ileum and ccecum mottled with slate-colored patches; Peyer's patches prominent, and several ragged ulcers situated in their course, and in some of the solitary glands; ulcers flat, with smooth edges. Intestines contained fluid fceces of a yellow colour, resembling pea- soup. Commentary.—This was another undoubted case of typhoid fever, with intestinal disease, terminating by peritonitis, the result of a perfo- rating ulcer. The leading facts were communicated to me with great * Reported by Mr. A. Dewar, Clinical Clerk. CONTINUED FEVER. 865 clearness after the boy's death by the captain of the vessel, in whose log was recorded the day of the attack, the remission, and the renewed attack on the twenty-first day. He also had observed no eruption on the skin, but of course his information on such a point was of no great value. The three cages now given have enabled you to study the principal phenomena presented by typhoid fever. With regard to its diagnosis, if you rely on the characters prominently given by Dr. Jenner, especially with regard to the eruption, it must be evident you will be frequently deceived. It so happens that iu none of the three cases was an erup- tion observed, although, in two, it was carefully sought for; and in one of these latter the nature of the disease was placed beyond all doubt by dissectiou, which, after all, is the only certain proof of typhoid fever. I have been in the habit of considering the most trustworthy symptoms distinguishing this form of fever from typhus, to be the remissions; a peculiar character of the countenance expressive of abdominal pain; the diarrhoea (especially when the stools resemble pea-soup); and marked tenderness on pressing deep down into the right iliac lesion. I acknow- ledge, however, that these symptoms, in the absence of an epidemic of typhoid fever, are often deceptive, even when the disease has continued beyond the thirtieth day. * Typhoid fever is, on the whole, a rare disease in Edinburgh. It is common, however, on the opposite coast of Fife, aud at Linlithgow. The late Dr. John Reid used to remark, when he was pathologist to the Infirmary, that all the bodies he opened affected with typhoid ulcera- tions of the intestines, came from one or other of these places. On the other hand, in Paris, and in many places on the continent, it is the pre- vailing form of fever. In the fever wards of this Infirmary you have the most extensive opportunities of studying typhus ; in the hospitals of the continent, and especially at Paris, Berlin Prague, and Vienna, you will see typhoid or enteric fever on a large r-cale. These facts serve to clear up much of the confusion which has entered into the discussions con- cerning continued fever by foreign aud domestic writers. They also explain why the doctrine of Broussais, who conceived typhus to be gastro-entcritis—although everywhere on the continent adopted for a time—was, from the first, rejected as false by this school. At the same time there have been certain epidemics in Edinburgh during which typhoid fever has been prevalent, as there have been always cases of true typhus mixed up with the enteric fever of the continent, Thus, in the epidemic of 184C-7, an unusual number of typhoid cases were mingled with the typhus; and I have more than once seen distinguished physi- cians and teachers on the continent much puzzled by finding no morbid lesion in fatal cases of fever, which, from my previous knowledge ot the disease in Edinburgh, I had no difficulty in recognising as being those of genuine tvphus. . Now, it is an interesting inquiry to ascertain what are the causes which should occasion such a general typhoid fever abroad, and such a general typhus in this country. Foi- my own part, I have been lea from long observation of the fever, both here and on the continent, to form the opinion that it is in some way connected with the diet, which, 55 866 DISEASES OF THE BLOOD. among the lower orders, is very different in France or Germany from what it is in this country. Acid wines and food, impoverished diet, excessive use of vegetables aud fruit, predispose on the continent to intestinal disorders. I have thought this theory strengthened by the fact, that when, in 1846-7, typhoid fever was so largely mingled with typhus in Edinburgh, owing to a failure in the potato crop, various kinds of substitutes were employed by the people, and scurvy became common. TYPHUS FEVER TREATED BY QUININE. Case CXCVIII.*1—Mrs. Macdonald, a nurse in the Infirmary, set. 50—admitted November 10th, 1851. Seven days ago was unusually exposed to cold, and two days afterwards experienced vomiting, pain in the back and epigastrium, with head- ache, and prostration of strength, which last symptom was apparently increased by a purgative taken on the 8th. On admission the skin was exceedingly hot; pulse 102, strong; tongue white and furred; great thirst, and headache; anorexia and nausea; slight bronchitis. On the 11th, an emetic was ordered, and two hours after its opera- tion the quinine treatment to be followed. On the 12th, it is reported that she took four quinine powders of 10 grains, at intervals of two hours, but vomited the fifth. Three others, however, were retained during the night, so that 70 grains have been administered. At present, she is in no way relieved. Skin hot and dry; pulse 100, strong ; tongue furred; pains in head and epigastrium unabated. Eight leeches to be applied to the head, and Quin. Sulph. gr. v. every two hours. Nov. \3th.—Has taken five nwre quinine powders. Pulse now 7S, full; considerable vomiting, and pains in epigastrium ; other symptoms the same. Cold douches to the head; warm fomentations to the epigastrium. Pill of bismuth and opium every four hours. Nov. 14th.—Head and stomach much relieved. It is reported that last night the limbs were partially convulsed, and her eyes fixed, a state that lasted seven minutes. Nov. 15th.—Confusion of intellect and restlessness. Pulse rapid and weak. § iv. of wine. Nov. 17th.—Has remained in the same condition. Slight puffing of the cheeks observed on expiration. Nov. 18th.—Puffing of cheeks more marked; unable to move the right arm ; great prostration. Wine 5 vj. Blister to the head. Xov. 19th. —Died comatose. There has been no eruption. Commentary.—No examination of this woman's body eould be obtained, and we are therefore in doubt as to whether an exudation had or had not taken place between the membranes of the brain. The cerebral compli- cation, however, was in this case well marked. At first, indeed, there was nothing more than usual; but the vomiting was obstinate, and latterly the convulsion and partial paralysis indicated distinctly the organ affected. Having previously resolved to try the quinine treatment, it was given energetically iu this case, but without any effect on the pro- gress of the fever. It may even be contended that it did harm, seeing we had a cerebral complication to deal with. Of this, however, at an early period, we could not judge, although it appears to me that the quinine practice is contra-indicated in such cases. Case CXCIX.f—George Johnson, boot-maker, aet. 21—admitted 8th December, 1851. Had severe rigors on 29th November, which were followed by the usua * Reported by Mr. J. L. Brown, Clinical Clerk. f Reported by Mr. A. Dewar, Clinical Clerk. CONTINUED FEVER. 867 everish symptoms. No exposure to contagion. On admission, tongue densely furred, coated, and cracked; no appetite ; intense thirst; skin hot and dry; confused in his ideas, without great pain in the head; pulse 108, fulL Dec. 9th.—Slept very ill, and continues the same as yesterday. Pulse 120, full. R. 01. Ricini, 3 vj. Vespere.— $ Sulph. Qnina; "j; Div. in pulv. vj. One every two hours. Bowels freely moved in the afternoon; great heat of skin; much mental excitement; pulse 120, full and strong; no eruption. Dec. 10th.—Slept well; no restlessness; skin cool and moist; no headache; slight singing in the ears; pulse 87, of good strength. Pulse rose to 88 during the day, and in the evening was full and strong. Quinine repeated; 10 grains given at flrsf, then 13 grains every two hours. Dec. 11th.—Pulse 84, of good strength; thirst great; skin moist; no eruption. Dec. 12th (14th day).—Thirst le.-s ; some appetite; no eruption; slight deposit in urine. Improved from this time, and was dismissed January 5th. Commentary.—This was a slight case of fever from the beginning, with no alarming symptoms, recovering on the fourteenth day. Whether this result was in any way owing to the quinine is doubtful, for, as we shall see, there were other cases very similar, in which the fever was of no longer duration. When first given, it certainly brought down the pulse, and all the symptoms abated. On their return, therefore, the treatment was again had recourse to, and the dose increased to thirteen grains. Ou this occasion, however, no further benefit was obtained; and it appeared to me that the disease terminated with critical sediment in the urine, on the fourteenth day, in the usual manner. There was no eruption in this case. Case CO*—John Craik, blacksmith, set. 23—admitted January 5, 1852. On December 28th, had severe rigors, followed by feverish symptoms, aud during the night, severe cough, and much expectoration. On admission, tongue red and moist; slight sore throat; no appetite; constipation; pulse 80, of good strength ; severe cough, and considerable expectoration, tinged with blood; mucous rales are heard over chest, chiefly at base of lungs; skin soft and dry ; no eruption, or exposure to contagion. January 7th.—Bowels freely opened; cough very severe. Ordered saline mixture ; blister to front of chest. Jan. 8th (11th day).—Very restless; delirious; drowsy and stupid; cough abated; pulse 108, weak. Vespere.—Pulse 121, quick; skin hot and dry. Quinine treatment ordered.. Jan. 9th.—Skin cool and moist; pulse 90, weak ; tongue moist and red; extreme deafness. Jan. 10th.—Slight diaphoresis. Jan. 11th (14th day of fever).—Skin hot and dry; flushed and delirious; marked rose-coloured eruption over chest and abdomen; great thirst; sordes on lips and teeth; tongue red and moist, dark in centre.' Jan. 12th.—Delirious; eruption remains; sordes disap- pearing ; skin hot and dry ; cough severe ; crepitation distinct at base of right lung; no dulness, but marked resonance. Ordered antimonial mixture. Jan. 13th.—Coun- tenance flushed; pulse rapid and weak; great prostration. Blister to right side; wine =iv. Jan. 14th.—Symptoms urgent. Jan. 15th.—Great thirst; tongue foul; crepitation gone, and the respiration is heard very indistinctly; vocal resonance well- marked. Jan. 17th.—Improving; no dulness, nor increased vocal resonance; some sibilant rales ; slight deposit in urine. Steady improvement until February 20, when there was cedema of lower limbs; urine normal. Is now quite convalescent. Dis- missed. 1 Reported by Mr. W. H. Broadbent, Clinical Clerk. 868 DISEASES OF THE BLOOD. Commentary.—In this case it will be observed that, although the qui- nine produced at first an apparent improvement, the fever, with delirium and the usual symptoms, shortly returned, and ran a rather protracted course, owing to the pulmonary complication. Case CCI *—Anne Dowie, aet. 18, servant—admitted December tOth, 1851. Seized with pain in the head, heat of skin, and general debility, Dec. 3d. Next day general pain over the body, which has continued since. On admission, pulse 120, feeble- tongue dry, red, and fissured; no appetite ; great thirst; bowels constipated ; skin hot and covered with a clammy sweat, and presenting on the chest and arms an eruption of numerous minute petechial spots, which have existed for some days; slight couch and expectoration; scattered bronchitic rales over chest. Dec. 11th.—The quinine treatment was ordered. After the fifth dose of 10 grs., slight deafness, rincmw in the ears; one more dose taken, after which the medicine was stopped. Dec. 12th.__Pulse 80, " excessively small and weak ; " surface cooler. In the afternoon, the pulse was 86, strength much increased; skin warm and moist; tongue dry, rouoh and fissured • much thirst; respirations 43 in the minute; slight subsultus. 13lh.__Pulse 84 of good strength; skin moist; eruption unchanged ; lips covered with sordes • tongue dry and cracked. On the 14th, she had smart diarrhoea, which was checked by an astringent mixture. 15th (12th day).—Appearance of patient much better; pulse 88 of good strength: eruption faded; tongue cleaner. 17th (14th day).—Couoh trouble- some ; a good deal of opaque dirty-looking muco-purulent matter expectorated ; moist rales heard on auscultation; thirst and anorexia continue ; urine turbid but without sediment. 19th (16th day).—Urine loaded with lithates; patient improving. After this date she recovered rapidly, and was discharged on the 15th January, quite well. Commentary.—This was a well-marked case of petechial typhus, in which the quinine treatment was tried, without apparently in any way arresting its course, although the physiological action of the drug upon the pulse was remarkably well characterised. Case CCIL*—Isabella Adamson, set. 20, servant—admitted December 19,1851, with eczema of the scalp and face. Rigors appeared Jan. 4th, followed by febrile symptoms. Rose-coloured exanthematous spots appeared on the chest and arms on the 9th. On the 10th, the treatment by quinine commenced. On the 11th, the imme- diate effects of the quinine have disappeared, and the report is—Pulse 100, full and compressible; had no sleep; pain in head very intense; no sweating; tongue furred and cracked; eruption darker. 14th.—Confusion of the intellect; vertigo; pulse 110, weak and intermitting; sordes on lips and tongue; subsultus tendinum. 17///.— Head symptoms have been relieved by a blister; and she now began slowly to improve. On the 24th, pulse 80; returning appetite; sordes disappeared. On the 28/A, convalescent. Commentary.—This also was a remarkably well-characterised case of fever of considerable severity, evidently caught in the ward, running its usual course, notwithstanding the quinine treatment was commenced so early as the sixth day. The eruption here presented rose-coloured spots at the commencement, becoming darker afterwards. Seven cases of con- tinued fever treated by quinine have thus been recorded, which we may now contrast with six cases treated in the ordinary way. * Reported by Mr. W. H. Broadbent, Clinical Clerk. CONTINUED FEVER. 869 TYPHUS FEVER TREATED WITHOUT QUININE. Case CCIII.*-Anthony Kerrachar, labourer, set. 20-admitted November \o 1851. On the 7th, had rigors, followed by confusion of head and general feverish symptoms. So exposure to contagion. On admission, tongue furred and white- intense thirst; no appetite; expression anxious, only slight headache; no eruption' Xov. 13.—Cough severe ; dulness at lower part of left lung; cough mixture. Nor. 20. —Feverishness gone ; sleeps well; expression good. Dismissed on Dec. 8, 1851. Case ('CIV.*—Laurence Cochrane, labourer, set. 43—admitted December 1st 1851. Had first severe rigors, Nov. 28th, followed by febrile symptoms. No exposure to contagion. Had fever six years ago. On admission tongue furred and moist; appetite gone ; constipation; pain in back and loins, and great weakness. Complains of cough ; no expectoration; chest resonant, but crepitation is heard at base of left lung; pulse 100, full and regular. Dec. 2d.—Bowels well moved; pain unrelieved ; appetite returned: no eruption. Dec. 12th.—Fever disappeared, but very weak. Dismissed January 12th. Commentary.—Both these cases, although complicated with pulmo- nary disorder, ran their usual course, and in this respect resembled Case CXCIL, in which quinine was given. In neither was there any eruption. Case CCV.f—Isabella Stevenson, set. 44, washerwoman—admitted November 10th, 18.51. On the 3d, first experienced pain in the head, followed by sweating but says she had no rigors. She was in bed, complaining principally of cephalalgir, during the whole of last week. On admission, the skin is dry and hot, but at nioht always bathed in perspiration. No eruption; tongue furred; no appetite; thirst moderate; intense headache, with occasional stupor; pulse 120, small, threadlike. Cold to the head and stimulants. On the 12th, crepitation was heard in the left lunc posteriorly. 13th.—Great dyspneea; moist and dry rales over anterior of chest. These symptoms increased, and she died Nov. loth. Seetio Cadaveris—Forty-eight hours after death. Both lungs anteriorly were emphysematous in the highest degree, presenting numerous bullae, with deep fissures between them, with patches of collapsed lung here and there. If anything, the left lung was most affected. Posteriorly, both lungs more or less collapsed, and on section, the lining membrane of the bronchi was deeply congested, and the tubes, on pressure, yielded an abundant muco-purulent discharge. Spleen small, weighing one ounce and a half; brain and other organs healthy. Commentary.—This woman came into the ward on the same day as Case CXC VIII., the fever was equally severe, and if anything the head- ache was more violent. It was resolved to give quinine in one case and treat the other in the usual way. It so happened that both died. Case CCVI.t—Margaret Menzies, set. 16, servant—admitted December 28, 1851. Seized with lassitude and febrile symptoms on the 22d, but without distinct rigors. On admission, pulse 100, full; tongue coated; head.iche and vertigo; skin dry and * Reported by Mr. A. Dewar, Clinical Clerk. f Reported by Mr. J. L. Brown, Clinical Clerk. 870 DISEASES OF THE BLOOD. hot, with rose-coloured elliptical spots scattered over the abdomen and chest, which appeared this morning; they are of mulberry colour on the arms. January 1st.— Urine loaded with lithates; eruption disappeared; skin cool; pulse natural. Jan. 3d.—Convalescent. Case CCVII.*—Christina Swan, servant, aet. 25—admitted December 16th, 1851. Had rigors on the 14th, followed by febrile symptoms, but had headache and other premonitory symptoms on the 11th. The day before admission (15th) an eruption appeared on the body. On admission, pulse 120, small; tongue florid at edges, furred at the sides ; no appetite ; great thirst; cough. The entire surface is covered with a mulberry-coloured eruption, in small crescentic patches, and though not raised, strongly resembling that of rubeola. Eyes red and suffused, not sensitive to light. December 19th.—Was delirious last night. Mouth and teeth covered with sordes; tongue dry and cracked ; is now insensible ; pulse 120, small. Subsultus tendinum, bronchitis on both sides, with pneumonia in lower half of right lung. Dec. 25th.— Since last report, constant low delirium, which to-day is somewhat diminished. Cough and expectoration very troublesome. Absence of respiration from right back, with pealing vocal resonance. Pulse rapid and weak ; eruption faded. Blister to head. Wine 5 vj, and brandy 5 iv. Dec. 29th.—No delirium, but lies in a comatose state. A lateritious sediment in the urine has appeared, and a swelling in the right parotid gland. Pulse 98, more full. January 1st.—Consciousness returning; cough much diminished, and respiration audible in right back; skin cool. An abscess forming in the neck, below right side of jaw. From this period convalescence was slowly established ; the abscess was resolved, and she was dismissed February 2d. Commentary.—This was a very severe case of typhus, with pulmonary complication, which, however, by means of stimulants liberally given, struggled through on the twenty-first day. The eruption in her case was very peculiar, closely resembling that of rubeola, which it was main- tained to be by several persons who saw it. It appeared on the second day after the rigor. But there was none of the intolerance to light, or coryza of measles; and, moreover, she and her friends stated that she had previously had the disease. Under these circumstances, it is pro- bable that it constituted the " mulberry rash " of Jenner, appearing early. Case CCVIII.f—Bridget M'Fayden, aet. 20, labouring woman—admitted Decem- ber 17, 1851, with psoriasis of the arms and legs. Rigors appeared January 4, fol- lowed by slight febrile symptoms, which became fully established en the 10th. 11th.— Delirious; face flushed; pulse 120, rather strong and jerking; no eruption. 17th.— Quite unconscious. Head shaved and blister applied. 18th.—Head relieved; pulse rapid and weak. Ordered 4 oz of wine. On the 24th, sediment of lithates in urine. She gradually improved after this date, and on the 26th was convalescent. No eruption. Diagnosis of Continued Fevers. On reviewing the nineteen cases of continued fever previously given, with a view of determining how far we are enabled to distinguish its * Reported by Mr. J. L. Brown, Clinical Clerk. f Reported by Mr. W. H. Broadbent, Clinical Clerk. CONTINUED FEVER. 871 varieties at an early period, it will, I think, appear that this is impossible. If there be any fact connected with the disease better established than another, it is that at the onset we are unable to say whether any given case will turn out to be a febricula or a typhus, a relapsing or a typhoid nvn^r ^w^?dy carefully the symptoms presented by Cases CXCII., CXC1V ., CXCV., and CO, you will be satisfied of this. We may, indeed, when acquainted with the prevailing type of an epidemic, often be led to guess,_ with more or less correctness, as to its probable course, but exactitude is impossible. Should the fever cease on the seventh day,' then it may be febricula or relapsing fever. The latter is determined by the return of the disease; but I know of no circumstance, beyond the type of the epidemic, which can lead us to predict that event. On the other hand, should the fever continue beyond the seventh day, then we have to do with typhus or the typhoid form. Notwithstanding all that has been said as to the means of distinguishing these varieties by means of the eruption or of the abdominal symptoms, I believe that in practice it will be found to be impossible before the twenty-first day. We have seen, in the three cases of typhoid fever which have fallen under our observation, that no eruption existed in any of them. With regard to the ten cases of typhus fever also, in five there was no erup- tion (Cases CXCVIIL, CXCIX., CCIIL, CCIV., CCVIII.); in three there were rose spots (Cases CC, CCIL, CCVI.); in one a mulberry or measly eruption (Case CCVII.); and in one petechiae (Case CCI).* Then, with regard to diarrhoea, it is only diagnostic of typhoid fever after the fourteenth day. Thus, in case CXCV., it first appeared on the twenty-eighth day, and in case CXCVI., on the fifteenth. Iu Case CXCVIL, on the other hand, it is said to have been present from the first, but such an occurrence, however it may excite our suspicions, is far too common in all fevers to be much regarded as more particularly indicative of typhoid than of typhus fever. From all these considera- * This paragraph has been criticised by a writer in the " British and Foreign Medi- cal Review"' for October 1853, who is a strong supporter of Dr. Jenner's opinions, It may be worth while, in turn, to analyse his arguments. He admits that if the eruption is not distinctive, the objection to Dr. Jenner's views would be well founded. He says, however, that in Ca?es CXCIX., CCIIL, and CCVIII., the eruption may have been absent, simply on account of the youth of the patients. But typhus fever frequently attacks young people, and if the diagnostic eruption can only be depended on in persons after the age of 25, its value cannot be very great. Case CXCVIIL is declared to be a cerebral disease, and Case CCIV., a pulmonary one. Cerebral and pulmonary complications were undoubtedly there, but I can assure the critic that they were cases of typhus fever notwithstanding. Thus, however, he disposes of the five cases which are hostile to his views. Then, as to the three cases of typhus (Cases CC, CCII , and CCVI.), with rose spots, he denies that such spots are exan- thematous. But if not exanthematous, what are they? Certainly they were not macular or petechial. Then, because it is said in Case CCII. that they became darker afterwards, and in Case CCVI. it is noted they are of a mulberry colour on the arms, therefore they must have presented the ordinary character of a typhus rash. All I can say is, that to me they were in no way distinctive. The absence of eruption in the three typhoid cases (CXCV, CXCVI., and CXCVH.), is thus explained by the reviewer :--" As the rose spots only appear in 85 per cent., it is not impossible that they might have been absent in these three consecutively, and may have been pre- sent in the next fifteen." But if so, how in Edinburgh, where typhoid fever is rare, is our diagnosis to he assisted by a supposed peculiar form of eruption, which need not occur in all the cases of the disease admitted into the clinical wards for perhaps twelve mouths? 872 DISEASES OF THE BLOOD. tions, the distinctions which have been made out between the various forms of continued fever, are for the most part retrospective, and can only be determined in the advanced stages. It is of the utmost impor- tance to take this into consideration, in endeavouring to estimate the value of particular kinds of treatment. The same arguments whicii apply to the uncertainty of diagnosis, may be urged against the general doctrine, that these forms of fever are dependent upon separate poisons, run a different course, and are govern- ed by laws as distinct as those whicii regulate the various kinds of erup- tive fever. Without denying the existence of various kinds of continued fever I am of opinion that this doctrine has not been established. On the contrary, I believe that internal complications, and the accidental circumstances of season, diet, constitution, and otlier causes of a like nature, modify fever in particular individuals at different times, and that to these the variations observed are in many cases attributable. More- over, I am satisfied that typhoid and typhus fever may occur together, epidemically, run into one another, and be mutually communicable. This was very well shown in the Edinburgh epidemic of 1 S4G-7, in which both diseases occurred together at the same time, and in the same localities, some individuals coming from the same house affected with typhus, and others with typhoid, the latter having intestinal lesion after death, as proved by dissection. In an elaborate paper by Dr. Charles Murchison,* he endeavours to prove that typhus and relapsing fevers are caused by overcrowding, with deficient ventilation and destitution. Typhoid fever, on the other hand, he considers to be caused by emanations from decaying organic matter or by organic impurities in water, or by both of these causes combined. The arguments he has brought forward in support of this view merit careful consideration, and should be remembered in any future inquiry into the origin of epidemics. At the same time, the facts which came under my notice in the remarkable epidemic of this city, already referred to, cannot, I think, be explained by any such supposition. Morbid Anatomy of the Edinburgh Epidemic Fever during the Winter Session 184G-7, when Typhoid Disease was prevalent. During this epidemic, I opened the bodies of sixty-three individuals who had died of typhus and typhoid fever, with the following results :— Spleen.—The organ most frequently affected was the spleen.. In the majority of cases it was more or less enlarged and softened, presenting a mahogany-brown colour, and creamy consistence; so that when pressed, the whole of its parenchyma could be squeezed out of its capsule. In ten cases the spleen contained yellow fawn-coloured discolourations with abrupt margins, sometimes diffused in masses varying in size from a walnut to that of a hen's egg, at others, disseminated in miliary spots through the organ. In two cases, these altered masses of the spleen's substance had softened and burst iuto the peritoneum, causing fatal peritonitis. Iu another case, a distinct line of separation was observed to be forming round a mass about the size of a walnut. Medico- Chirurg. Trans, of London. VoL xii. CONTINUED FEVER. 873 On examining this altered texture in the spleen with a power of 250 diameters linear, it was found to cousist of—1st, numerous molecules and granules; 2d, free nuclei; 3d, compound granular cells of various sizes; 4th, fragments of the fibrous tissue and fusiform corpuscles of the organ. The granu- lar cells were frequently ruptured, more or less broken down, and appeared to me at that time to constitute the structural character of a new formation which had been described by Roki- tanski and other German pathologists, as typhus deposit. This deposition, according to them, bears the same relation to the constitu- tion of the blood in cases of typhus fever, as tubercle and cancer do to the tubercular and Fis.4So. Fig. 4%. cancerous cachexise. Althougli the facts described by Rokitanski and others are quite correct, as well as his description of the structure of this altered tissue which I confirmed in 1846-7, further observation has con- vinced me that tliese alterations are not peculiar to typhus, and do not constitute a distinct form of exudation. They consist, in point of fact, of a peculiar degeneration of the splenic pulp, which follows a greater or less increased growth of the glandular cells, the morbid anatomy of which is displayed in a series of preparations I placed in the University Museum, where they can be studied. Lungs.—The organs most frequently affected after the spleen were the lungs. The most common lesion was bronchitis, the bronchial lining membrane being of a deep mahogany or purple colour, more or less infiltrated with serum or exudation. The fine bronchial tubes were fre- quently filled with a muco-purulent matter, and in a few cases were choked up with a reddish-brown gelatinous substance, more or less fluid —probably a modified form of the exudation described by Eemak, as discovered by him in the sputum. The apices of the lungs were very commonly cedematous, yielding on section a copious grayish frothy fluid. In fifteen cases, the lungs were more or less consolidated by exu- dation, which seldom presented the characters of normal hepatization. It was sometimes of a dirty yellow tint, at others of a brownish choco- late colour, existing in masses of irregular outline, and of variable size, resembling the discoloured portions of the splenic pulp, formerly alluded to. In three cases there was pulmonary apoplexy. The dirty yellow or chocolate-coloured exudation into the lungs was ascertained, on microscopic examination, to consist of,—1st, numerous molecules and granules, filling up the air vesicles, and infiltrated into the areolar tissue; 2d. naked nuclei; 3d, enlarged and isolated epithelial cells, with multiplying nuclei; and 4th, several compound granular cor- puscles. This material was also supposed to belong to the so-called typhous deposits, but is more probablv in part an altered exudation, dependent on the constitution of the blood, and partly a desquamation of the epithelium, with tendency to multiplication of inclosed nuclei. Intestines.—The intestines presented the lesion so well described by i Ficr 495 Structure of a decolorized mass in the spleen. F& 496. The same after the addition of acetic acid. 2oO diam. 874 DISEASES OF THE BLOOD. Bretonneau, Louis, Cruveilhier, and others (dothinenteritis, typhoid ulcer etc.), in nineteen cases. It consisted of a peculiar alteration of the round and oval glandular patches of the small intestine, exhibiting in its first stage a flesh-coloured mass, raised above the mucous membrane, pre- senting in the round patches the form of a pimple, or a split pea, and iu the oval ones an abrupt elevation, resembling an inverted dish. In the second stage this mass was more or less softened, especially round the edges, exhibiting a tendency to separate and slough. In the third stage, the slough had separated, leaving an ulcer, with abrupt edges, equal in area to the size of the gland affected, but varying in depth, occasionally passing through the muscular, and resting on the peritoneal, coat of the intestine. In this latter case, the peritoneum externally often presented a red or violet patcb of congested vessels, indicating the ulcer below. The elevated patches were observed occasionally to extend as high as the duodenum, and as low as the rectum. In one case numerous dothinenteritic elevations, about the size and shape of a split pea, extended all over the ascending and transverse colon. In a few cases the isolated follicles in the large intestine were observed swollen and empty, presenting in their centre a dark blue or black spot. In others, the round and oval patches of the small intestine exhibited a grayish or slate-blue appearance. Perforation of the intestine from ulceration, causing fatal peritonitis, occurred in three cases. Dysentery, with flakes of lymph attached to the mucous surface over the ascending and trans- verse colon, was associated witb intense dothinenteritis in one case. Oval and round cicatrices, exhibiting different stages ofthe healing pro- cess of the intestinal typhous ulcer, were observed in two cases. On examining the matter found in the intestinal glands in the above cases, it was shown to consist of numerous molecules and granules, asso- ciated with free nuclei and cells of the glandular sacs, which were unusu- ally distended, and filled with cell elements, in various stages of develop- ment and disintegration. In this respect it closely resembled the altered substance of the spleen, formerly described, and indeed appeared to con- sist of the same glandular lesion. Mesenteric Glands.—In all the cases where the intestinal ulcerations were recent, the mesenteric glands were enlarged, soft, and friable, and Fig. 497. Appearance of exudation and epithelial cells in the lung in a case of typhoid pneumonia. Fig. 498. Another portion ofthe same lung, after the addition of acetic acid. Fig. 499. Portions of normal epithelium separated from the air vesicles. 250 diam. CONTINUED FEVER. 875 of a grayish or reddish-purple colour. Some of these glands reached the size 01 a hen s egg. On section they presented a finely granular surface, of a dirty yellow-grayish or dark fawn colour, and their sub- stance was generally soft and friable, but sometimes, in one or more parts of the swollen gland, broken down into a fluid of creamy con- sistence. Ou examining this creamy matter, or the fluid squeezed from the gland, with a power of 200 diameters linear, it was found to contain numerous cells, generally spherical, varying in diameter from the l-150th to the l-35th of a millimetre. In some cases numerous nuclei were con- tained in the cell, occupying three-fourths of its interior, generally about the l-200th of a millimetre in diameter. At other times from one to four of these: nuclei were seen scattered within the cell. On the addition of acetic acid the cell-wall was rendered very transparent, whilst the nuclei were unaffected Many of them were free, and at first looked like altered blood corpuscles, from which they were at once distinguished by the action of acetic acid. (See Figs. 200 to 202, p. 172.) Blood.—The blood, in the great majority of cases, was fluid, and of a dirty brownish colour. In those instances, however, where the disease had been protracted, and especially in such as presented well-marked glandular disease, firm coagula were found in the heart and large vessels. Other Lesions.—With regard to the other lesions observed in the 03 bodies, it may be said that in two there were glossitis, and laryngitis with tonsillitis; in one, abscess of the kidney; and in one, abscess of the posterior mediastinum. The brain did not appear to participate much in the disease. It presented only occasional congestion, with slight effusion into the subarachnoid cavity, or into the lateral ventricles. In seven bodies no lesion whatever could be discovered. Such is a summary of the appearances observed in sixty-three bodies of patients who died of fever during the prevalence of the typhoid form of the disease, during 184G-7. The proportion of typhoid to typhus cases I have now no means of ascertaining. On the whole, however, the account given is a faithful description of the frequency with which the individual lesions occurred, and of their minute structure. With regard to the nature of typhoid, as of all other forms of fever, we know little; but, from what has been said, it is impossible to avoid seeing that the spleen, mesenteric and intestinal glands, are especially liable to be affected. Now these glands constitute part of an apparatus which, I believe, secretes the blood (see Leucocythemia); and if so, we begin to catch a glimpse, at all events, of the connection between altera- tions of these structures and of the blood in fever. Further researches, however, are required to determine the nature of such connection, as well as how far in this disease the glands operate upon the blood, and the blood upon the glands. Of the numerous questions which will be found discussed in syste- matic works relating to the pathology and mode of propagation of con- tinued fever, I shall only here allude to one, namely, Whether it be or be not advisable and right to admit fever cases into the general ward of a hospital. 31 y reply is decidedly in the affirmative, being satisfied it is far better in every point of view to dilute the contagious element, rather 876 DISEASES OF THE BLOOD. than to concentrate it by providing special wards for typhus cases. Pre- vious to 1825, a few fever cases were treated in each clinical ward of this Infirmary without injury to the other patients, the disposition of the fever beds being represented' in shadow, in Fig. 500. The space around them was partially isolated by a screen partition, seven feet high, with a door at each end. At present the arrangement of fever beds in the clinical wards is represented, Fig. 501. Each bed has 1100 cubic feet \ STAIRCASE I \flUH5CSf NURSCSFttlClll Fi&r. 501. of space, and 8-£ feet of head room. There is a window on each side of every fever bed, and a space of six feet between it and the adjoining ones. The result of this system has been most satisfactory, as during the last ten years there has been no spread of fever in the wards, except on one occasion, which was traced by Dr. Christison to the rules of the house having been neglected.* Treatment of Continued Fever. The general treatment of continued fever which I have found most * Monthly Journal of Medical Science, March, 1850. Fig. 500. A clinical ward of the Royal Infirmary in 1817, 60 feet by 24, showing the arrangement of fever beds, and the screen which isolated them. — (Christison.) Fig. 501. Clinical ward, No. XL, 1858, 81 feet by 24, showing the present ar- rangement.—(Christison.) CONTINUED FEVER. 877 useful, and which you have seen practised in this Infirmary, consists, during the stage of excitement, of giving saline antimonials, administer- ing slight laxitives if occasion requires them, and ordering the head to be shaved and cold applied. Wine and stimulants are required at a later period when the pulse becomes weak. In prolonged cases, the effect of pressure on the skin from decubitus must be carefully guarded against, whilst the different complications which arise will require care- ful management. Salines and Laxatives.—At an early period of the disease, when the skin is hot and the pulse rapid and strong, the saline mixture generally ordered is the following:—R Sol. Tart. Antim. ? ss; Liq. Ammon. Acet. 3" ij; Aqua;, 3 vss. M. Fiat mist., a table-spoonful to be taken every four hours. Should a laxative or purgative be required, not other- wise, castor oil is the one usually employed. Water or thin lemonade may be taken ad libitum. Cold to the Head.—The oppressive headache of fever is greatly alle- viated by cold applications to the head. Indeed none but those who have experienced it can understand the feeling of relief and grateful sensation of ease which is in this way produced. The best method of applying cold I have found to be as follows :—A wash-hand basin should be placed under the ear on one side, and the head allowed to fall over the vessel by bending the neck over its edge. Then from a ewer a stream of cold water should be poured gently over the forehead, and so directed that it may be collected in the basin, care being taken not to wet the dress or bed-clothes. It should be continued as long as it is agreeable to the patient, and repeated frequently. In hospitals, and more especially in fever wards, this method requires too much attend- ance. You will have observed, indeed, that I seldom order cold to the head, experience having taught me that it is more frequently converted into warmth to the head. For notwithstanding every injunction to the contrary, all that is done in these cases is to moisten a piece of double rag or lint in cold water, and lay it upon the warm head of the patient. In a few seconds it is converted into a warm and steaming fomentation, and too frequently allowed to remain in this condition for hours. Hence, unless cold can be applied properly (and iu large hospitals that can scarcely be expected without procuring a nurse for every two or three patients) it is better not to order it at all. It has occurred to me, how- ever, that a water-pipe might be conveyed round the walls of fever- wards, with a vulcanized india-rubber tube and stop-cock attached, so that with a little contrivance the patients might procure a flow of cold water and regulate it for themselves. I am satisfied that much relief would be in this way obtained. To secure the application of cold efficiently, it is necessary that the head be shaved. In all severe cases this is indispensable. Such prac- tice, however, is often stoutly opposed by the friends of young women, who are unwilling that they should lose a handsome growth of hair. I have occasionally compromised the matter by allowing the long hair to float in cold water, and act by capillary attraction on the scalp, so as to keep up a refreshing feeling of coolness. Wine and Stimulants.—When after being rapid and strong, the pulse falters, becomes soft and weak, very often without losing its frequency, 878 DISEASES OF THE BLOOD. it will become necessary to administer wine or other stimulants. The quantity of wine usually given is from three to six ounces a day; but in some cases marked by unusual depression, or when the individual has been accustomed to alcoholic drinks, a larger quantity, or instead, from one to four ounces of spirits may be required. Nothing is more difficult than to lay down rules as to the extent to which stimulants ought to be given in certain cases, or as to the period when they should be adminis- tered. The pulse, strength of constitution, previous habits ofthe patient, but above all the type of the prevailing epidemic, must be your chief guides. Nothing, perhaps, is more indicative of experience and practical tact in the treatment of fever than the judicious use of stimulants iu this disease, and certainly there is no other method of acquiring the necessary knowledge than that of carefully watching their effects in a large number of patients. Among all the agents at your command, there are none whicii will enable you to conduct a case of fever to a favourable termination more successfully than stimulants, when properly managed. Indeed, it is easy to conceive that in a disease where loss of appetite, and abstinence from food, constitute essential phenomena, a period must arrive sooner or later, when artificial support is absolutely required. You should be careful, however, not to prolong their use more than is necessary. Very singular anecdotes still linger about the clerks' rooms of this infirmary, of instances where whole bottles of whisky were consumed daily by fever patients ; and where, notwithstanding their recovery, owing to some mistake in the order-book, the whisky was still supplied, and disappeared with surprising regularity. Regulation of the Diet.—During the early period of fever, the patient generally loathes all kind of food. Care must be taken, however, that after a few days have elapsed, nourishment should be introduced in the form of drink, and diluted milk, toast and water, thin panada or similar fluids given, with a little toast or biscuit. Should collapse come on, together with the stimulants, chicken broth or good strong beef-tea should be administered. I am inclined to think that the danger from fever is not the result of over, but of under, nourishment, which, by reducing the strength, leaves the patient less capable of struggling with the subsequent weakness. I have especially noticed, with regard to relapsing fever, that those who have fed well in the interval, have been less affected by the re-accession. The body is also drained of its saline constituents, whilst such as enter with the food are, with it, cut off; hence I have found it useful to add a large amount of common salt to the beef-tea, which also renders it more sapid and agreeable to the patient, and serves to clear away the accumulation of fur and sordes that gather about the mouth. On the otlier hand, when convalescence comes on, we should take care not to indulge the appetite too much. With regard to the complications of fever I have nothing further to say, than that they must be treated according to circumstances, always keeping in remembrance that active depleting means are never useful, and seldom fail, by diminishing the vital powers, to augment the collapse and increase the danger. Can we cut short a Continued Fever ?—There can be little doubt that it is of immense importance to cut short the disease, if possible. With- out speaking too positively, I have been induced to believe in this possi- CONTINUED FEVER. 879 bility, under certain circumstances, by means of emetics. A fortnight after being appointed Physician to the Fever Hospital of this city, in 1S44,1 experienced lassitude, headache, and that peculiar cold feeling in the back, which generally usher in fever. I took an emetic of antimony and ipecacuanha, and on the following day was well. Three weeks afterwards, I experienced the same symptoms; but thinking it possible, that, after all, the emetic had not really been the cause of their removal, I allowed the disorder to proceed, which terminated in a prolonged relapsing fever, with three distinct relapses. I think I have observed the same thing in other cases; and now, as a rule, whenever called in at the early period of fever, I always order an emetic. This practice, so far as I have observed, never does harm, often good ; and, although the point is of course impossible to demonstrate, it has, I think, been suc- cessful in checking at the onset many cases of fever. With regard to cutting short beginning fever by quinine, as con- tended for by Dr. Dundas, I regret to say that the trial you have seen made of it has entirely failed. Iu none of the seven cases (Cases CXCV., CXCVL, CXCVIIL, CXCIX., CC, CCL, and CCII.) in which it was given, notwithstanding the physiological action of the drug was well marked, did it in any way shorten the disease, or produce on its pro- gress, so far as I could ascertain, any amelioration whatever. On the other hand, it may be argued that iu one case (Case CXCVIIL). it was injurious, by increasing the cerebral complication. Dr. Christison also tried it in one case, and Dr. W. Robertson in eight cases, both with a want of success. Thus, in sixteen cases it has been carefully and energetically tried with uniform failure in all. Therapeutic Action of Quinine in Fever.—The effects produced by large doses of quinine are worthy of observation. With these I became first familiar in the wards of M. Piorry, in La Pitie Hospital, Paris, during the year 1838. At that time quinine was given in enormous doses, with a view of cutting short intermittents, and diminishing the size of the spleen. In this way I frequently saw 50 grains of quinine or 100 grains of salicine given in one dose, the administration of which was followed by the same effects you have observed to follow repeated doses of 10 grains in the Royal Infirmary. In both cases the principal phenomena induced are vertigo, dizziness of vision, ringing in the ears, often complete deafness, with confusion of ideas, occasionally coma with contraction of the pupil. At the same time the force and frequency of the heart's contractions are diminished, and the pulse, from being 120, ■ strong and full, was frequently reduced in a few hours to 80 beats, which were soft and even weak. The skin at the same time becomes cool and often moist from slight diaphoresis. This sedative action on the heart is apparently the result of the comatose condition produced by the primary action on the brain, as is proved by the fact that the disappear- ance of the cerebral induces cessation of the circulatory phenomena. In large doses, therefore, quinine is a narcotic. At all events, its principal action seems to be on the nervous system, through which it seems to operate on the blood-vessels and blood. Of late years it has been called an anti-periodic, from the specific effects it exercises, not only on inter- mittents, but on all diseases which exhibit a tendency to return at periodic intervals as certain cases of epilepsy, neuraglia and even 880 DISEASES OF THE BLOOD. relapsing fever. This property is altogether peculiar, and is distinct from what ought to be understood by febrifuge, unless indeed the state- ments and views of Dr. Dundas should be subsequently confirmed. Quinine is also spoken of as being a tonic when given in small doses. This property seems to have been attributed to it on account of its bitter- ness, as well as its remarkable effects in the cure of ague. Rut whether it increases the appetite, stimulates the digestive organs, or in any other way operates by increasing the tone of the system and improving the nutritive powers, is a circumstance which, though generally adopted as true, admits of strong doubt. If quinine be a narcotic in large doses, it is the only one of that class of remedies which is tonic in small doses. No doubt it is very frequently given to convalescents and weakly per- sons, who get better under its use, but whether this is owing to the quinine, or would not have occurred equally well without it, is a matter very difficult to determine. Of one thing I am satisfied, namely, that it is far inferior in tonic properties to many metallic and other vegetable drugs, aud, consequently, a medicine with such known valuable anti- periodic properties, the supply of which also is yearly diminishing, should not be wasted in endeavouring to produce effects so very doubtful as the tonic virtues which have been ascribed to it. For many years, there- fore, I have not given quinine as a tonic, and have yet to meet with a case where it is necessary to administer it in order to increase the strength of the system. REMITTENT FEVER—CAN IT BE SEPARATED FROM HYDROCEPHALUS? Case CCIX.*—Blanche Scott, ast. 3 years, of scrofulous habit—admitted into the clinical ward November 10th, 1851. Her mother states that she enjoyed good health until a fortnight ago, when she was attacked with severe diarrhoea—the stools being thin, of a dirty green colour, offensive odour, and mingled with slimy matter. She became dull and peevish during the day, but restless and uneasy at night, when the skin became hot, and the countenance flushed. The diarrhoea and fever continued eight or ten days, accompanied with loss of appetite and great thirst. During the last four days there has been delirium ; loss of consciousness; occasional moanmg; uneasy gestures in demand for drink; hands frequently raised to the head, with a slight scream ; constant picking of the nose and angles of the mouth with her fingers ; latterly retching and vomiting, and passage of the urine and fceces in bed. Symptoms on Admission.—On admission, she presents the following symptoms: —Unconsciousness of surrounding objects, not recognising even her mother; pupils not contractile to light; slight strabismus of right eye; frequently puts her hands to the head, which is rolled about uneasily; continual grinding of the teeth, low moaning, and occasional muttering. Tip of tongue, which is all that can be seen, very dry, and of scarlet colour; loss of appetite ; constant thirst; vomiting; involun- tary discharge of foeces and urine; on pressing the abdomen uneasiness evidently experienced, and moaning increased. Skin hot and dry; no eruption; a small * Reported by Mr. J. L. Brown, Clinical Clerk. REMITTENT FEVER. 881 abscess at the back of the neck, with a sanious discharge. Action of heart feeble and fluttering. Pulse 140, small, and occasionally intermittent. Breathing short and hurried ; no rales. The head to be shaved, and a blister to be applied over the scalp. To have § ij of sherry wine. Progress of the Case.—November 12th.—The fever increased towards night, and she was very restless. This morning it has abated. Skin now cool; pulse 120, stronger and regular ; no strabismus ; still unconscious. Pus has formed below the blistered cuticle. Nov. 13th.—Accession of fever last night; the pulse rising to 160, and becoming sharp. This morning consciousness has returned ; fever abated; tongue dry, brown, and cracked; swallows without difficulty; pulse 120. Nov. 15th.—There are still accessions of fever at night, and remissions in the mornino-. The scalp is swollen and boggy to the touch, and pus oozes from it on making pressure. All movement of the head causes the child to cry. No tenderness of abdomen. Bowels are opened three times daily. Fceces are more consistent, of dull green colour, and offensive smell. Pulse 110, more full. Three parallel inci- sions were made through the infiltrated scalp, by which a considerable quantity of pus was evacuated. To take Zj of cod-liver oil three thnes a day. Chicken diet. Continue the wine. From this period she rapidly improved. The remittent fever ceased on the 18th. Extensive sinuses formed in the scalp, covering the occiput and neck, which, however, gradually healed on the application of a sulphate of cop-_ per lotion. Slight bronchitis appeared on the 25th. The appetite soon after became very good; her strength improved. The incisions in the scalp had perfectly cica- trised on the 1st of December, and on the 11th she was discharged; the abscess in the neck, however, not having quite healed. Commentary.—In this case the fever was of a distinctly remittent type—the accessions being very marked at night, and the remissions very considerable in the morning. It commenced with intestinal, which were followed by cerebral symptoms. AVas it a case of gastro-enteritis, or of cerebral meningitis, or, as these disorders are called by some, remittent fever, or acute hydrocephalus ? No doubt those two separate diseases exist; but if you ask me by what symptoms you may distin- guish one from the other in children at an early period, I should be at a loss to reply. In the whole range of practical medicine, this must be allowed to constitute a question of the greatest difficulty to decide. Indeed, I am inclined to consider that it cannot be done until the disease is so far advanced as to render the cerebral symptoms unequivocally predominant. In systematic works on the practice of physic, you will find the diagnostic characters of the two diseases set forth with wonder- ful order and propriety; but if you depend on these at the bedside, you will, in the majority of cases, be greatly disappointed. Now, if the symptoms observed in the case before us be taken into consideration, it will be seen that they partake of the characters of both diseases. Such I believe to be really the case, the old distinctions between remittent fever and hydrocephalus having no basis on morbid anatomy. The former, however, is connected with irritation in the digestive organs, the latter with cerebral congestion or inflammation. It is clear that these two lesions may be conjoined in different cases in various degrees, and hence the different aspects presented in practice. The so-called remittent fever and acute hydrocephalus of authors, then, cannot be sepa- rated, and in most instances are mingled together. The case of Scott was one of this description, commencing with symptoms of intestinal 5<5 882 DISEASES OF THE BLOOD. derangement, accompanied by fever of a remittent type, complicated at a later period by cerebral congestion of an asthenic character; in short, the hydrocephaloid disease of Marshall Hall. The treatment was in accordance with this view of the case, consisting of small quantities of wine, good nourishment, blisters to the scalp, and subsequently cod-liver oil. Several of you expressed the opinion that this was a case of hydrocephalus, and a few were inclined to give mer- cury. As to hydrocephalus, much depends on what is meant by that term. If by it is understood cerebral meningitis, then it was not hydro- cephalus ; but if it means certain cerebral symptoms, independent of any particular lesion, then it was. Such symptoms, however, may arise from exhaustion, as well as from over-excitement, and the one we had to do with was certainly a case of this kind, coming on, as it did, after pro- tracted diarrhoea and fever. As to mercury, I have no hesitation in saying, had we depended on it, as some recommend should be done in similar cases, the patient would never have recovered. It has been said that mercury is the sheet-anchor of the practitioner in hydrocephalus. I have never seen it beneficial in undoubted cases of cerebral meningitis, and the diagnosis in the vast majority of instances is so uncertain as to warrant the suspicion, that the recoveries which have taken place were not those of true inflamma- tion. In this little girl, notwithstanding the delirium, the coma, the screams, the tossing the hands towards the head, the strabismus, and the insensible contracted pupil—all of which have been placed among the principal evidences of hydrocephalus, the treatment was brought to a successful conclusion by stimulants and nourishment. I do not tell you that this will always succeed; but whenever such symptoms follow pro- tracted diarrhoea, and are accompanied by remittent fever, I am satisfied you may place more reliance on such treatment, aided by the powers of nature, than upon the vaunted, but in my opinion hypothetical, powers of mercury. INTERMITTENT FEVER. Case CCX.*—Tertian Intermittent cured by Quinine. History.—John Kelly, a labourer—admitted into the clinical ward October 20th, 1851. Had always enjoyed good health until three months ago, when he was attacked with intermittent fever in Lincolnshire, while working at the harvest. At first it assumed the quotidian type, but after three weeks it became tertian, and continued three weeks longer. Then being at Morpeth, there was an interval of a fortnight. On leaving Morpeth he was much exposed to cold and wet; the disease returned, and has continued up to the present time. Progress of the Case.—The day after admission, he had a well-marked attack of fever. The cold stage continued fifteen minutes, and the hot and sweating Ltages three quarters of an hour, followed by languor and depression. He was ordered to take five grains of sulphate of quinine three times a day, and a scruple of the drug two hours before the next expected paroxysm. He had two other attacks on the * Reported by Mr. W. M. Calder, Clinical Clerk. INTERMITTENT FEVER. 883 24th and 26th, the latter being very slight. On the 28th there was no attack, and the scruple dose was suspended. Discharged cured November 5th. Commentary.—The cause of intermittent fever is tolerably well ascer- tained. It is found in all countries which are low, swampy, and humid, and in localities where the ground is marshy, and presents a moist allu- vial soil, especially in the neighbourhood of extensive woods. We must not suppose, however, that marshes and a moist alluvial soil are the only causes of intermittent, for in India it sometimes prevails in hilly districts, at a considerable elevation, and is known by the name 'of hill-fever. We may therefore conclude with Dr. Fergusson, that the cause of intermittent is a condition of the atmosphere occasioned by evaporation from the earth's surface, by solar rays rather than by currents of air. The fre- quency ofthe disease during the autumn months is in favour of this theory. The occurrence or absence of intermittent fever in particular districts, according as the circumstances just alluded to be present or absent—be induced or prevented—is another proof of its correctness. Thus it is not a common affection in Paris, but in 1838 I saw it very frequent in the wards of M. Piorry, at La Pitie Hospital. It arose among the work- men of the St. Germains and Paris Railway, who, at a particular part of the line, which was low and marshy, caught the disease in great num- bers. They nearly all came to La Pitie, as M. Piorry cured the disease rapidly by large doses of quinine, and was in consequence celebrated among them; and thus, while numerous cases were always present in that hospital, it was very rare in Paris generally. On the other hand, there are many places in which ague was once common, where it is now rare, from the draining of marshes, or local improvements in cities. Thus it was formerly common in London, in the district which surrounds the Tower, but disappeared when the ditch was allowed to become dry. I have also been told that, in Edinburgh, when the valley which now separates the old from the new town was a marsh, ague was frequent. At present it is very rare, and never met with except in individuals who have caught the disease elsewhere and travelled to this city. With regard to the nature of intermittent fever, we know nothing, although we infer that the peculiar condition of the atmosphere alluded to causes a peculiar change of the blood, on which the disease essentially depends—but the nature of that change—why it should occasion an intermittent instead of a continued effect—why it should produce in different people a quotidian, a tertian, or a quartan, etc. etc.,—of all this we are ignorant. I cannot see that its pathology has in any way been advanced, by endeavouring to connect it with diseased spleen. Xo doubt this organ is frequently enlarged in ague, and in chronic cases becomes hypertrophied and indurated. Rut it is also especially liable to undergo changes of texture in continued fever, as we shall subsequently see. Piorry contends that congestive enlargement of the spleen is the primary change, and that the general fever is a result. He has brought forward numerous cases, showing that in ague, this organ may be demonstrated by percussion to be enlarged, and that recovery is commensurate with its diminution in bulk. He cites one case where an individual was knocked down in the street by the shaft of a carriage which struck him on the left side over the spleen, and in whom the resulting fever was 884 DISEASES OF THE BLOOD. distinctly intermittent. This may have been a coincidence. Careful observation, however, has satisfied me that there is no uniform rela- tion between the enlargement of the spleen and the intensity of intermit- tent fever, as M. Piorry supposes. We have seen that in leucocythemia the spleen has been much hypertrophied, and no ague occasioned. On the other hand, without denying that lesions of the spleen are very common in connection with ague, we are unable, in the present state of pathology, to determine whether this be a cause or an effect, or to indicate why lesion of this organ should sometimes be connected with an intermittent, at others with a continued fever. The treatment which experience has proved to be most certain and rapid, is that by quinine ; and I am satisfied that tolerably large doses are more efficacious, than small ones frequently repeated. I usually give five grains three times a-day, and a scruple two hours before the occurrence of the attack, and have never seen a case which resisted this treatment. Much larger doses have been given. Thus I have seen Piorry give fifty grains for a dose, with the effect in recent cases of at once cutting it short, and rapidly reducing the engorgement of the spleen; but a permanent and quick cure I believe to be. equally well effected by the medium dose formerly recommended. Quinine in large doses produces very inconvenient effects, such as cephalalgia, vertigo, tinnitus aurium, deafness, and other symptoms, which, should any cere- bral complication exist, may render it fatal. During the prevalence of intermittent at La Pitie, in 1838, a man was treated with large doses of the drug, and the head symptoms attributed to its stimulant action. He died, and on examination, acute meningitis was found with exudation of lymph on the membranes. Some years ago, Dr. Douglas Maclagan introduced the sulphate of bebeerine as a substitute for quinine, and, at the time, I tried it, with great success. Of late years, however, it seems to have lost its virtues; whether from change in the mode of preparation, or otherwise, I do not know. Certainly its good effects cannot now be depended on. Salicine is a useful drug in intermittent, and from numerous experiments I saw made with it in the words of La Pitie, in 1838, it may be depended on when given in double the quantity of quinine. In some chronic cases which have resisted quinine, arsenic has been found useful. I have frequently seen in the south-west of England, a case cured at once by a scruple of Cayenne pepper suspended in water. Indeed, a vast number of remedies have been fouud occasionally beneficial in intermittent fever, but there are none so uniformly successful as quinine. ERUPTIVE FEVERS. There are certain diseases which, in an arbitrary classification, may be considered as febrile eruptions, or as eruptive fevers. They comprehend especially scarlatina, erysipelas, variola, and rubeola. Occasionally roseola, herpes, or other cutaneous eruptions, may be attended with fever, but they are separated from the others by their non-contagious or non-infectious nature. Plague and glanders, on the other hand, are true SCARLATINA. 885 eruptive fevers; and with the others mentioned, obey certain laws, which may be shortly mentioned. 1. They may be infectious and contagious. Ry infection is under- stood the power of being propagated through the inhalation of air tainted by the breath or perspiration of the affected person. Ry contagion is understood communication of disease by actual contact. 2. The present theory with regard to the cause of these diseases, is, that it depends upon a morbid poison, a small quantity of which enter- ing the blood produces in that fluid a peculiar change which is analogous to that of fermentation. To distinguish this change in animal from what occurs in vegetable fluids, the term zymosis has been introduced by Mr. Farr (from t,vp6w, to ferment). . 3. Some of these animal poisons, if excluded from the air, or care- fully dried, will retain their communicating property for a longer or shorter time. This enables us to preserve matter for artificial inocula- tion. Hence also they have been supposed capable of attaching them- selves to fomites—that is substances of a rough surface or downy tex- ture, such as wool, cotton, wearing apparel, dust, etc. It is on this theory that quarantine regulations are founded, the whole of which, together with the facts, real or supposed, that support them, require a thorough revision. 4. All the animal poisons are distinguished by peculiarities in their mode of incubation and development. Thus a period of latency exists between exposure to the poison and accession of the fever, or first rigor. Again, the eruption appears at different periods after the fever is declared. Thus— Period of Latency Appears after first Kigor from from Scarlatina.....................4 to 8 days...................18 to 24 hours. Erysipelas.....................4 to 7 days...................24 to 60 hours. Variola........................8 to 14 days...................48 hours. Rubeola........................7 or 8 days...................72 hours. 5. All the eruptive fevers, strictly so called, invariably run a natural course, and cannot be cut short. It follows that— 6. The treatment of febrile eruptions has for its object conducting these cases to a favourable termination. To this end exactly the same general rules are to be followed as I previously gave when speaking of continued fever, and the same indications exist for the use of salines and laxatives, cold to the head, wine and stimulants, and regulation of the diet. These I need not again repeat, and I shall confine my observa- tions at present to the more special treatment of the diseases we have studied in the wards. Scarlatina. Case CCXL*—Mary Clark, set. 17, servant—admitted 20th December, 1851. On the afternoon of the 17th her throat became sore, and in the evening she was attacked with rigors, followed by pain iu the head and back, and other febrile * Reported by Mr. W. H. Broadbent, Clinical Clerk. 886 DISEASES OF THE BLOOD. symptoms. Last night she first observed a red rash upon her chest and arms; this is of a reddish brown colour, and resembles the ordinary eruption of scarlatina; it disappears upon pressure. Pulse 126 and feeble; fauces, tonsils, and back of pharynx red and congested; has great thirst and anorexia; tongue moist, with a white fur in middle, through which the red papillae project; bowels costive; urine sp. gr. 1030, contains no albumen—a deposit takes place, containing epithelial scales and crystals of triple phosphates. R; Tinct. Hyoscyam. § ss; Liq. Amnion. Acet. et Aqua; puras aa § iij. M. § j tertid qudque hord. Dec. 22.—Rash disappeared from arms, but is still visible on the chest; pulse 86, and soft; less pain in the throat, although fauces and palate are still congested. Dec. 24.—Convalescent, and she was dismissed on the 27th of December cured. Case CCXIL*—Isabella Husketh, aet. 22, a woman of abandoned character, and addicted to intemperance, was admitted 19th of December 1851, in a state of high delirium. It was ascertained that, on the 14th, she had been seized with rigors fol- lowed by great debility, catarrh, and general febrile symptoms. On the following day an eruption appeared on her skin. On admission, she was in a state of violent delirium, and required to he tied down in bed. Her eyes were suffused, and very sensitive to light; pulse 120; tongue dry and parched, florid-red at the edges, with the papillae projecting through a white fur in the centre ; teeth covered with sordes; great pain in throat, increased on swallowing ; submaxillary glands tender on pres- sure, but not enlarged ; eats nothing, but has great thirst; bowels costive; skin hot and pungent; arms and chest covered with a bright scarlet exanthematous eruption. Six leeches applied to the throat—saline mixture. Dec. 20.—Delirium continues; pulse 125; pain in throat relieved. Vespere.—Delirium greatly increased. Nine leeches applied to temples, and to have a draught of morphia, and some wine. Dec. 21.—Slept during night, and is nearly sensible to-day; tongue dry and florid; eruption fading; considerable sore throat. Blister to be applied to the throat. On the 23d the eruption had quite disappeared. The throat symptoms, however, gradually increased. On the evening of the 26th, the breathing was observed to be very short and hurried, and on the morning of the 27th the patient died. Commentary.—The first case is an instance of mild scarlatina, run- ning its ordinary course, and terminating in recovery on the seventh day. The second case is an example of severe scarlatina, occurring in a woman addicted to intemperance, and in whom all the symptoms of typhus fever, associated with sore throat, were present, proving fatal on the thirteenth day. Of all the eruptive fevers, scarlatina is the most rapid in its invasion, and the most variable in its course. Great watch- fulness is therefore demanded on the part of the practitioner, especially when the crisis is to be expected, so that if prostration comes on rapidly, or other untoward symptoms appear, he may be prepared to meet them. Perhaps, also, scarlatina is the most infectious of the eruptive fevers, so that complete separation of the patient from the other members of a young family is at all times to be insisted on as soon as possible. A chief peculiarity of scarlatina is, that, in addition to the general fever and characteristic eruption, the tonsils and mucous membrane of the mouth and pharynx are also apt to be inflamed. This occasions difficulty of deglutition, with soreness of the throat, symptoms which require for relief topical remedies, such as fomentations, astringent and slightly acid gargles, or a linctus, etc. If sloughing or ulceration occur, * Reported by Mr. J. L. Brown, Clinical Clerk. SCARLATINA. 887 the application of the stronger acids, or the nitrate of silver, is often necessary. The difficulty of deglutition sometimes impedes the intro- duction of food into the stomach, and in this way assists in producing prostration, and prevents the administration of stimulants or medicine. It may also, in severe cases, impede respiration, and assist in producing asphyxia directly. A fatal result, however, when it does occur during the primary attack of scarlatina, is generally dependent on the same causes which induce it in typhus fever—namely, congestion of the brain, as indicated by delirium, passing into coma, and followed by prostration of the vital powers. In addition to the throat complication, there are various others, all of which may require a special treatment. In the vast majority of cases, a general treatment, directed in the first place to subduing the excess of fever, and afterwards to supporting the strength, is indicated. Many efforts have been made by different practitioners to check or modify the intensity ofthe disease by administering various drugs, or carrying out particular kinds of treatment. Hence, during certain epidemics, or in its visitations to particular educational institutions, various practitioners have been sanguine enough to believe that their especial mode of practice has been more successful than any other. I do not consider it necessary to direct your attention to the numerous plans which have been thus proposed, because all of them have been only partial in their operation, and no one of them has been more successful than another. You must remember that the causes of scarla- tina are as mysterious and unknown as are those producing any kind of fever; and that its fatality, like that of fever, is to be traced to consti- tutional circumstances in individuals, to unhealthy localities, or to the so-called type of the particular epidemic. Nothing, therefore, is more difficult, under such circumstances, than to judge whether the non-fatality, observed at one time, or in a certain establishment, is referable to this or that practice. At all events, I have been unable to satisfy myself that any general rule of empirical or rational practice is to be derived from the contradictory accounts which have from time to time been made public on this subject. . . Dr. Andrew Wood, who has had great experience as physician to Heriot's Hospital and other educational establishments in this city, recommends the following treatment:—Several common beer bottles, containing very hot water, are placed in long worsted stockings, or long narrow flannel bags, wrung out of water as hot as can be borne. Ihese are to be laid alongside the patient, but not in contact with the skin. One on each side, and one between the legs, will generally be sufficient; but more may be used if deemed necessary. The patient is to lie between blankets during the application of the bottles, and for several hours afterwards In the course of from ten minutes to half an hour the patient is thrown into a most profuse perspiration when the stockings may be removed. In mild cases, the effect is easily kept up by means of draughts of cold water, and if necessary by the use of two drachm. doses of°Sp. Mindereri every two hours. In severe cases, where, the pulse is very rapid-the beats running into each other-w.he;;e f \e™P; tion is eithei absent or only partial, or of a dusky purplish hne-^ere the surface is cold-where there is sickness or tendency to diarrhoea- 888 DISEASES OF THE BLOOD. where the throat is aphthous or ulcerated, and the cervical glands swol- len, then he follows up the use of the vapour-bath by four or five grain- doses of carbonate of ammonia, repeated every three or four hours. Should this be vomited, then brandy may be given in doses proportioned to the age of the patients. Carbonate of ammonia he considers to act beneficially: 1st, by supporting the powers of life ; 2d, by assisting the development of the eruption ; and, 3d, by acting on the skin and kidneys. Where the vapour-bath was used early in the disease, and its use con- tinued daily, or even twice or thrice a-day, according to circumstances, he has found that the chance of severe sore throat was greatly obviated. In regard to supervening dropsy, he considers that, by the use of the vapour-bath, with the other necessary precautions as to exposure, diet, etc., its recurrence is rendered much more rare. In the treatment of the dropsical cases, it was also very useful, and in some instances might be trusted to entirely. Dr. Wood also condemns all depleting treatment, and even purgatives, during the first ten days, thinking them not only not required, but positively dangerous, as tending to interfere with the development of the eruption. In the later stages, as well as in the dropsy, however, he thinks purgatives are often beneficial. Shortly after this treatment was proposed at a meeting of the Medico-Chirurgical Society of this city, I tried it in the following case :— Case CCXIII.*—Margaret Welsh, aet. 18—admitted 2d July, 1852. She is a ser- vant girl, and had always enjoyed good health until June 29th, when she experienced distinct rigors, followed by sore throat and febrile symptoms. She admits having called previously on a family in which the disease existed. On the evening of the 30th a bright red rash appeared on the skin, and has continued ever since. On admission the scarlatinal eruption is well characterised on the chest and arms. The skin is hot; pulse full, hard, and 132 in the minute. Tongue furred, with elongated red papillre projecting through the white crust; great difficulty in deglutition; throat sore ; tonsils and mucous membrane of pharynx swollen and red. There are also cephalalgia, slight deafness, and restlessness at night. Respiratory functions normal; urine healthy; cata- menia regular. She was ordered by the resident clerk eight leeches to the head, a saline antimonial mixture, and eight grains of Dover's powder. On first seeing her the follow- ing day, 3d July, I found her in much the same condition as is described in the previous report; the skin still being hot and dry, and the eruption very vivid on the chest and arms. Hot bottles were ordered to be applied, encased in worsted stockings wrung out of hot water, as recommended by Dr. Andrew Wood. July 4th.—A slight perspiration followed the use of the vapour-bath last night. To-day, the rash has partly disappear- ed from the arms, but is now present on the legs as well as chest. Pulse 130, small; urine not coagulable. An astringent gargle for the throat—the vapour-bath to be again applied. July 5th.—Profuse perspiration resulted last night from the use of the vapour- bath. To-day the rash has entirely disappeared; but there is great tenderness of the skin and in the joints on motion. July 9th.—Has continued much in the same condi- tion, hut to-day the appetite has somewhat returned, and she has eaten a good break- fast. Her joints are swollen, and there is still considerable pain on moving them. Desquamation commencing; throat ulcerated, and to be touched with a weak solution of nitric acid ; pulse 84, soft; § iv of wine daily. July 2§th.—Since last report has been slowly gaining strength, but is still far from well. The urine has been care- * Reported by Mr. J. R. Williams, Clinical Clerk. SCARLATINA. 889 fully examined daily, and has never presented coagulability on the addition of heat or nitric acid. To-day a distinct blowing murmur was discovered with the first sound of the heart, loudest at the base, and propagated along the vessels of the neck; pulse 76, of good strength. August 4th.—Went out a little to-day, and in the evening the feet commenced to swell. August Oth.—Swelling of feet increased. To have a squill and digitalis pill three times a-day. August 9th.—03dema of feet continues; urine healthy. Venesectio ad § viij. August 11th.—OZdema of feet disappeared. This morning had a rigor. Was ordered an emetic. August 12th.—To-day is feverish, with great thirst and heat of skin; pulse 128, strong. A saline mixture ordered. August 17th.— Febrile symptoms continue, with tenderness over epigastrium ; and eight leeches were ordered to be applied there. The cardiac dulness is extended. No friction, but a blowing murmur, as formerly noticed at the base of heart; respiration somewhat em- barrassed. August 20th.—Respiration normal; no tenderness over epigastrium; pulse 100; regular and soft. The urine all this time has been tested daily, but has never been coagulable. To-day, however, a deposit existed in the urine, and several casts of the tubuli uriniferi may be observed in it with a microscope. September 7th.— Since last report she has been convalescent, and all her symptoms have gradually dis- appeared. The blowing murmur over base of heart is still present, but not so loud, and the increased dulness has disappeared. Dismissed. Commentary.—In this case, the disease, instead of being shortened or rendered milder, was unusually prolonged, and was followed by rheuma- tism, dropsy of the inferior extremities, and by pericardial effusion. The febrile symptoms terminated by critical deposition in the urine so late as the fifty-second day. Although admitted June 29, she was not strong enough to be dismissed from the Infirmary until September 7th. This was certainly an unfortunate case to commence the trial of a new treat- ment ; and yet the girl had been always healthy, and there was nothing to indicate at the commencement that the sequelae would be so severe or so prolonged. I persevered with this plan in four or five other cases, but in all of them it failed to bring about speedy resolution. At last I came to the conclusion that the heat, damp, and exposure, which it was difficult to avoid, tended especially in the class of servants and young women who entered the Infirmary, to rheumatism. I then adopted quite an opposite treatment, kept the skin dry and cool, and have had every reason to be satisfied with the result. Several very severe cases which entered the wards during the winter and summer months of 1856-57 were treated in this way with the best results, of which the following are examples :— Case CCXIV.*—Thomas Corrigan, set. 19, a labourer—admitted September 19th, 1856 He first felt sore-throat on the evening of the 16th, followed on the 18th by rigors and febrile symptoms. To-day the rash first appeared, and on admission presents a dusky-red colour, covering the face, neck, arms, haunches, and thighs. The throat is much swollen externally on both sides. The mouth is with great difficulty opened, when the tonsils are greatly enlarged and ulcerated. The back of the tongue is swollen and covered with a thick crust; anteriorly it is red aud dry. Pulse 116, lull and bounding. Respirations 27 in the minute. Deglutition difficult. Skin dry and pungently hot. Urine turbid, and of a reddish brown colour, not altered on the ad- * Reported by Mr. H. M. Maclaurin, Clinical Clerk. S90 DISEASES OF THE BLOOD. dition of heat. Chlorides scanty. Other organs healthy. Warm fomentations to be applied to the throat, and to use the steam inhaler. R^ Via. Antim. 3 ss; Aqwz Acet. Ammon. 3 j ; Aquas % ivss. M. Sumat 3 ss quartd qudque hord. September 20th.— Has been occasionally delirious. Other symptoms the same. To omit fomentations, inhalations, and mixture. R; Acid. Sulph. Dil. 3 ij; Syrupi 3J; Infus. Rosar. 3 vij. M. Sumat 3 ss quartd qudque hord. September 2lst.—Delirium has been violent during the night. At present pulse 76, full and strong. Deglutition and respiration somewhat easier. R> Vin. Colchici Z ij; Spirit. Aether. Nit. 3 iij; AquK 3 vss. M. Sumat semiunciam quartd qudque hord. September 22d.—Urine to-day clear; chlorides more abundant; no albumen. Pulse 69, not so full. Tongue still dry. Rash has disappeared. Sept. 23d.—Urine natural. Desquamation of the skin commencing. Swelling of tonsils and sore tbroat greatly diminished. From this time he rapidly recovered, and was dismissed quite well October Oth, Case CCXV.*—Eliza Campbell, aet. 24, a married woman, of weak constitution, with two children, the eldest of whom is recovering from scarlatina, was admitted December 19th, 1856. On the 12th she experienced lassitude and general malaise. On the 15th she had rigors, followed by febrile symptoms, and pain in the back. On the morning of the 16th, a rash appeared over the breast and other parts of the body. On the 18th her husband observed that her mind was wandering, and next day brought her to the Infirmary. On admission, there is a uniform scarlatina eruption over the back, abdomen, and arms. On the legs there are numerous spots of purpura extending up the thighs. Skin hot and dry. Mouth dry. Tongue brown and cracked in the centre. The jaws are separated with difficulty, showing the uvula and fauces of a scarlet colour, without swelling of the tonsils. Bowels costive. Pulse 108, small and weak. Is conscious, though rather confused, and very restless. Other organs healthy. Ordered 3 iij of sherry wine and 3 iv of lemon juice, to be taken during the day, with strong beef-tea. An injection of warm water to unload the bowels. December 20th.— Violent delirium during the night. At the visit pulse 160. Head to be shaved and cold applied. December 21st.—Had several hours' sleep during the night, and awoke better. Pulse 110. Eruption fading. Urine dark and turbid, with a copious sediment of urates. To have Z ss of Sp. Aether. Nit. every two hours, and 3 ij of Brandy, in addition to the wine daily. December 22d.—The rash is fainter. Desquamation com- mencing. Purpuric spots also disappearing. Still dryness of mouth and cracked tongue. Deglutition easy. Continue nutrients and diuretics. From this time she became convalescent. On December 24th there were still traces of the eruption in some places, while desquamation was advancing in others. On the 29th the cuticle separated from the hands entire. She remained weak for some time, and was not strong enough to be dismissed until January 24th, 1857. Commentary.—In the first of these two cases there was violent angina, in addition to the severe fever, with delirium, and yet the disease pursued its natural course, crisis occurring on the seventh day, and he rapidly recovered without an untoward symptom. In the second case, occurring in a woman of a weak habit of body, who had been underfed, the scarla- tina was associated with purpura, violent head symptoms, but no angina. Strong stimulants and nutrients were administered from the first, with diuretics to assist elimination, and ultimately she did well, without any sequoias, although, from her previous weak condition, convalescence was prolonged. * Reported by Mr. H. M. Maclaurin, Clinical Clerk. SCARLATINA. 891 It has frequently been observed, that the urine in scarlatina, especi- ally when dropsy supervenes, becomes albuminous. Dr. James W. Reg- bie, who has with great pains tested the urine in a considerable number of cases, considers its presence almost uniform. Aware of what he has written on this subject, I have tested the urine daily in certain cases, without observing it. This non-persistent coagulability of the urine, as well as various deposits which appear in it on critical days, must, when they occur, be considered as an evidence of the excretion of morbid products, which have circulated in the blood. Hence they are common, not only in scarlatina, but in all inflammatory affections as well as fevers. This point you must have seen me very obs3rvant of in watching for the resolution of inflammations and fever at the bed-side.—(See p. 141.) It sometimes happens, however, that the critical discharge is compara- tively slight, and that the organic elements are not dissolved so as to constitute fluid albumen. This appears to have occurred in the follow- ing case, for whilst morphological evidence of the crisis existed in the urine, in the form of cells and casts, no albumen could be detected by heat and nitric acid. Case CCXVI.*—Alexander Johnston, aet. 14—admitted June 23, 1851. Three days ago he experienced distinct rigors, followed next day by a general scarlatinal eruption. On admission there was restless delirium, and constant moving of the head from side to side on the pillow. He was apparently conscious when spoken to, but could not answer questions; the tongue was protruded with difficulty, dry, and of bright red colour, studded with florid elevations; deglutition was much impeded ; bowels open; pulse 130, weak; urine voided with difficulty, and diminished in quantity, sp. gr. 1025—not acted on by heat and nitric acid; skin hot and dry, covered with the bright-red scarlatinal eruption. Ordered salines and slight diuretics. He continued in the same condition, the angina increasing and the coma alternating with delirium becoming more pronounced until the sixth day. During this period all the urine passed was carefully examined. The amount was diminished (17 oz. per day), but it was free from deposit, and unaffected by heat or nitric acid. R Sp. Aether. Nit. Z "j ; Pot. Acet. Z ij ; Tr. Colchici § ss ; Aquas § iij. Fiat mist. ^ A teaspoonful to be taken every four hours. On the following day all coma and delirium had disappeared. He answers questions when put to him ; skin cool; eruption faded ; pulse 96, weak ; passed 30 oz. urine, which is turbid, with small flakes of a mem- branous character floating in it. On the eighth day the quantity of urine excreted was 50 oz., and was still more loaded with sediments. On examining the urine with a microscope, it was seen to contain—1st, membranous flakes, composed of aggre- gated rounded particles, apparently agglutinated together, and strongly resembling some forms of vegetable tissue ; 2d, rounded and irregular masses with spicula ; 3d, amorphous molecular masses. (See Fig. 67, p. 85.) The whole of these elements, on being analyzed chemically by Mr. Drummond, were found to consist of urate of ammonfa. Next day the urine was only slightly turbid, and on the following one it was perfectly clear. From this time the boy gradually recovered. Commentary.—This was a very severe case of scarlatina. The angina was intense, occasionally rendering deglutition impossible. There was delirium on the third day, alternating at night with coma, which was often profound. The worst result was apprehended. It occurred to me * Reported by Mr. G. Scott, Clinical Clerk. 892 DISEASES OF THE BLOOD. that the head symptoms, in this as in several cases of typhus, might probably depend, not so much upon inflammation of the brain, as upon absorption of, and poisoning by urea, an idea that appeared supported by .the diminished quantity of the renal excretion, as well as its freedom from all deposit. Remembering the alleged virtues of colchicum in increasing the elimination of this secretion, I ordered it in combination with diuretics, and the result was remarkable; for on the next day not only had the fever diminished, but the urine was increased in amount, and loaded with urates to an extent and in a form I had never previously seen. It may be argued that the fever had terminated by a natural crisis on the seventh day; but I cannot help thinking that in this case nature was assisted by the colchicum and diuretics. I have since given this medicine in various cases of uraemia, and in inflammations, where the excretion of urates should be favoured, at the period of crisis with the best effects. Erysipelas. Case CCXVII.*—Marion Smails, aet. 28—admitted January 8th, 1851. She stated that, on the morning of the 6th, she was quite well, but that, after being out for some time, she felt a burning pain in her left cheek, and observed a red spot upon it. This redness gradually extended down towards the neck, and was accompanied with considerable swelling. She applied a mustard poultice to her cheek, which 're- lieved the pain somewhat at first, hut afterwards caused a great aggravation of it. On admission, besides the local pain, she complained of great thirst and of a bad taste in her mouth. The tongue was moist; bowels regular; pulse 66, full and strong. The cheek was ordered to be fomented with a lotion of lead and opium. January 11th.—Swelling and redness are much less, as is also the pain. Jan. 17th.—Redness of the skin completely disappeared. Complains only of a slight soreness in the throat. Dismissed cured. Case CCXVIILf—James Maclaren, aet. 59, a porter, of intemperate habits— admitted November 16th, 1851. Eight days ago was seized with rigors, followed by intense febrile symptoms, which prevented sleep. On the 13th he experienced pain in the left side of his nose, accompanied by redness of the integuments, which rapidly spread over the cheek, eye, and brow of the same side. On the following morning the redness appeared on the right cheek, and in the evening had covered the whole face. On admission there is great thirst; loss of appetite; furred tongue; hot skin; full and burning pulse, 100 in the minute; great headache, with drowsiness; tingling pain in the face, which is of a deep red colour, in some places approaching purple. The blush extends over the forehead and anterior part of the scalp, and pits on pres- sure. Two bullae have broken, and recently formed scabs on the right side of nose. Ordered an antimonial saline mixture, and the face to be dusted with flour. November 17th.—Last night there was low muttering delirium, and this morning vomiting. In the evening, pulse of the same frequency, but more soft. To omit the mixture. Nov. 18th.—Redness more extended over the scalp, and fresh bullae have appeared on the forehead. Pulse 80, soft; constipation. To have § iij of brandy daily, and to take at present half an ounce of castor oil. Nov. 10th.—To-day much better. Pul.-o 80, of good strength; swelling of eyes diminished; redness fading; bullae scab- bing. From this time he gradually got well, and was dismissed cured, November 30th. * Reported by Mr. T. M. Lownds, Clinical Clerk. f Reported by Mr. A. L. Mackay, Clinical Clerk. VARIOLA. 893 Commentary.—The first of these cases was so mild, as, perhaps, to merit the name of erythema. The latter was a very severe one, occur- ring in a man of intemperate habits, but terminating in convalescence on the twelfth day. In this latter case a study of the symptoms will bIiow we have again, as in scarlatina, all the phenomena of typhus fever; and when erysipelas proves fatal, so in like manner it is by coma and subsequent collapse. Erysipelas, however, is opposed to scarlatina, in being the least infectious of the eruptive fevers, in being the least fatal, and in running a much slower course. In many other respects there is a close analogy between them observable in the kind of fever, the sequelae, and critical discharge of coagulable urine. The general indications for treatment are the same. The special treatment is directed by means of topical applications to diminish the local inflammation. For this purpose numerous remedies have been tried—such as dusting the part with flour, lotion of acetate of lead and opium, cerates, oil, etc. etc.,—any of which serve the purpose of cooling the surface, rendering it more soft, and diminishing irritation. There can be no doubt that erysipelas is occasionally a fatal disease, from the intensity of the fever, and amount of integument involved. It is generally supposed that, when it attacks the face and scalp, it is more dangerous that when a similar amount of surface in any other part is affected. This opinion does not appear to be founded on very exact observation. Even when the scalp is extensively invaded, death from erysipelas is a rare occurrence. On going round the wards of the Hotel Dieu in May, 1851, with M. Louis, I saw several severe cases of erysipelas of the scalp, which, I was told, were under no treatment whatever— because, as M. Louis informed me, according to his experience, erysipelas of the scalp was never fatal, unless it occurred in individuals of bad con- stitutions, or was associated with some complication. I need not say that, without forming any such exclusive opinion as this, it must be very difficult, in a disease that so generally tends to recovery, to judge how far this or that remedy is beneficial. Mr. Hamilton Rell has recom- mended fifteen to twenty-five drops of the Tr. Ferri Muriatis every second hour, as a most beneficial remedy in erysipelas. _ Rut how this medicine is more successful than the spontaneous operation of nature, it must be very difficult to demonstrate. Variola. Case CCXIX.*—Mary Hogan, aet. 7, was admitted Dec. 9th, 1851. Never had been vaccinated. Felt slightly indisposed Dec. 4th; and on the following day com- plained of severe headache, pain in the* back, nausea, loss of appetite, and great thirst. Tliese symptoms continued, and on the afternoon of the 7th, a bright red blush was observed on the face and chest, gradually spreading over all the body. On the 8th, the red blush became covered with numerous minute elevated papulae; and on the 9th, when admitted, numerous vesicles could be detected on the face, arms, and legs. Tongue furred, but moist. No dysphagia. Was ordered a purgative of sulphate of magnesia. December lOth.—The vesicles are numerous and close together on the face, and in some places confluent. Eyelids much swollen and nearly closed. Bowels are open; * Reported by Mr. J. L. Brown, Clinical Clerk. 894 DISEASES OF THE BLOOD. pulse 140; tongue florid. The hair was cut short, and mild mercurial ointment, thickened with starch, spread over the face. She was also vaccinated. Dec. 13th.— Pustules fully maturated and umbilicated over the trunk and extremities. The mer- curial paste forms a thick indurated crust over the face. Dec. 15th.—Many of the pustules over the body have burst and discharged their contents. No constitutional disturbance. Xo pain or itching of the face; all swelling of the eyelids disappeared. Dec. 18th.—Pustules have all burst, except a few on the feet. Was dismissed Janu- ary Oth, cured. The face scarcely presented any trace of the disease, and afforded a remarkable contrast to those other parts of the skin which had not been covered with the paste. Case CCXX.*—Michael Hogan, aet. 9, admitted December ]0, 1851, a brother of the former case, and also never vaccinated. Felt unwell on the 8th, with shivering, pain in the head, and usual febrile symptoms. -On the next day vomited, and then observed an eruption on the skin. On admission, the face, trunk, anns, and legs are spotted with bright papulae at considerable distance from each other, and he says the fever has considerably abated. On the 15th the pustules on the face were fully matu- rated, and here and there a few of them were observed to be confluent. On the 18th those on the inferior extremities were in the same condition. Last night he experi- enced again considerable headache, and to-day the pulse is 120, full; the skin hot, and febrile symptoms well developed. 10th.—Headache violent last night, with great rest- lessness and insomnia; but to-day these symptoms have abated. From this time con- valescence commenced, but he recovered slowly, and was not strong enough to go out until December 19th. A few pits existed on the face, where the pustules had been confluent. Commentary.—The general treatment of small-pox is similar to that of the other eruptive fevers. There is a special treatment, however, applicable to it, which deserves some consideration. The Ectrotic Treatment of Variola. Various methods have been proposed, for the purpose of arresting the development of the eruption in variola, and preventing the cicatrices which are likely to form. The treatment, called ectrotic (cK-rn-pwo-Koj, to render abortive), has been practised principally in France. Serres, Bre- tonneau, and Velpeau, cauterized each vesicle as it appeared with nitrate of silver, which immediately arrests its further progress. This is a very tedious process, while painting the surface with a solution of the caustic, causes so much pain and febrile disturbance, that it cannot be safely employed. Dr. Oliffe, of Paris, recommended the vigo-plaster of the French Pharmacopoeia; and having seen, in some of the journals, that mercurial ointment, thickened with starch, had proved very serviceable in the practice of M. Briquet, and others, in the Paris hospitals, I tried it in numerous cases which were admitted into the wards, and have seen the good effects of the practice. The two cases you have just had an opportunity of observing, however, especially demonstrate this. Case CCXIX. presented the most confluent form of the disease I ever saw. The entire face was so crowded with the papules and minute vesicles of the incipient stage, that there was literally not room to place a pin's head anywhere on the sound skin. It was evident that the whole sur- * Reported by Mr. W. M. Calder, Clinical Clerk. VARIOLA. 895 face of the face would be one mass of suppuration; and such of you as have had an opportunity of observing a similar case of the disease, must be aware of its horrible aspect, the excessive agony produced, the great swelling of the eyelids, the dreadful suppuration and fcetor of the dis- charge, the violent secondary fever, and the frightful cicatrices with whicii the countenance is afterwards covered. In this case none of these symptoms were present, and there can be no doubt that the ectrotic treatment really checked the progress of suppuration, and modified the disease. From the moment the plaster was applied, all smarting and pain in the face ceased; the eyelids were never swollen ; no suppuration occurred ; there was no secondary fever; and on the mask leaving the face there was no pitting or suppuration. In other parts of the body the eruption passed through its usual stages, and the girl was dismissed from the house well, thirty days after the first commencement of the eruption. Considering this case was likely to be a very severe one, I felt myself authorised to use every means in my power to check the disease ; and as it has been asserted that vaccination, even after the com- mencement of the eruption, modifies its progress, I caused the girl to be vaccinated on first seeing her. At that time the face, as we have seen, was closely covered with papulae and vesicles ; and I do not think that vaccination alone could have produced the remarkable result we have witnessed. I do not mean to deny altogether the influence of vaccina- tion in such cases, but I have no hesitation in ascribing the beneficial result almost entirely to the ectrotic treatment. To satisfy yourselves still more, if possible, as to the great advantage of this treatment, the case of the boy (Case CCXX.) may be contrasted with that of the girl (Case CCXIX.) who also had never been vacci- nated. His was evidently a very mild case, the eruption discrete, and the constitutional disturbance slight. I allowed it to run its natural course, and the result was in every respect different from that in which the plaster had been applied to the face. The secondary fever was tolerably smart, and subsequent prostration proportionally severe; recovery was delayed to the thirty-ninth day, and notwithstanding the generally dis- crete character of the eruption, a few pits existed on the face. Since I first practised this ectrotic treatment in small-pox, I have met with numerous instances in which slight salivation followed the use of the mercurial plaster. Dr. George Paterson* of Tiverton, however, published a case in which the salivation from the employment of the strong mercurial ointment was excessive and dangerous. I quite agree with that physician in thinking the occasional occurrence of such violent salivation would seriously compromise the otherwise remarkable advan- tages of the ectrotic treatment. , . Rut it may be asked whether, after all, the mercury is in any way necessary to the success of this treatment. Its original propounded in Paris may indeed have supposed that the absorbent powers of the drug constituted the true cause of its success, but it seems to me that another explanation may be offered. There is, for instance, a close analogy between the mode of healing of wounds and ulcers, so well described by Dr. Macartney of Dublin-that is, the so-called « modelling process, - and what takes place in the ectrotic treatment of small-pox. In the * Monthly Journal, Dec, 1852. 896 DISEASES OF THE BLOOD. former, cicatrices are far less liable to be produced than after healing by the first or second intention, and in the latter the pitting or cicatrization is prevented. The artificial plaster therefore takes the place of the natural scab or clot of blood, protects the parts below, and enables them to heal slowly but more perfectly than if exposed to the air uncovered and uncompressed by superjacent crusts. If this be the correct theory of the ectrotic treatment, the mercurial might be discarded, and any kind of plaster which would concrete on the face might be expected to produce the same beneficial result. In 1854 I determined to try the effects of such a plaster, aud after two or three failures succeeded in pro- curing one that answers perfectly. The first case I treated with simple lard, thickened with starch and powdered charcoal, but it was so little coherent, that the patient, during the night, rubbed it off on her pillow or with her hands, and on her recovery she was pitted all over. In another case I tried carbonate of magnesia saturated with oil. Rut this also failed. In a third case, however, common calamine (zinci carbonas), saturated with olive oil (proposed by Mr. Bird, one of the clinical clerks), formed a coherent, tough crust, which remained on the face, and was found to answer well. Numerous cases of natural small-pox have been since treated in this manner, with the resjilt not only of preventing the pitting, but of diminishing the local and general symptoms, exactly in the same manner as I have formerly detailed, as being the effect of the mercurial plaster. The following is one of these :— Case CCXXL*—Alexander Ross, oet. 13, never been vaccinated, was seized with shivering on the 7th January, followed by the usual symptoms of fever. Entered the Infirmary on the 9th, when a few papules were observed on the face and arms. On the 12th the face was thickly covered with vesicles, which from their closeness would certainly have become confluent. The mask of calamine and oil was now applied. The disease ran its usual course, the eruption being confluent on the arms and trunk. Throughout the progress of the case the application of calamine saturated with oil preserved a firm and coherent crust, and was renewed from time to time. The patient experienced no smarting of the face, there was no swelling of the eyelids, no purulent discharge, or local unpleasant symptoms of any kind. The secondary fever was toler- ably smart, delirium being present two days. On the 22d the mask came off, leaving a clean smooth surface, free from all trace of pitting. Dismissed quite well on the 26th. The following formula, after numerous trials, has been found to con- stitute the most efficient plaster :—Carbonate of zinc, 3 parts; oxide of zinc, 1 part, rubbed in a mortar with olive oil to a proper consistence. Dr. AVallace, of Greenock, in pursuing this treatment, ascertained that the tincture of iodine, which has been recommended as an ectrotic, is of little use, and was led to employ as the best application a solution of gutta percha in chloroform, first used by Dr. Stokes, and recom- mended by Dr. Graves of Dublin. The general subject of small-pox opens up to our consideration a multitude of considerations, of which we may notice threte. 1. There can be very little doubt that the small-pox is again becom- ing frequent among us, a circumstance which some have attributed to * Reported by Mr. Bird, Clinical Clerk. ( VARIOLA. 897 deterioration of the vaccine lymph. That this cause does operate to a certain extent is very probable; but, for my own part, I have been led to the conclusion, that the terror for the disease which formerly prevailed among the public, has, through the protective discovery of Jenner, and the energy through which vaccination was originally pursued, in a great measure declined, and that this is the principal cause. At present, multitudes of the lower orders no longer have their children vaccinated, and hence why our hospitals are so frequently encumbered with cases such as those we have just witnessed. We have no remedy for this but rendering vaccination imperative by penal enactments, as is done in some continental states. For the mode of vaccination, I must refer you to the account given in systematic works on the practice of medicine. It consists, as you know, of making a puncture just sufficient to penetrate the epidermis of the skin, and to enable the vaccine lymph to be applied to the vas- cular dermis. For doing this surely and rapidly, the little instrument I now show you, invented by Dr. Graham Weir* is the best you can employ. It consists of a small handle of ivory, with four needle points projecting from one extremity, and a small curved knife for collecting and separating the vaccine matter at the other (as shown in the cut). The skin is opened by a crucial scratch with the needle points, which are held vertically, and are lightly applied, so as merely to remove the cu- ticle. The advantages of this instrument over the lancet are, that the operation is done more speedily, and that it opposes a larger surface for the absorption of the lymph, whicii is less liable to be washed away by too great an effusion of blood. 2. Sometimes small-pox occurs epidemically in a remark- ably benign form. It then presents all the characters de- scribed by some authors as varioloid. Occasionally it occurs twice, or becomes what is called recurrent, and it has been known to arise frequently after vaccination. In all these circumstances, when mild, it so resembles chicken-pox, as not to be distinguished from it. But more than this, it was observed in the epidemic that prevailed in Edinburgh in 1819 and 1820, that small-pox and chicken-pox existed together frequently in different individuals inhabiting the same room, and sleeping in the same bed. Well authenticated cases occurred of individuals inoculated with small-pox, in whom the eruption assumed the appearance of chicken-pox; and again persons inoculated with chicken-pox had small-pox well characterised. The work of Dr. John Thomson, entitled " An Account of the Varioloid Epidemics in Scotland, 1820," contains many facts of this description, which were well known at the time, and an account of numeruus experiments carried on in the Castle garrison of this place, which have never been controverted, and which fully establish an essential Fis- 502. unity iu the nature of the two affections. It is evidently incon- * Monthly Journal, 1847-48, p. 69. Fif 502 Dr. Weir's scarificator for vaccination. 57 i 55 898 DISEASES OF THE BLOOD. sistent to suppose that two distinct contagions should exist at the same time, each of which is protective against the other. Those who admit this doctrine must maintain that, whenever the chicken-pox contagion prevailed, the small-pox contagion was excluded, or the reverse; or, on the other hand, they must admit that variola is produced by the same contagion that gives rise to chicken-pox. The work of Dr. Thomson furnishes ample proof of the correctness of the latter proposition. Dr. Gregory and others who oppose this opinion, do so on the ground of the incubative stage being shorter; the whole disease less prolonged, and the constitutional symptoms being mild. These circumstances, you will observe, only point to difference of degree and intensity, not of kind. Dr. Gregory also alleges that he has seen variola occur after cow-pox, and cow-pox after variola, and therefore they cannot be identical. So far, however, does this appear to me no argument, that, if possible, it confirms Dr. Thomson's observations. The variola he speaks of occur- ring after cow-pox is evidently modified small-pox, and cow-pox may, in the majority of cases, be reproduced at pleasure. 3. Dr. Jenrier, through life, was of opinion that cow-pox, the grease in horses, swine-pox, and small-pox, were only modifications of each other. He believed that in giving to man cow-pox, he was in reality giving to him small-pox iu its primitive aud mildest form. Whether cow-pox or small-pox is the original form has been disputed. It occurs to me as more probable that cattle caught it from man, rather than man from cattle, an opinion confirmed by the experiments of Mr. Ceely of Aylesbury, recorded in the " Transactions of the Provincial Medical and Surgical Association," (vols. viii. and ix.) He showed that by operating on the mucous surfaces of the animal, the cow readily receives the poison of human small-pox, which the constitution of the animal converts into the vaccine. I need not enter at length into the^discussion which has been raised on this subject. Suffice it to say, that the identity of the two diseases appears to me to be established by the following incontro- vertible facts :— 1. The prevalence at the same period of the cow-pox among cattle, and the small-pox among men. 2. The transmission by contagion of the small-pox to cattle, and the consequent development of cow-pox in these animals. 3. The transmission by inoculation of the small-pox to cattle, and the resulting development of cow-pox in those animals. 4. The transmission by inoculation of the cow-pox to man, and the development thereby of a pustule similar in character to the vaccine pox of the cow. 5. The transmission by inoculation of the cow-pox to man, and the consequent development of an eruption similar, if not identical with small-pox. All these propositions have been established by numerous facts, which you will find ably stated in the " Report of the Vaccination Section of the Provincial Medical Association." See also Mr. Simon's Government Report on the " History and Practice of Vaccination, 1857." SYPHILIS. 899 SYPHILIS AND MERCURIAL POISONING. Case CCXXII.'— Syphilitic Ulceration of the Face. Anne Bruce, aet. 24—admitted Jan. 10th, 1852. Her face presented a most frightful appearance, being covered, as well as the neck and upper part of the chest, with circular masses of pustular scabs. These varied in size, from a fourpenny piece to half-a-crown, several being in some places crowded together. Some of the pro- minent scabs were dry, others soft, with fcetid pus oozing from their bases. In a few places they had fallen off, exposing circular, unhealthy-looking ulcers. Wher- ever the skin could be seen, it was of a fiery-red colour, and puckered with old cicatrices. The lower lip was swollen and dragged downwards, and the left lower eyelid was ulcerated and everted. The metacarpal bones of the left hand were enlarged, and the skin covering them red and painful. No ulceration of the throat or other complaints, with the exception of weakness. External appearance highly cachectic. The history she gave of her case is as follows: About five years ago she con- tracted primary sores from her husband, who had suffered from a very malignant form of them in the West Indies. Shortly after, she was attacked with a minute pustular eruption of the skin. This shortly disappeared, but was succeeded by occasional blotches on the skin, which sometimes broke, but always went away slowly. Eighteen months after the commencement of the disease, one of these appeared on her chin, when, being alarmed, she came to Edinburgh. The practi- tioner she consulted placed her under a mercurial course, and she was salivated for six weeks. The disease in the face, instead of healing slowly as formerly, now ulcerated, and began to spread. Six months afterwards, she was again salivated for four weeks, but the whole of the lower half of the face was now involved, and she entered the clinical ward of the Royal Infirmary. She is confident that these are the only occasions on which she has taken mercury. She remained iu the house upwards of a month, and went out with the face nearly well, from the use of topical emollient applications, and the internal use of small doses of iodide of potassium. Six weeks afterwards, however, she was exposed to cold and wet, when the blotches, scabs, and ulcers returned in the face, and gradually spread to the neck and chest, as formerly described. She was ordered four grain doses of Iodide of Potassium in a mixture containing = i of tincture of Cardamoms, and 1 vij of compound infusion of Gentian. The face was dressed first with a zinc lotion, afterwards with one of chloride of lime, and subsequently with an ointment of iodide of lead. Gradually the further ulceration was checked, and the ulcers healed, and on the 19th of February she was so much relieved, that she insisted on going out. I saw her in the following June, with the face cicatrized all over, but quite well. Commentary.—It is very rarely that we have an opportunity of seeing so frightful a case of mercurial syphilis as the one just noticed; it fully equalled many of the horrible representations I now show you in the work of Diverge. You will have observed from the history of this patient, that, previous to the exhibition of mercury, she was subject to the slow formation of boils, which, however, spontaneously disappeared. * Reported by Mr. G. A. Douglas, Clinical Clerk. 900 DISEASES OF THE BLOOD. The moment her system was saturated with that drug, the boils and ulcers first became stationary, and then commenced spreading over the integument. This is an important fact too little attended to by those who practise the mercurial treatment. Case CCXXIII.*—Syphilitic Laryngitis. Margaret Dickie, a staymaker, aet. 25—admitted September 9th, 1851, labouring under occasional vomiting, frequent cough, with haemoptysis, and copious purulent expectoration. There was considerable sweating at night, and her general health, owing to want of sleep and the harrassing cough, was much broken down. At the commencement of the winter session in November, I found her taking an acid mix- ture to relieve the sweating, a cough mixture to diminish the cough, together with cod-liver oil. The chest had also been blistered. Careful percussion and ausculta- tion convinced me that the thoracic physical signs were perfectly normal. I then examined the fauces, which were covered with purulent mucus, but presenting here and there red and prominent follicles. The cough was also ascertained to be con- vulsive, the voice hoarse and broken, and, on placing the stethoscope over the larynx, a loud ringing sound accompanied the inspiration. From these facts I had no difficulty in diagnosing laryngitis; and on ascertaining that the woman was a prostitute, and addicted to drink, there could be little doubt that it was of syphilitic origin. The fauces were freely touched with a solution of nitrate of silver ( 3 ss to 5 j of water). This was repeated on the following day, and on the next the upper part of the glottis was touched, causing severe convulsive cough. I subsequently passed the sponge, saturated with the solution, into the larynx every second or third day during the month of November, which at first caused very severe and prolonged convulsive cough, that gradually became somewhat diminished. On the whole, however, no great amendment was produced, although the expectoration and cough during the intervals were lessened. The local applications were then suspended, but it soon appeared that they had been beneficial in checking the symptoms, from their severity again increasing, especially the amount of expectoration streaked with blood, and the want of sleep at night owing to the severity of the cough. In the second week of December, therefore, the topical applications were resumed, together with occasional blisters to the larynx, and once more a certain amount of benefit was ob- tained. But as this treatment, combined with the internal administration of iodide of potassium and bitter infusions, for a period of four weeks, seemed to produce no further improvement, she was dismissed on January 7th, 1852. Commentarg.—Syphilitic disease of the larynx is one of the most common of the secondary forms of the disease, a fact indicated by the hoarse and broken voices so frequently noticed among women of aban- doned character. The topical treatment with the sponge, and a solution of nitrate of silver, does not seem to be useful as in simple laryngitis; but even here its effects on the mucous membrane are evidently beneficial. Case CCXXIV.f—Syphilitic Rupia, followed by Keloid Growths on the Cicatrices— Syphilitic Psoriasis. History.—John Young, aet. 24, boiler-maker, native of New-Monkland—admitted * Reported by Mr. C. D. F. Phillips, Clinical Clerk. f Reported by Dr. T. A. Carter, Clinical Physician. SYPHILIS. 901 Nov. 29, 1858. The patient states that, until eighteen months ago, he was perfectly healthy, but at that time, while residing in Kilmarnock, he contracted a chancre upon the prepuce. This was treated by the external application of black-wash; and he took what he believes to have been mercurial pills internally. The sore under this treatment healed in a week. He then went to Leith, and after remaining there a fortnight, discovered that an ulcer had spontaneously formed exactly where the pre- vious one had existed. He at this time (July 31st, 1857) entered the surgical wards of the Edinburgh Infirmary, and there took pills which produced soreness of the mouth and gums, and increased salivation lasting for about three weeks. The ulceration of the throat, from which he then also suffered, was frequently cauterized, and black-wash was applied to the preputial sore. This plan of treatment was fol- lowed by a course of iodide of potassium. During his residence in hospital an erup- tion made its appearance, which was evidently rupia, as proved by the numerous large cicatrices which are at present visible all over the surface of the body. He gradually got much better, and was dismissed after six weeks' residence. At the time of his dismission, however, there were, according to his own account, numbers of adherent crusts of rupia scattered over the greater part of his body. After leaving the Infirmary he went to Motherwell, where his throat again became sore; fresh pustules of rupia formed, many of the old crusts and sores enlarged, and deaf- ness supervened which continued for eight or ten days. He applied to a medical man, who syringed his ears with warm milk and water, and gave him some liquid to take internally, which he says benefited him while he continued to use it. Fifteen weeks after this time he went to Cumbernauld, and there purchased a quack's book containing a prescription for sarsaparilla and- iodide of potassium, which he has con- tinued to take from time to time until the present date. The medicine did not cure the disease, but kept it, he believes, from " turning worse." Six months ago patches of psoriasis commenced to appear on the neck and shoulders, which were soon fol- lowed by a similar eruption over other parts of the body. Twelve weeks ago a medical man made three attempts to inoculate him with syphilitic virus, repeated at intervals of eight days, but without success. The operation was performed by scraping some of the matter off a glass upon which it had been dried, and inserting it under the skin by means of a lancet. Symptoms ox Admission.—The entire surface is scattered over with round and oval cicatrices of rupia, which are closest on the thighs, are not so common on the breast and abdomen, but pretty general on Hie back. In the centre of some of the cicatrices on the upper extremities and back are a few flesh-coloured solid elevations, some occupying only a portion, others the entire surface of these cicatrices. In the latter case they constitute nodular swellings or tumours of a flesh or pinkish colour; smooth on the surface and elevated above the level of the skin from one-eighth to one-quarter of an inch; they are indurated and tough to the feel, oval or round in form, and vary from one-eighth of an inch to one inch and a half in diameter. The largest of them is situated over the left shoulder, and about a dozen are scattered over the neck, back, and superior extremities; there are none over the chest abdomen, or lower extremities. In addition to these there are irregularly shaped patches of psoriasis scattered over the head, neck, abdomen, arms, legs, and back. On two of the largest patches irregular ulcers have formed, which are about half an inch in diameter, and are at the. present time covered with elevated brown crusts. There are numerous small pustules resembling those of acne over the shoulders back, breast, and face, some of which are advancing toward* suppuration- Other systems normal He was ordered to take five grains of the Iodide ot Potassium three times a day, and to apply pitch-ointment to the patches of psoriasis morning and night. 902 DISEASES OF THE BLOOD. Progress of the Case.—The treatment just stated was continued for two months. The patches of psoriasis gradually lost their scaly character, and assumed the appear- ance of copper-coloured blotches, and the intervening portions of the skin, owing to occasional baths, became much clearer and freed from the acne. He is still in the house (March, 1859). Commentary.—This case offers a good example of the inutility of mercury, and perhaps even of the evils it produces on the economy, for no one can say how much of the pustular and scaly disease might not have been owing to the effects of that drug. The keloid growths were evidently fibro-vascular tumours, occurring in the cicatrices, and gave him no inconvenience whatever. It is seldom I have seen the skin of a young man so disfigured, presenting, as it did, circular and oval marks of the former rupia, the pink swellings, and the large copper-coloured blotches here and there. The literature of syphilis is exceedingly rich. The origin of the word, the source of the disease, the time of its appearance, its subse- quent course, and the identity of its different forms at various times, have all been keenly disputed. Even at the present day, its exact nature and mode of treatment excite lively discussion; for such are the discordant facts reported, and such are the prejudices resulting from education, and ex parte statements, that it is extremely difficult to form an unbiassed, not to speak of a correct opinion. All then that I shall venture upon here, is to communicate some of my own reflections and observations on this subject. The venereal disease presents a great variety of symptoms, which are generally considered as primary and secondary. They may, with more propriety perhaps, be divided into primary, secondary, and tertiary, as follows : Primary symptoms— 1. Ralanitis. 2. Gonorrhoea,— \ 8imPh or Iterative. ( Acute or chronic. 3. Chancre. 4. Granular disease of os uteri. C Testes, Prostate, Rectum, 5. Irritation fa. other organs,— < Schneiderian Membrane, { Conjunctiva, etc. Secondary symptoms, affecting the— 1. Lymphatic glands,—Bubo. 2. Mucous membrane,— Ulcerations. 3. Skin,— Ulcerations or eruptions. 4. Eye,—Iritis, etc. Tertiary symptoms— 5. Disease of bone,—Exostosis, Caries, Necrosis. The forms of syphilitic disease which commonly fall under our notice, in the medical clinical wards, are such as affect the skin, fauces, and SYPHILIS. 903 larynx. They all require the same constitutional treatment, but the two latter demand also local applications, some of which have been referred to when speaking of laryngitis. All the different kinds of skin disease formerly described may occur in an individual affected with syphilis. They then become modified in their general appearance, course, aud seats of predilection. Thus it has been observed that the ordinary red colour of skin diseases assumes, in those affected with syphilis, a darker or coppery tint. This is especially observed in the scaly eruptions, the patches of which are also smaller, while the scales are thin, and of a gray colour, often approaching black. The pustular scabs are bard and thick, of a dark greenish or black colour, furrowed on the surface, and deep in the skin. The ulcers are deep, circular, with hard and callous edges. The cicatrices are unequal, round, or spiral, white and depressed. These eruptions may occur all over the surface, but are most common on the forehead, face, nose, back, and shoulders. In children they generally assume the form of maculae or of ulcerations ; in adults, of tubercular and scaly disorders, although ulcers are also very frequent. Diaynosis of Syphilis. It has been said by some persons that they can readily detect a syphilitic from all other skin eruptions. Rut I have known errors made in this respect by the most experienced and eminent dermatologists, one of which I may relate. A young gentleman, on rising one morning, found himself covered with an exanthematous eruption. He had dined out the previous day, and indulged in eating more than usual. He applied to an English physician practising in Paris, who pronounced it to be urticaria, recom- mended a dose of salts, and assured him that it would disappear in a couple of days. Some friends, however, advised him to consult M. Biett, at that time chief physician to the HOpital St. Louis, and certainly one of the most experienced dermatologists in Paris. He did so, and the eruption was stated at once to be syphilitic, and a course of mercury recommended. It was with the utmost difficulty that his English medi- cal adviser could prevail upon him to wait two days before commencing the mercurial treatment, when, however, he had the pleasure of seeing his diagnosis justified, by the disappearance of the eruption. .Now, 1 need not say, that if such an error could occur to one so experienced as M. Biett, how much more readily may it happen to a practitioner com- paratively unacquainted with such disorders. The same difficulty occurs with primary and secondary syphilitic ulcers. The question here is, Is there anything in the aspect of the sore itself which will enable us to determine its nature ? Here, also, 1 have seen the greatest mistakes made by the most experienced surgeons. M. Ricord was so doubtful, after long practice of the characters of a common chancre, that he commenced a series of inoculations to deter- mine which was, and which was not, a true venereal sore. 1 am satis- fied aL, that individuals, whose systems have been impregnated with mercurT frequently have' ulcers, which are constantly mistaken for 904 DISEASES OF THE BLOOD. venereal ones, although really the results of a poison with which the body is impregnated. The following case, which I observed twenty-two years ago, was the first which strongly impressed my mind with this truth. A girl, seven years of age, entered the surgical hospital in 1836. She had a round ulcer over the tibia, about the middle of the left leg. It presented all the characters of a venereal ulcer, as described by Hunter. On inquiry, it appeared that her bowels having been somewhat deranged, the mother had gone to a druggist's shop, and asked for some opening powders. She received twelve, which contained a white, finely powdered substance. One was given morning aud night. In four days profuse salivation came on. The whole dozen powders were given, however, and a cachectic state was induced. Owing to some accident, she received, a violent blow on the leg, and the ulcer mentioned made its appearance. There had never been a venereal taint in the family, and the parents were perfectly health}-. The clinical professor declared publicly, that had the girl been seventeen instead of seven years old, no asseverations on her part could have persuaded him that the sore was not syphilitic. Thus, then, it is only when the symptoms arise in a certain order, that we can positively declare syphilis to be present. If an individual has chancre, which is followed by bubo, or ulcerated throat; and this is accompanied by, or precedes, eruptions on the skin, then we may feel pretty confident. Again, when deep-seated pains in the bones follow the previous symptoms, we may consider them to be syphilitic. The circumstance of an osseous disease more frequently affecting the shaft than the extremities of a long bone will serve to distinguish syphilitic from scrofulous disease, and the existence of caries in conjunction with the peculiar ulcerations formerly alluded to, will confirm our suspicions. You should remember, however, that great caution is always required. The common idea that the gonorrhoea and excoriations in men, which often follow impure connection, are a proof of disease in the female, has led to great error; as it is now ascertained that they may occasionally arise from the presence of the menses, some unusually acrid discharge, or other non-venereal cause. A hasty opinion given to the effect that this or that eruption is syphilitic, has introduced discord into families, and produced incalculable mischief. The tertiary syphilitic symptoms also have frequently been confounded with the deep seated pains of rheumatism, neuralgia, malacosteon, etc. Moreover, if such opinion leads to the entering upon a mercurial course, the original disorder is often replaced by an artificial one, not unfrequently more destructive in cha- acter, which is again confounded with syphilis, and so the error is per- petuated. Propagation of Sgphilis. Actual contact from impure connection is the most common mode by which syphilitic sores are communicated. A gonorrhceal discharge also applied incautiously to the conjunctiva or other mucous membranes, will excite inflammation in them. The secondary forms of the disease are always the result of inoculation; but this may arise, not only from the poison being absorbed directly from a primary sore, but may be coinmu- SYPHILIS. 905 nicated by the mother to the foetus in utero,—by the infant to the nurse, —and again by the nurse to the infant. The following case, which was most carefully investigated, and was the subject of legal proceedings, illustrates how nurses may be affected by syphilitic infants. In 1842, the late Dr. W. Campbell brought to me a woman with a child in her arms, to obtain my opinion, whether a skin eruption on the latter was or was not syphilitic. I pronounced that it was, aud that the woman should cease to nurse it, although her nipples at that time were in no way affected. The child was the offspring of respectable parents, and had been sent to her to nurse. In consequence of my opinion, the infant wTas returned to the friends, whose medical attendant maintained the eruption to be non-syphilitic. The woman who applied to me (nurse 1) was received as a wet-nurse into another family, and the child was sent to another nurse (nurse 2). In a week the child died; and a few days afterwards nurse 2 was attacked with sore nipples. Nurse 1, shortly after entering her new situation, also perceived sores round her nipples; and the medical attendant of the family, after consultation with me, caused her to be discharged. She, in consequence, brought an action against the medical man, who had caused the syphilitic infant to be sent to her, and had mistaken the disease. The lawyer she employed then took ine to visit nurse 2, whose whole bod}7 was covered with a syphilitic tubercular eruption. Both nurses ultimately succeeded in obtaining compensation from the medical attendant. Pathology of Syphilis. Syphilis is caused by a poisonous virus, which, mixing with the blood, taints the constitution, and predisposes it to those forms of secondary and tertiary disorders formerly alluded to. The nature of this virus is involved in the same mystery as that of other animal poisons. All that we know of it is from observation of its effects. Sir A. Crichton, adopting Liebig's view of a catalytic action produced in the blood, pointed out, in 1842, that this catalytic action was soon destroyed in cases of scarla- tina, small-pox, and similar acute diseases. Here "the fever, which destroys both the desire for food and the process of chymification, and consequently the supply of new elements for the further formation of new virus, is cut off. Rut in syphilis and yaws, which do not affect the brain or vital functions for a long time, the patient, by daily taking food in abundance, supplies every day new elements for the production of fresh quantities of poison, and consequently the disease goes on and is protracted indefinitely." This theory is supported by the comparatively mild character of syphilis in warm climates, where the natives live chiefly on vegetable food, and is abundantly proved by the good effects of a low diet and the most simple means, when contrasted with the effects of so-called specifics. . For my own part, I believe that the virus of syphilis, if left to itself, and if the health of the patient be attended to, will generally wear itself out. Unfortunately we are only commencing to observe the natural progress of syphilis, and consequently we are unable to determine how long uuder ordinary circumstances, it takes to accomplish this. So far 906 DISEASES OF THE BLOOD. as I know, we have co specific for any kind of animal poison, for you will remember that Jenner was of opinion (and there can be little doubt that he was correct), that in giving vaccination to man, he was merely giving him small-pox in a modified form. The idea that mercury is a specific for the syphilitic poison, and the incalculable mischief it has occasioned, will constitute a curious episode in the history of medicine at some future day. It is now well known that the poison of mercury produces a cachectic disease and secondary sores in the body, which have been to a great extent mistaken for those of syphilis. It consequently has happened that mercury given to cure primary sores, has produced a constitutional disorder closely resembling that of syphilis ; more mercury has then been administered, increasing the mischief, and so the disease has been perpetuated. The real fact, however, is, that the syphilitic poison is no exception to the general rule, which informs us that all con- tagious diseases of the blood run a certain course, and that we have not yet discovered a specific cure for one of them. The great proof of this is, that the intensity of the disease in modern times has declined exactly in proportion as its treatment by mercury has diminished, and the disor- der been left to follow its natural course. When we treat syphilis on the same principles that we do scarlatina and small-pox, it will prove infinitely less fatal than those disorders. Treatment of Syphilis. The treatment of syphilis may be said to be of two kinds, namely, the simple and the mercurial. The profession are rapidly deciding in favour of the first, although some of its members still give mercury in inveterate cases. Many of the cases we meet with, therefore, have taken the drug, and we have to eradicate the effects of the mineral poison as well as of the original disease. The Simple Treatment is divided into internal or medical, and external or surgical. The first consists in the observation of certain hygienic rules, and the employment of general therapeutic means. The diet must be light and mild—meat and all stimulating viands retarding the cure; even with the lightest diet, the hunger should never be quite appeased. The regimen must be the more diminished and rigid in proportion to the youth and vigour of the patient. Diluent beverages, decoctions of barley, liquorice, and linseed, alone or mixed with milk, should be taken freely, to the amount indeed of several pints a day. Perfect repose must be secured by confinement to bed. Constipation must be obviated by the use of emollient clysters or mild laxatives. The air should be maintained at the same temperature—this is an indispensable precaution in chronic, consecutive, and mercurial affections. Exercise is only useful in the convalescent stage. In chronic syphilis, however, it may often be carried to fatigue with advantage. Tepid baths, repeated three or four times a day, are always attended with advantage. In the external or surgical treatment, strict attention to cleanliness, and the position of the diseased parts, should never be lost sight of. Emolient decoctions or fomentations, or dressings of simple cerate, are the best applications, and the dressings should not be too frequently SYPHILIS. 907 renewed. The greatest benefit is derived from the external use of a con- centrated solution of opium (in the proportion of about 3 ij to ? j of water); it soothes excessive irritability in all cases. When the suppu- ration is moderated and the surface of the ulcer cleansed, Stimulating dressings, consisting of solutions of the sulphates of alum and copper, the nitrate of silver, and sub-acetate of lead, favour cicatrization. Tn inveterate cases, more especially those labouring under tertiary symptoms, the iodide of potassium, which was introduced by Dr. Wal- lace of Dublin, and used by him with considerable success, may be employed. I have myself given it in numerous cases with benefit, in doses of 5 gr. three times a-day, conjoined with emollient applications to the affected parts. The Mercurial Treatment used to consist in keeping up slight saliva- tion, by means of the internal administration of blue pills or some other form of mercury, sometimes conjoined with mercurial frictions or fumi- gations, at least for the space of a month. More recently much smaller doses, so as to produce scarcely sensible effects, have been given for a longer or shorter time. The physiological action of the drug may be produced by administering any of its preparations continuously in small doses. If combined with opium they act less on the bowels, and more on the system generally. It is necessary during decided salivation that the patient do not expose himself to cold. A certain irritability is produced, and the con- stant soreness of the gums, the metallic taste in the mouth, not to speak of the inconveniences of profuse salivation, which occasionally occurs, render this species of treatment anything but agreeable to the patient. Roth kinds of treatment have now been extensively tested. Iu the year 1822, the Royal Council of Health in Sweden having been charged by the king to conduct a series of experiments upon the different modes of treating venereal diseases, reports from all the civil and military hos- pitals were ordered to be drawn up annually. These reports establish the inconveniences of the mercurial system, and the superior advantages of the simple treatment. In the various hospitals of Sweden, 40,000 cases had been under treatment, one half by the simple method, the remaining half by mercury; the proportion of relapses had been, in the first class, seven aud a half, in the second thirteen and two-thirds, in one hundred. Dr. Fricke's experiments in the Hamburg general hospital were first made public in 1828. In four years, out of 1649 patients of both sexes, 582 were treated by a mild mercurial course, and 1067 with- out mercury; the mean duration of the latter method was 51 days, and that by mercury 85. He found that relapses were more frequent, and secondary syphilis more severe, when mercury had been given. When the non-mercurial treatment was followed, they rarely occurred, and were more simple and mild when met with. He tells us that he has treated more thau 5000 patients without mercury, and has still to seek cases in which that remedy may be advantageously employed. He has never observed caries, loss of the hair, or pains in the bones follow his treat- ment, and in all such cases which have come under his care, much mer- cury had been given. ,,.,-, , In 1833, the French Council of Health published the reports sent in 908 DISEASES OF THE BLOOD. by the physicians and surgeons attached to regiments and military hos- pitals in various parts of France. Some of the reports are in favour of a mild mercurial course, others in favour of simple treatment. They all agree in stating the cure by mercury to be one-third longer than by the other treatment. At Strasburg, mercury was only given to very obsti- nate cases. Between 1S31 and 1834,5271 patients had been thus treated, and the number of relapses and secondary affections calling for the em- ployment of mercury was very small. No case of caries, and only one or two instances of exostosis, had been observed. Full reliance may be placed on these facts, as regiments remain in garrison at Strasburg for five or six years. In the various reports now published, more than 80,000 cases have been submitted to experiment, by means of which it has been perfectly established that syphilis is cured in a shorter time, and with less proba- bility of inducing secondary syphilis, by the simple than by the mercurial treatment. These facts are now very generally admitted, and malignant syphilis is gradually disappearing. Twenty years ago, the most frightful secon- dary and tertiary cases were met with, and the usual treatment was profuse salivation. At present, such cases are rare. Abroad, owing to wise police regulations, the disease is infinitely more innocent than it is even at present in Scotland; and under the salutary influence of a mild and simple treatment, its virulence is daily abating. In appreciating the value of this important revolution in practice we should not forget to eulogise those who had first the boldness to introduce it. The credit of this is mainly due, in England, to Mr. Fergusson, and other Rritish army surgeons, who practised it during the Peninsular campaign (Medico-Chir. Trans., vol. 4)—and to Mr. Rose of the Cold- stream Guards (Ibid, vol. 8). In Scotland, the writings and lectures of the late Professor John Thomson of this University were mainly instru- mental in convincing Scotch practitioners of the evils of mercury in venereal diseases. In England, the Hunterean theory aud practice have been deeply rooted, and in Ireland have been supported by the writings of Carmichael and Collis. Mercury in consequence is still very generally employed in those parts of the kingdom. The gigantic experiments made abroad, however, ought to convince the most sceptical—if not, let him compare what syphilis is in Scotland with what it was, and especially observe that we never see an instance of the disease such as those recorded (Cases CCXXII. and CCXXIV.), unless the patient's system has been contaminated with mercury. For au account of the treatment by inoculations, or what is called " syphilization " in Italy and Norway, which was apparently commenced in Case CCXXIV., I must refer you to papers by Drs. Murchison and Lindsay, in the Edinburgh Monthly Journal for June 1852, p. 575, and November 1857, p. 407. See also the Brit, and For. Medico-Chir. Review, Vol. 45, p. 118. RHEUMATISM AND GOUT. 909 RHEUMATISM AND GOUT. General Pathology and Treatment. The present theory with regard to these affections is, that they are both connected with an increase of lithic acid in the blood. Iu rheuma- tism, this is dependent on excess of the secondary, and in gout on excess of the primary, digestion. In rheumatism, however, there is considera- ble excretion of lactic acid by the skin (Todd), whilst in gout there is an excess of soda, which, uniting with the lithic acid, produces a com- pound of lithate of soda, that may be detected as such in the blood (Garrod), while sometimes it exudes into the cellular tissues of the skin, constituting tophaceous deposits. In both diseases there is an undue balance between the excess of lithic acid and the power of excretion—in rheumatism by the skin, and in gout by the kidney. This pathology serves to explain the similitudes and differences existing between the two affections. In both there is a certain constitutional state, dependent on deranged digestion, during whicii exciting causes occasion local effects. These exciting causes in rheumatism are bad diet, hard work, exposure to cold and wet, and its subjects generally are the poor and labouring population. In gout the causes are good diet, indolence, repletion, indi- gestion, and its subjects are for the most part the rich and sedentary. The local manifestations in both are acute wandering pains, with pain and swelling—in rheumatism of the large, and in gout of the small joints, constituting the acute attack in the one, and the so-called regular attack in the other. These are combined with a tendency to various complica- tions of the internal viscera, which are more or less dangerous to life. The general indications of treatment are, in both diseases, (1st) so to regulate the nutritive functions as to ensure a due balance between the amount of matters entering the blood as the result of digestion, primary or secondary, and the amount of matters discharged from the economy by the excretory organs, (2d) To conduct the acute attack to a favour- able termination, carefully watching the internal viscera, and being pre- pared to act with vigour should these become affected. Hence the treatment of these diseases resolves itself into what may be called cura- tive aud preventive—the first having reference to the acute attack, the second to the means most likely to hinder its return; the one must be carried out by remedies which act upon the blood and excretory organs, the other by the management of diet and exercise. Although the general pathology above mentioned, which considers rheumatism as a blood disease, may be considered, on the whole, as cor- rect, we are not yet enabled to explain by it the symptoms of an acute attack of the disease, where in addition to the constitutional disorder, we have local pain, occasional heat, redness, and swelling, with febrile symp- toms. Most practical men have attributed these phenomena to a super- induced inflammation, although it has not been shown that exudation occurs, or that it is followed by the usual results of that condition. Be- sides its erratic character is opposed to what we know of the process of true inflammation and calling it an unhealthy inflammation in no way 910 DISEASES OF THE BLOOD. clears up the mystery. The real pathology of acute rheumatism, there- fore, has yet to be determined, and as a preliminary step, a careful histo- logical examination of the affected tissues is absolutely necessary. So far as I am aware, this has never yet been attempted, if we except some observations by Hasse on the structure of the bones in rheumatism (see Monthly Journal of Medical Science for June 1*47). Our treatment of this disease, therefore, is purely empirical, some- times directed against the pain, at others against the supposed inflamma- tion ; now attempting to combat the pathological condition of the blood, then striving to remedy its effects by acting on the excretions, and not unfrequently giving specifics, in the hope that any change in the consti- tution, however produced, may be beneficial. In no disorder, probably, has such a crowd of opposite remedies and plans of treatment been ex- tolled, and yet none of them can be depended on, so that it has been hinted that six weeks' rest is the most useful prescription (Warren). The latest author on rheumatism endeavours to explain the fact by observing, that this need not be wondered at by " those who consider the true nature of the disorder, and the variety of circumstances under which the physician may be called upon to minister to his patient's relief. The bleeding, which in the young, plethoric, and robust, may be necessary to allay excessive vascular action and cause free secretion, may in the weakly induce irritability of the heart, and a consequent attack of car- diac inflammation. The opium, whicii in one person may prove of the greatest service in promoting free perspiration, and in allaying the gene- ral irritability of the system, may in another check the biliary and other secretions, and thus prevent the elimination of the rheumatic poison. The continued use of calomel, and the constant purging, which may be beneficial to one patient by removing large quantities of unhealthy secre- tions, may unnecessarily exhaust the strength of another, and tend very greatly to impede recovery. And so in regard to every remedy which has been proposed. What is useful at one time proves useless, or posi- tively injurious, at another ; and the conclusion is forced upon us, that what is wanted, ' is far less the discovery of untried methods of treating disease than of discriminative canons for the proper use of those we pos- sess ;'—far less the discovery of any new medicines, than the adaptation of our present remedies to the exigencies of each case." (Fuller on Rheumatism, p. 73.) These judicious observations may serve to explain the cause of our failure; but until we obtain more exact information regarding the special pathology of rheumatism, it is in vain to hope for a ratioual treatment. Occasionally I have tried the effects of special remedies in this dis- ease, and watched a series of cases, all whicii were treated in the same manner. Thus I have tried aconite, aud believe that alone it is of little service; colchicum also I have given frequently, and am of opinion that in pure rheumatism it is of no advantage, although in gout it is invaluable. Treatment of Acute Rheumatism by Nitrate of Potash. During the session 1851-2,1 made another trial of this kind with the nitrate of potash, a remedy formerly recommended by Dr. Brocklesby, RHEUMATISM AND GOUT. 911 and which had been given with good effect by M. Gendrin, in the wards of La Pitie in Paris, as recorded by Dr. Henry Rennet (Lancet, 1844, vol. i. p. 374). It has more lately been pressed on our attention by Dr. Rasham (Medico-Chir. Trans., vol. xxxii.), who tells us that from one to three ounces of the salt, if freely diluted in water, may be taken by the patient in the course of twenty-four hours, without any injurious results, but with the effect of relieving in a marked manner the swelling, heat, and pain in the joints. In the following cases the remedy was tried iu much smaller doses, and it appears to me with more than average success. Case CCXXV."—Mrs. Anderson, set. 48, sick nurse—admitted December 30, 1851. States that previous to the present attack she had always enjoyed pretty good health, with the exception of a liability to a slight cough; had been lately subjected to much fatigue in her occupation as a sick nurse, and had been exposed to cold from sittino- up for several nights in succession in a large room, heated by a fire, and venti- lated by keeping the windows open. Having no adequate protection from the cold draught thus caused, she became affected with sore throat, and had pain in the chest. This occurred in the latter part of October last, and from that time up to November 20th she suffered from slight shivering and uneasiness; transient pain in different parts of the body; nausea and vomiting. About a fortnight before admission, she had a distinct rigor, followed by heat of skin and other febrile symptoms, with very severe pain in the joints especially, much increased by any attempt at motion. The vomit- ing also continued; and last week she suffered from pain and palpitation in the cardiac region, and at the same time an aggravation of her former symptoms. At present she cannot move without suffering excruciating agony, having severe pain apparently in every joint of the body. Heart's sounds, impulse, rhythm, and position normal; pulse about 100, weak. Irregular fits of copious clammy perspiration, of acid smell; no cedema of the joints. Urine scanty, dark-coloured, deposits crystals of the triple phos- phates, with some mucus. Tongue loaded; anorexia; thirst; occasional vomiting; no tenderness on pressing the epigastrium ; bowels confined ; pulmonary functions nor- mal. R Muriatis Morphia? semigranum; Pulveris Aromatic! grana quinque. M. Ft pulv Mittantur talcs sex. One to be taken every half hour. Dec. 4th.—She took three of the powders last night, after which she fell asleep; and this morning feels somewhat better; she has also had the bowels emptied by an enema, and is now using a diuretic mixture. Dec. 5th.—Pains in limbs much the same ; gets no sleep; perspi- ration still copious; urine not increased in quantity; vomiting continues; has been taking diuretics and Dover's powder. Dec. 6^-Had an exacerbation last night, the p°ain in the joints and limbs being excruciating. I? Potass* Nitratis semiun- ciam; Aqua; uncias sex. Misce et signetur-a tablespoonful every four hours. Dec. 7th -Has taken three doses of the medicine; she perspired a good deal during the night; urine not increased in quantity; pain is less severe. Dec. 8th.-StAl sweats a good deal; pains much the same as yesterday. Adde misturee Nitratis Potass., , j. Dec 9th -Pains better; copious perspiration; urine increased in quantity; increase of the nausea and vomiting and of the thirst. Dec. WWL-Pain, nearly gone,; sick- ness continues; refuses to use her medicine; pulse 80, weak; much general debi- ity. After this date the pain ceased entirely, and she was shortly afterwards dis- charged cured. Commentary—Tins was a severe case of both general muscular and * Reported by Mr. William Broadbent, Clinical Clerk. 912 DISEASES OF THE BLOOD. articular rheumatism, of a fortnight's standing, when she entered the house. There was still, however, great pain on the slightest movement, which, during two days, in no way yielded to morphia, diaphoretics, and diuretics. On the exhibition of the nitrate of potash, profuse diaphoresis came on, whicii was apparently kept up by the medicine, with marked amendment to the rheumatic pains, followed by rapid recovery. The improvement could not be attributed to the occurrence of any critical day in this case; and the night previous to the exhibition of the remedy, there had been a marked exacerbation. Every one who saw this case felt persuaded that the good effects were attributable to the nitrate of potash. Case CCXXVL*—Jane Irvine, set. 17, servant—admitted 19th December, 1851. States that seven days ago, whilst engaged at her usual occupation, she was suddenly seized with severe febrile symptoms, and constant pain in the left ankle, which was increased by pressure and motion; it was red and tumefied. On the following day the right ankle became similarly affected, and then in succession the knees, shoulder?j wrists, and fingers; the pain still continuing, but modified in severity in the parts first attacked. She has been undergoing treatment by diaphoretics, without, however, hav- ing experienced any relief from them. On admission the pulse is 100, full and soft. A soft bellows murmur, synchronous with the radial pulse, accompanies the first sound, heard loudest at the base, and is propagated along the course of the large arte- ries. Cannot sleep from the pain, which is general, and is causing intense suffering. Tongue moist, preternaturally red at the tip and margin; -no appetite; thirst, nausea, and vomiting; the bowels are costive; some tenderness on pressure in the epigastrium. Urine high coloured, deposits a slight sediment of lithates. Skin moist, from copious perspiration; knees and ankles are swollen and painful on the least pressure. The right wrist, especially near the metacarpal bone of the thumb, is at present the seat of greatest suffering, and is red, painful, and swollen. Ordered to be bled to -" xvj-> aud to have a purgative enema. December 20th.—Is much worse to-day; the pains in the wrist and hands are especially aggravated. Copious perspiration still continues. R Potass. Nitratis, ?ss; Aqute, 3 vj. A tablespoonful every four hours. Dec. 21st.—Slept during the night. The sweating is still profuse. Urine in moderate quantity, sp. gr. 101G, deposits lithates. Pulse 90, weak ; cardiac murmur very indis- tinct. The pain is considerably relieved, except in the left lower extremity. Dec. 2-ld.— Still continues taking the Potass. Nit. ; the improvement more marked, and she can allow the limbs to be moved about to-day. Dec. 23d.—She presents quite a cheerful appearance to-day, and is entirely relieved from pain; all the joints can be moved quite freely, without exciting uneasiness. Pulse 68 ; skin cool; tongue clean ; appe- tite returning; bowels regular; urine natural—some sediment. Cardiac murmur is more distinct to-day. Convalescence proceeded satisfactorily from this date till January 5th, when she was attacked by typhus fever, from which, however, she ulti- mately recovered, and was dismissed well. Commentary.—This was also a very severe case of general rheuma- tism, which was in no degree benefited by diaphoretics, and a large bleeding on the seventh day. On the eighth day she was if anything worse, and then nitrate of potash was giveu, producing marked relief on the following day. On the eleventh day of the disease, and third * Reported by Mr. J. L. Brown, Clinical Clerk. RHEUMATISM AND GOUT. 913 from the exhibition ofthe salt, the disease was subdued, and she became convalescent. Here, again, the period of improvement cannot ba con- founded with critical days, and strictly corresponds to the administration of the remedy. The bleeding may have assisted its effects, but certainly was not followed, as is usually the case, by an evident amelioration. This girl had an endocardial murmur on admission, which continued during the progress of the case, and I ascertained from the medical practitioner who sent her into the house that she had laboured under this before the attack of rheumatism came on. Was this, therefore, an anemic murmur independent of the general disease, or produced by it ? We may ask another question, viz., Are all the endocardial murmurs occurring in conjunction with rheumatism caused by endocarditis, and attributable to the rheumatic diathesis ? These questions demand more careful attention to these murmurs in young women than has, I think, hitherto been paid to them. For my own part I am satisfied that tliese anemic murmurs in young girls are very common, and that they have frequently been mistaken for sounds dependent on endocarditis. As the patient becomes more robust these murmurs disappear, and hence, probably, has arisen the idea of the good effects of mercury when given in such cases. Case CCXXVIL*—Janet Wright. This woman had been admitted October 22d, 1851, labouring under the usual symptoms of acute rheumatism, and had been under- going treatment by Dover's powder, diuretics, leeching, etc., up to the 6th December, without any benefit whatever, when on that day she was ordered R Potass. Nitratis, 3 iij; Aq. § vj. Misce. A table-spoonful every three hours. Dec. 7th.— Has taken four doses of the medicine, but without any good effect. Took a dose of Dover's powder last night, and slept well ; pain in the shoulders very severe, and also in the knees. Dec. 8th.—Pain still continues. Adde misturas Potass. Nitratis 3 j. Dec. 10th.—Has been using the medicine regularly; she says it makes her very weak, sleepy, and stupid. She sweats a good deal at night, and the urine is increased in quantity; is very thirsty, and complains of bad taste in the mouth; pains gone from knees. Dec. 13th.—Still continues the medicine. No return of pain in the knees ; greatly relieved in shoulders, etc. ; the increased secretion from the skin and kidneys continues. The improvement continued up to the 16th, when she was dismissed for disorderly conduct. Commentary.—In this case the nitrate of potash, after being taken for three days, had caused much diaphoresis and diuresis, followed by dimi- nution in the rheumatic pains and rapid improvement, at the time she was dismissed. Case CCXXVIII f—James Rough, set. 26, blacksmith, admitted December 29, 1851. States that he has suffered on two former occasions from attacks of rheuma- tism. During his last attack, three years ago, he was treated in this hospital, and it lasted five weeks. The present attack came on nine days ago with great severity, having been preceded with febrile symptoms, which appeared to have followed exposure to cold; the pain was very severe in all the joints, but especially so in the wrists and knees. He has noticed within the last year or two that considerable * Reported by Mr. William Broadbent, Clinical Clerk. f Reported by Mr. William Calder, Clinical Clerk. 58' 914 DISEASES OF THE BLOOD. palpitation of the h art ensues after much exertion, or indulgence in ardent spirits; but in his ordinary condition he is not troubled with it. At present the pain in the joints is not severe, unless on attempting motion ; pressure on the right shoulder and ankle causes considerable tenderness. The cardiac dulness measures a few lines more than two inches across; the apex strikes the thoracic parietes in the normal position. A very distinct bellows murmur accompanies the first sound, is heard loudest at the apex, and is not prolonged along the course of the great vessels; the second sound is more sharp and abrupt than natural. The radial pulse is not synchronous with thj impulse of the heart, but follows it after a very appreciable interval. .A few sibil'.nt rales can be heard here and there over the chest. Tongue is slightly furred; appetite is impaired; thirst not excessive. There is slight diarrhoea. The urine is normal. Skin is moist, but no excessive perspiration. R Potass. Nitra'i.s, 3 ss; Aq., 3 vj. M. A table-spoonful to be taken, diluted with much water, three times a day. Dec. 3lxt.—Pains much easier to-day. The bellows murmur is much softer also. Urine deposits some lithates. Is sweating a little to-day. Pulse 86, soft and regular. Jan. 2d, 1*52 (thirteenth day).—Has no pain to-dav. Continues to perspire a good deal; and the urine deposits a copious precipi- tate of the lithate of ammonia. Pulse 68, soft and regular. Complains much of weakness. After this date, the amendment continued uninterruptedly, although only one bottle of the Xit. of Potash mixture had been used, and he was dismissed cured on the 12th January. Commentary.—The employment of the nitrate of potash was followed by apparently marked effects in thi> case, producing diaphoresis and evident benefit on the twelfth day, and removal of pain on the thirteenth day of the disease. As the attack commenced nine days before admis- sion, we cannot suppose that the recovery was owing to the occurrence of a critical day. Besides the good effects were apparent the day after the exhibition of the salt, and on the following day the pains had dis- appeared. The valvular murmur with the first sound at the apex, and the character of the pulse, could leave little doubt as to the mitral incompetency; and, as he had been previously subject to rheumatism, there is every probability that the cardiac lesiou was the result of pre- vious attacks of the disease. In a large number of cases which I have subsequently treated with nitrate of potash, I havj satisfied myself that the disease is more readily subdued by this treatment than by any other. Treatment of Rheumatism by L,emon-juice. Case CCXXIX.*—Abigail Rankin, a servant, set. 39—admitted 15th December 1852. Had rigors on the 7th, followed by febrile symptoms aud acute pain in all the joints. On admission, pulse 100, full and strong; heart sounds normal; con- siderable febrile symptoms ; acute pains and swelling in all the joints increased on motion ; much sweating at night. Other functions healthy. Habeat Succ. Limonum 3 ij ter indies. On the 17th, she was ordered 3j of Dover's powder. Dec. 20th.— The pains have continued as acute as ever till to-day, although she has taken 3 vj of lemon-juice every twenty-four hours. At present she experiences somewhat less suffering on moving the joints. Habeat Succ. Limonum J iij ter indies. Dec. 22d.— * Reported by Mr. F. M. Russell, Clinical Clerk. RHEUMATISM AND GOUT. 915 There was great sweating last night, and to-day she is much better. Habeat Succ. Limonum 3 i ter indies. Some swelling of the left wrist joint remained until the 23d, on which all pain had left her. Dismissed well January Cth, 1853. Cask CCXXX.*-—Catherine Rooke, a?t. 21, married—admitted December 23d, 1852. Had rigors on the 14th, followed by febrile symptoms, and excessive pain, at first, in the knees and ankles, but subsequently in every joint of the body. On admission, pulse 81, of moderate strength; heart's sounds aud impulse normal; the joints are more or less swollen, painful on pressure and on motion; skin bathed with perspiration; febrile symptoms, with the exception of increased pulse, well marked; a considerable deposit of lithates in the urine. Other symptoms normal. R Pulv. Doveri, gr. x statim sumend. R Sol. Mur. Morph. Z ss; Potassas Bitart. 5ss; Sp. Aether. Nit. 3J; Aqua;, 3j; Ft. haust. hord somni sumendus. On the 25th, purgatives of calomel and jalap were ordered. Dec. 26th.—The pain and swelling of the joints have somewhat diminished, but are still very acute. Habeat Succ. Limon. ? j ter indies. Jan. 2, 1853.—The pains have slowly subsided since last report, but there is still considerable soreness and stiffness of the knees. The arthritic swellings have everywhere disappeared. Jan. 4th.—Acute pain has returned in the right arm and back. Omittatur Succ. Limonum. R Potassie Xitratis 3SS: Aqua; 3 iv. M. Sumat ^j ex aqua, § iv. ter indies. Jan. Oth.— The pains have now disappeared; marked improvement. No critical discharge. Dis- missed well January 7th. Case CCXXXL*—Thomas Aitken, aet. 30, blacksmith—admitted December 25th, 1852. Fourteen days ago, after exposure to cold, he was attacked by rigors, followed by febrile symptoms and pain in his joints, which have continued up to this date. On admission, pulse 74, rather weak. A blowing murmur with the first sound loudest at the apex, whicii it seems resulted from a previous attack twelve months ago. Slight swelling only in his right hand and wrist, but there is pain in all the joints, more or less of an erratic character. Febrile symptoms very slight. Slight bronchitis. Habeat Succ. Limonum, 3 ss. ter indies. On the 28th, the dose of lemon juice was increased to ~j. On Jan. 2d, he was much better; but on the 4th the pains returned, but not so violently. On the 12th he was free from pain, having had some diarrhoea, and taken a two-scruple dose of Dover's powder. On the 22d the pains returned, but again subsiding on the 21th, he was dismissed. Cam: CCXXXII.*—James Ollason, a?t. 20, clerk—admitted January 4th, 1S53, with organic disease of the heart of long standing, and chronic rheumatism of au erratic character, sometimes violently attacking one joint and sometimes another, accompanied with swelling and tenderness. Lemon juice in 3 j doses was tried three times a day, for four days; but, being evidmtly of little benefit, was then abandoned for opiates and sedatives. Commentary.—In no one of these four cases in which lemon-juice was given, although in two six ounces and in one nine ouuees were taken daily, did it° appear to me that the disease was in any way con- trolled or alleviated by the remedy. In Case CCXXIX. six ounces were taken daily without any effect, and then the quantity was i:icre-ises to nine ounces daily, until the 21st day of the disease, when sweatiug and resolution of the symptoms followed, more from natural crisis * Reported by Mr. Alexander J. Macarthur, Clinical Clerk. 916 DISEASES OF THE BLOOD. perhaps, than from the effects of the juice. In Case CCXXX. the remedy was continued for ten days, and until the 21st day of the dis- order was fairly passed. The nitrate of potash was given with the immediate effect of relieving the symptoms—although here also it is not improbable that a natural crisis of the disease was then established. In any case the inefficacy of the lemon-juice appeared manifest. Cases CCXXXI. and CCXXXII. were cases of sub-acute and erratic rheumatism, which also resisted the lemon-juice; the first for a month, the second for four days. On the whole this trial of the remedy was in no way favourable, and is strongly contrasted with the good effects of nitrate of potash, which I formerly brought before you. Case CCXXXIIL*—Diaphragmatic Rheumatism. History.—John Robinson, a bookbinder, aet. 24—admitted February 5th, 1858. He says that on Sunday last, January 31st, he caught cold when at a funeral, and experienced some pain across the back and chest, especially on the right side. He felt extremely weak and experienced great difficulty in breathing. On the follow- ing day he noticed an eruption on the extensor surface of both legs. Beyond a blister which was applied to the painful side, he has been subjected to no treat- ment. Symptoms on Admission.—Pain on inspiration over right side, laterally and posteriorly. Slight cough with scanty expectoration. Percussion good and equal on both sides. On auscultation slight harshness of inspiratory murmur; pulmonary sounds otherwise normal. Pulse 110, soft.—Tongue furred, but moist; bowels open; skin hot; perspires abundantly. The extensor surfaces of both legs are covered with urticaria. Other symptoms normal. To have scruple doses of nitrate of potash in half a tumblerful of water three times a day. Progress of the Case.—Feb. 8th.—Perspired profusely yesterday, and to-day there is a copious sediment of urates in the urine. The pain is greatly relieved. The urticaria is nearly gone, but there is an erythematous spot over each petella. Feb. 15th.—Has now no pain, and complains of weakness only. R Quince Sulph. gr. i.; Acid. Nitric, m. x. ; Aqua: §j. ; At. Ft. haustus ter in die sumendus. Dis- missed well, March 10th. Commentary.—Deep-seated rheumatic pains in the chest are very apt to be mistaken for pleural or pulmonary diseases. In the present case I found most of the clinical clerks disposed to consider the disease a pleuro-pneumonia, and they had framed a report which gave consider- able colour to their opinion. A careful examination of the chest, how- ever, convinced me that the lungs were sound, whilst the febrile symp- toms, the pain on inspiration and its seat, satisfied me we had to do with diaphragmatic rheumatism. The treatment, therefore, was governed by this view of the case, and we saw the usual phenomena of critical dis- charge by urine and skin on the seventh day of the disorder. He was of weak constitution, however, and lingered in the house some time longer. In the same manner intercostal rheumatism is very likely to be mistaken by inexperienced persons for pleurisy, especially if they are not sure of the non-existence of friction or other physical sign in the * Reported by Mr. Adolphe Baraud, Clinical Clerk. RHEUMATISM AND GOUT. 917 chest, which their pre-conceptions have suggested to them exists there. But if they carefully compress and rub the muscles between the ribs, while the chest is at rest, pain will be elicited even to a greater extent than occurs during inspiration; a symptom which is diagnostic. Such cases formerly must have frequently been mistaken for pleurisy, and bled of course with the effect of ultimately causing a cure. In agricul- tural districts, slight intercostal or diaphragmatic rheumatism is most common at certain seasons of the year among labourers, who used con- sequently to be bled on a Saturday afternoon, rest all Sunday, and return to their work quite well on the following Monday. In such persons the venesection was supposed by both practitioner and patient to have cut short an incipient pleurisy Case CCXXXIV.*—Rheumatic Iritis, following Acute Rheumatism—Recovery. History.—John Duffy, set. 25, Ordnance surveyor—admitted April 6th, 1857. Three weeks before admission, when in the pursuit of his occupation, he got wet, and a day or two afterwards was seized with rigors followed by febrile symptoms, pains in all his joints, and swelling of both knees, and of the left elbow. After bein" in bed a fortnight and treated medically, he entered the Infirmary, where he took Pulv. Doveri and Tr. Colchici internally, and had Tr. Iodini applied locally. On taking charge of the case in May I first administered Nitrate of Potash ; subse- quently he was ordered warm baths, and then quinine with wine and generous diet, under wbich treatment he became much better. Chronic pains, however, still continu- ing to linger about the joints, and especially the knees, cod-liver oil was ordered on the 25th of May, both internally and externally, and the quinine was discontinued. Occurrence of Iritis anu Proguess of the Case.—June 7th.—For three days has had slight redness of the conjunctiva;, with watering of both eyes, for which he was ordered a zinc lotion. June 9th.—Conjunctivitis on the right side increased, and a small bli.ter was applied over the right temple. June 10th.—Frontal headache. The conjunctiva, immediately around the cornea, is surrounded by a zone of straight vessels, radiating outwards. Inferior half of conjunctiva of uniform red color. To be cupped over right temple, and 3 v of blood extracted. Extract of belladonna to be applied externally round the eye. June 11th.—The whole of right conjunctiva of a deep uniform vermilion, and zone of vessels round the cornea of a darker shade. Atropine to be dropped into the eye to ensure dilatation of the pupil. To wear a lanre shade. June 13th.—Yesterday a weak lotion of Alum (gr. iij to I j of water) wal applied but has caused much irritation. Inner margin of iris thickened and irresrular pupil dilated. Discontinue lotion,. apply belladonna externally, and a warm poultice over the eye at night. June 14//,.-To-day iritis and conjunctivitis have appeared in the left eye. Much pain in head, and restlessness dur.ng the night. Appetite bad; tongue coated; pulse 76, moderate strength. To have Quince Sulph gr iij three times a-day. To go into the side-room, and the window to be obscured June 17th.-Left conjunctiva now of as uniform redness as the right, and iritis well developed; pupil, however, more dilated. Belladonna has been applied round both eyes Last nhmt had = j. of Castor oil, which not having operated, was ordered mdav, 01. CroLi. gutt. ^iLrn et Ext. Colocynth. Co. gr * June 20,,,-Both .rides which naturally are of a light-blue colour, present a dark, dirty green colour. The * Reported by Mr. Stewart Lockie, Clinical Clerk. 918 DISEASES OF THE BLOOD. pupillary margins are thick, and that of the right side irregular, especially at one place where an adhesion has formed. Both conjunctivae are of a uniform dense ver- milion colour. There is considerable pain in the head ; photophobia and lacrvma- tion. Discontinue quinine. R Pulv. Cinchon. Rubr. et Pulv. Sodw Bicarb, aa gr. v. Ft. pulv., to be taken three times a-day. July 7th.—To-day the light eye is much improved, redness of conjunctivas diminished, adhesion of pupillary margin disap- peared, and vision perfect. Left eye the same as before, but an adhesion has formed, which has rendered the pupil irregular for some days. Cephalalgia has been some- times better, sometimes worse. Belladonna has been constantly applied. Applicent. hirudines iij temper, sinist. July 14th.—The right eye is now quite well. Left eye appears if anything worse. The pupil is dim, greatly contracted, and its margin much thickened. Vision also is nearly gone ; he sees as if through a thick cloud. Applicent. hirudines ij tempor. sinist. July 22d.—The leeches, he says, relieve the frontal pain, and they were again applied yesterday. To-day conjunctivitis less, and evident improvement; pupil larger; vision clearer. July 28th.—Since last report the morbid appearances in the eye have gradually disappeared. Two leeches have again been applied, and a blister to the neck. General health much improved, although still weak. August 10th.—Has been quite well for some days; vision in left eye still slightly dim, but is getting clearer daily. Dismissed. Commentary.—This case of double rheumatic iritis, with conjunc- tivitis, was of the most severe description. So much, however, has been said about the danger of allowing such cases to run their natural course, and of the necessity of treating them with specifics, more especially with colchicum and mercury, that I resolved to treat this case without them. It was watched on this account with great interest by the clinical class, especially as it was seen from time to time by my friend, the ophthalmic surgeon to the Infirmary, who predicted the worst consequences. Yet notwithstanding the weakened condition of the patient when iritis came on, the severity of the disease in both eyes, and the apparent closure which was about to take place in one pupil, I persevered, and the result in perfect recovery justified my expectations. It may be argued, how- ever, that the case would have got well much sooner if mercurials had been given. It is very difficult to determine this point, because few oculists have informed us what is the ordinary course of a severe rheu- matic iritis with conjunctivitis. According to Wharton Jones,* if taken in time before much exudation has occurred, and properly treated, it may be cured in three or four weeks. What are called active remedies were not applicable in this case, even according to the principles of those who use them, and the amount of exudation was considerable. The complete recovery of the right eye, therefore, in five weeks, and of the left eye in six weeks, seems to me to have been on the whole a short period, considering all the circumstances, although, on this point, further observations are required. In the meantime, the case demonstrates that the most severe attacks of rheumatic iritis may get well, altogether inde- pendent of mercurials and active antiphlogistics. A similar conclusion had been previously arrived at by Dr. Williams of Boston, U. S., from a pretty extensive field for observation. (See p. 277.) * Ophthalmic Medicine and Surgery, p. 150. RHEUMATISM AND GOUT. 919 Case CCXXXV.*—Chronic Gout with Tophaceous Deposits in all the Joints. History.—Thomas Burns, a tobacco pipe maker—admitted November 4th, 1857. Says he first became ill in Glasgow about ten years and a half ago, with pain and swelling in both his big toes. Soon afterwards the ankles and knees became affected. He was confined for a month, being unable to walk, or even to put on his shoes. Since then he has had on an average three such attacks every year, spring and autumn being the worst seasons; but he has rarely been confined by them more than a week. The attacks have generally commenced with rigors, followed by more or less fever and swelling in one or other of the joints. Almost every joint in his body has suffered in this way at one time or another. At the first attack, he says, chalk stones formed in his toes, and since then they have appeared in his feet, knees, elbows, and hands. The right hand especially has been much deformed by them. He is in the habit of cutting down upon, and extracting them, whenever they approach the surface and are unusually painful. He has been twice in the Infirmary and on both occasions dismissed relieved. The present illness commenced suddenly six weeks ago, and has more especially affected the ankles. He has undergone a great amount of treatment, having been bled and cupped, and having taken much medicine. He had been accustomed to drink a good deal of porter, as well as of spirits, until three weeks before his first admission, in June 1856, since which time he has been more temperate. Symptoms on Admission.—He complains of pain in the left wrist and both ankle joints, whicii latter are swollen, and pit on pressure. The joints of the fingers are nodulated and crooked, especially those of the right hand, hard to the feel, with numerous tophaceous deposits visible through the shining and stretched integument, about the size of millet seeds. The elbow and knee joints are similarly affected, with several deposits over the olecranon and .patella of each limb. The toes are not so distorted as the hands. There is pain on pressure over the right lumbar region, with a slight trace of albumen in the urine. Other functions normal. R Potassas Acet. 3 iiss; Sp. Aether. Nit. 3 ss; Tr. Colchici 3 j ; Mist. Camph. ad 3 viij. M. 3" j to be taken three times a day. Progress of the Case.—November 25th.—Small abscesses have appeared over the patella and heel, to which poultices have been applied. The mixture has been apparently of no service, and is to be discontinued. Dec. 18th.—Last night was seized with severe lumbar pain, and general febrile symptoms, and on examining the urine it was found to be highly albuminous. The sediment contained numerous epithelial cells from the kidney, with granular and desquamative casts of the tubes. 3 v of blood to be extracted from the loins by cupping, and to have at night Pulv. Doveri gr. x. Dec. 21st.—Is much better. Albumen in the urine diminished. R Ammon. Phosphat. 3 j; Tr. Gent. Co. 3 j; Inf. Gen. Co. 3 v. M. A fourth part to be taken in half a tumblerful of water three times a day. Jan. 6th, 1858.—Since last report has been comparatively free of pain and doing well, but last night was again seized with severe febrile symptoms, accompanied by painful sensations throughout his body. To-day the joints of the extremities, especially those of the hands°are very painful. Tlie hands to be poulticed. To have Sol. Acet. Ammon. 3 j every 'hour. Jan 8th.—He has been perspiring much, and is better, although pains in joints are still very severe. The poultices have brought away several fragments of the tophi near the surface. They are of a pale yellow colour, friable, and when examined under the microscope present a mass of needle-shaped crystals of urate of * Reported by Mr. Wilkes, Clinical Clerk. 920 DISEASES OF THE BLOOD. soda. R Ammon. Phosphatis, Z ss; Tr. Colchici, Z j; Aquas, 3 vj. M. A third part to be taken three times a day. Jan. 22d.—The pains in the joints have now been absent for ten days, and he was dismissed. Commentary.—The above is only the second case of gout I have seen in the wards of the Royal Infirmary, and it is a matter of general observation that the disease is one from which the people of Scotland are remarkably free. This has generally been attributed to their frugal habits, but more especially to the driuking of whisky, instead of malt liquors and wines. Dr. William Budd has described gout to be common among a class of workmen on the Thames, whose occupation it is to raise ballast from the bottom of the river. " Those men," he says, " drink from two to three gallons of porter daily, and generally a con- siderable quantity of spirits besides."* Now, it is curious that this is what the man, whose case is before us, seems to have done, and to this habit, therefore, we may fairly ascribe the occurrence of the disease. He admitted that for some years he was accustomed to drink upwards of half a gallon of porter, besides from four to eight ounces of whisky daily. There was no hereditary tendency. The numerous local attacks frequently gave rise to excretion of the morbid products by the kidneys, with all the symptoms of Bright's disease, including albuminous urine and desquamation of cells with casts of the tubuli. Iu a week or so, however, they disappeared, and he enjoyed a temporary immunity from uneasiness. As to treatment, nothing seems to have been of permanent benefit, the tophaceous deposits apparently keeping up more or less irritation and tendency to local attacks, which in their turn excited constitutional ones, more especially the fever and urinary symptoms. SCORBUTUS. Case CCXXXVI.f—James Dermot, a;t. 21, railway labourer—admitted May 27th, 1847. Has been working on the Caledonian line of railway for nine months and enjoyed good health till three months ago, when he received a blow on the right tibia. This produced a sore, and an ulcer formed. His diet consisted of bread, coffee, ham, butter, and sugar; but no milk or fresh vegetables. On admission, an elliptical- shaped ulcer, about two inches in length, is seated over the middle of the tibia, covered with irregular livid granulations, and surrounded by a-raised purple edge. Another ulcer, the size of a shilling, is seated below this, and a third similar one on the outside of the leg. Eighteen months ago his left leg was burnt, and over the seat of the old cicatrix a number of ulcers, similar to those on the opposite leg, exist. One of these, towards the lower part of the leg, is the size of half-a-crown, and more livid than the others, which are smaller. The gums are swollen and fleshy, but not livid. Pulse 74, soft. Bowels constipated. To have full diet. R Aluminis Z j j Aquae 3 viij. Solve. Ft. Gargarisma. R Sued limonis 3 iij; Sacchari 3 iss; Aqua 3 iss. M. Sumat pro potu ex aqua indies. June 2d.—Ulcers looking more healthy. Tlieir surface to be touched with nitrate of silver. July 27th.—-Has slowly got well since last report, and is now discharged. * Library of Medicine, vol. v., p. 219. f Reported by Mr. J. Robertson, Clinical Clerk. SCORBUTUS. 921 Case CCXXXVn.*—John M'Kenzie, aet. 26, railway labourer—admitted July 7th, 1847. During the last two months his diet has consisted chiefly of coffee or tea, with bread, butter, and sugar, but no milk. Two weeks ago pain and swelling came on in his left leg. Soon afterwards the right leg was also affected, and both became discoloured. Epistaxis now occurred, and has continued at intervals ever since, and has been so severe during the last two days, that his nostrils have been plugged. On admission, the left leg is much swollen, and of a purple colour chiefly on its anterior and inner aspect. The right leg is similarly affected, but to a less degree. He complains of pain and stiffness in both limbs, especially about the ankles. The gums are slightly swollen, and livid at the edges, but do not bleed on masticating food. Pulse 80, soft. Tongue clean. Bowels regular. To have full diet. July 20th.—Since admission the symptoms have gradually disappeared, and to-day he was dismissed cured. Commentary.—During the year from October 1846 to October 1847 no less than 231 cases of Scorbutus entered the Royal Infirmary, of whom 30 also laboured under continued fever. Of the entire number nine were females, and seven died. In the previous year only one case entered the Infirmary, and in the following one only six. I myself treated between seventy and eighty of these patients, having succeeded Dr. Christison in the charge of a long shed which contained a large number of them, besides seeing others who came into my other wards. At the same period there existed a most extensive epidemic of typhoid or typhus fever. Yet it is singular that the causes which produced scurvy, mostly in the able-bodied population, and especially among the class of labourers or " navvies " then working at our railways, were of a kind distinctly different from those usually giving rise to continued fever. The potato crop had failed for two successive seasons, and caused among the poorer population the consumption of a diet not only deficient in vegetables, but of milk and fresh meat also. Among the railway labourers, the truck system, and the establishment of local stores, where provisions of inferior quality were given on a ruinous system of credit or exchange; greatly assisted the absence of vegetables in causing the dis- ease. The previous winter had been severe and protracted, so that whilst food of all kinds was high priced, the work and exposure of the labouring population were unusually severe. But scanty and improper diet, and especially such a kind as was deficient.in fresh meat, milk, or vegetables, could in almost every case be ascertained to be the cause of its occurrence. Accordingly, in a large proportion of the cases, it was found sufficient to give the full diet of the house (Case CCXXVL), to which, in unusually severe cases, two or three ounces of lemon-juice with wine were added (Case CCXXVIL). This, if the individual was not too prostrated before admission, always produced a cure in a period varying, according to the intensity of the disease, from three to six weeks. ' The vast majority of cases entered the house between the months of January and August. Dr Christison, who has given a most able history of the epidemic as it was observed in Edinburgh and in the Perth Penitentiary,! con- * Reported by Mr. J. Robertson, Clinical Clerk + Monthly Journal of Medical Science, June and July, 1847. See also Dr Ritchie on Scorbutics, as it appeared in Glasgow at the same time, July and August, 1847. 922 DISEASES OF THE BLOOD. clusively shows that to the absence of milk, or its equivalent nitrogenous constituents, much of the disease was owing. In the Perth Penitentiary treacle-water had been given instead of it, and on restoring the milk no fresh cases occurred. Dr. Lonsdale again showed, that in the agricul- tural valleys of Cumberland, milk was abundant.* and that the absence of potatoes and fresh vegetables was the evident cause. The probably correct conclusion is, that health demands a varied diet, and that a too rigid abstinence from milk and fresh meat, as well as from vegetables, may occasion the disorder. The observations of Dr. Christison unques- tionably prove the anti-scorbutie properties of milk and of the full diet of the Edinburgh Infirmary, as these very frequently constituted the only treatment of individuals who recovered rapidly. The following table, drawn up by Dr. Christison, shows the nutritive proximate principles in various dietaries, healthy, convalescent, and scorbutic. The numbers represent ounces avoirdupois. 1 Total. NON-NlTROGENOU8. Nitrogenous. I. HEALTHY. Starch. Sugar. Fat. jluten. Legum.] Album. Casein. Mus.fll. Total. 1. Scott. Prison standard. 2. Glasgow Prison, 3d rate 8. Edinburgh Prison, do. 4. Millbank Prison, 1821.. ! 5. Do. Convicts, 1S40. 6. Dublin Bridewell, 1847. 25-2 25 0 243 25-0 23 1 19o Is-.' 17-8 194 17-9 13-4 1-32 0-82 1-5G 0-03 011 016 013 0-55 0-57 060 3-96 407 3-S9 301 3 06 2-93 013 0-13 025 0-47 0 03 1-86 0 04 1-36 004 0-38 0-36 023 0-40 157 055 0-23 0-23 1-21 0-99 094 603 583 4-79 5 115 474 5-411 II. CONVALESCENT. T. Edin. Inf. full diet___ 19 4 20-1 11-6 11-1 110 150 1-26 3-SS 236 1-S2 -• 001 049 1-50 003 1-65 2-16 552 4-40 III. SCOEBUTIC. 9. General Prison, 1S4C>... |10. Millbank Prison, 1S23.. 111. Do. Soldiers, 1840-1. 12. Do. do. improved, 1841. 242 209 18-9 19-2 17\S 16-6 15-3 150 1-56 ;; 111 020 0-3S 0'38 396 3 80 2-97 3-04 013 0-23 0-21 003 00-4 007 0 55 0-30 0-7S 0-64 4-74 3-98 ] 3-7s 3-89 __ ._ ___ Note.—1, 2, 3. The standard third-rnte diet of the Scotch prisons, as used in the General Prison at Perth, in healthy years. 4. Diet of Millbank Penitentiary, London, before being • chang-d to No. 10. 5. Millbank diet of civil convicts, who remained free of scurvy, while i the military prisoners were attacked under tlie diet, No. 11. The data given by Dr. Baly, | physician to the prison. 6. The present diet of the Dublin prison, where male convicts are kept for Ion? terms. 7. Edinburgh Eoyal Infirmary full diet, under which scorbutics promptly recovered. S. Convalescent diet of a fever patient of the wealthy ranks, rapidly recovering ■ flesh and strength. 9. Diet of the General Prison before the scurvy broke out. 10. Ditto before the Millbank epidemic at London in 1823. 11. Ditto before tlie military prisoners I i in Millbank Penitentiary were attacked with scurvy in 1S40-41. 12. Improved diet on that ] occasion, but found ineffectual. The individuals subjected to the dietaries iu the I. and III. Divisions were all in confine- ment for long terms. Dr. Garrod,f from an examination of the composition of food, under the use of which scurvy was capable of occurring, as well as of such sub- stances as had been proved beyond doubt to be anti-scorbutic, was led to the conclusion that the absence of potash was the cause of scurvy. In *Op. Citat., August, 1847. f Monthly Journal of Medical Science, January, 1848. POLYDIPSIA. 923 this way he shows, 1st, That potash is deficient in scorbutic diet; 2d, That all bodies proved to be anti-scorbutic, including fresh meat and vegetables, milk, lemon-juice, etc., contain a large amount of potash; 3d, That in scurvy the blood is deficient in potash, and the amount of that substance thrown out by the kidneys is less than what takes place in health ; 4th, That scorbutic patients, when kept under a diet which gave rise to the disease, recover when a few grains of potash are added to their food. The salts of potash, such as the nitrate, oxalate, and bitartrate, are well-known anti-scorbutics, but the efficacy has always been ascribed to the acid rather than to the alkali; 5th, That deficiency of potash in the system seems capable of explaining some of its symptoms, especially muscular weakness, as potash is a necessary constituent of the muscular system. These views undoubtedly merit attention, and it is much to be regretted that they were not made known until the epidemic whicii had called them forth had disappeared. POLYDIPSIA. Case CCXXXVIII.*—Sudden Polydipsia—Incurable. History.—Margaret Shearer, a French polisher, set. 34—admitted May 31st, 1854. States that a year and a half ago she went to work at six o'clock a.m. in her usual state of good health, and at eight o'clock, two hours afterwards, was suddenly seized with great thirst, which has continued ever since, accompanied by excessive discharge of urine. About three months afterwards, sha was obliged to give up work on account of a pain in the loins. At various times she has expe- rienced loss of appetite, nausea, fulness of the abdomen, palpitations, constipation, or diarrhoea. Thinking that her strength had diminished of late, she entered the Infirmary. Symptoms ox Admission.—On admission, the amount of urine passed in twenty- four hours was 424 ounces—pale in colour—of sp. gr. 1005, not coagulable by heat or nitric acid, and containing no sugar, as determined by Trommer's test. She is a stout able-bodied woman, and speaks of occasional slight complaints. She has a pale countenance, furred tongue, and dry skin; but in every other respect is quite healthy. Dr. Alison, who first treated her, ordered warm baths and astringents, and afterwards galvanic shocks to be passed through the epigastric region. On taking charge of the case in the middle of June, I ordered bitter tonics, and the diet was carefully arranged, and the amount of water drunk limited, and mixed with milk and a little magnesia. No change, however, occurred, and she confessed that she could not admit' of restraint with regard to the amount of drink. During the whole month of July, she was weighed daily, and the amount of water drunk and emitted from the kidneys carefully measured. Her average weight was eight stone, which underwent little variation. The amount of water drunk varied from 370 to 520 ounces, the average being 440 ounces. The amount passed varied from 350 to 500 ounces; and it was observable that it was always from 20 to 50 ounces less than the quantity drunk. The sp. gr. varied from 1001 to 1005, and was frequently tested for sugar, with the uniform result of its never being detected. The bowels were generally open every other day, and the stool was of normal consistence and healthy appearance. * Reported by Mr. James Thorburn, Clinical Clerk. 924 DISEASES OF THE BLOOD. Progress of the Case.—From the Oth to the 14th of July, I tried the influence of narcotics, and she took three grains of opium daily, with 3 iss and then 3 ij of solution of morphia. Under this treatment she frequently appeared drowsy and stupid, but sound sleep was never prolonged, and no diminution of the thirst and diuresis was perceptible. She then took large doses of gallic acid, and subsequently, at her own request, cod-liver oil, under the use of which she became stouter, stronger, and the appetite improved. August 22nd.—All other treatment was suspended, and she was ordered to take ten minims of the liq. iodini comp., which was continued to the 14th of September without any effect. On the 16th she was ordered IJ Mass. pil. aloct. et myrrhce 3j ; Ferri sulph. 3ij; Ext. hyoscyam. 3ij. Ft. massa in pil. xij dividenda. Two pills to be taken twice daily. On the 26th there was diarrhoea when the pills were discontinued, and an astringent mixture ordered. The report on the 1st of October was—" general health good," and from an observation made for the first seven days of this month, it appears that the thirst and diuresis had somewhat diminished, the amount of urine varying from 280 to 350 ounces. There was no further change up to October 10, when she left the house. Commentary.—I prefer calling this case polydipsia to diabetes insi- pidus, as frequent careful inquiry established the fact that it commenced with thirst, and that the increased flow of urine was a simple result of the quantity of water drunk. In the present state of science, no reason- able theory can be conceived, explanatory of the fact, that a woman, apparently in good health, is suddenly seized with great thirst, and thereupon drinks two or three gallons of water daily, passes a correspond- ing quantity of urine, and that this continues for nearly two years with- out any marked change in her health. Where there is no scientific indication, the treatment is wholly empirical, and even the results of experience are wholly negative and useless. Astringents, diaphoretics, galvanic shocks, narcotism by means of opium, cod-liver oil, iodine, and purgatives, all failed. The latter, by increasing the alvine discharges, diminished somewhat the excretion of urine, but we could not flatter ourselves that she was in any way benefited by her four months' treat- ment in the Infirmary. Case CCXXXIX.^—Polydipsia—Excessive Amount of Albuminous Urine—Phthisis Pulmonalis— Waxy Liver, Kidneys, and Spleen. History—Thomas Kegan, aet. 40—admitted December 13th, 1848. Patient states that he was in the enjoyment of good health till last May, when he first expe- rienced intense thirst, and began to drink large quantities of water. At the same time he observed that his urine became very much increased in quantity, and he required to get up three or four times in the course of the night to micturate. He had no pain in the region of the kidneys or on making water. This polydipsia and excessive micturition continued undiminished till five months ago, when he expe- rienced a dull aching pain in the small of the back. This pain in the loins after- wards degenerated into a feeling of weakness, which has continued ever since. On the 29th October he went into the Glasgow Infirmary, complaining of loss of appe- tite, great thirst, weakness, and loss of flesh. He remained in this Institution for six weeks, and took several remedies without any benefit. During the last fortnight his appetite has returned, and he has been much better. * Reported by Mr. George Shearer, Clinical Clerk. POLYDIPSIA. 925 Symptoms on Admission.—There was dulness ou percussion and cracked-pot sound over the upper third of left lung in front. Over this part there were heard tubular breathing and loud mucous rales; over the rjght apex prolonged expiration. Posteriorly percussion equal on both sides. Crepitation and sibilant rales on left side. There is frequent cough, with copious muco-purulent expectoration. Tongue dry, clean, red, and tremulous. Appetite good, but thirst excessive. Drinks, as nearly as can be ascertained, a gallon of water daily. Bowels regular. He is much emaciated; skin dry. He has not perspired any for several weeks. No cedema or ascites. The urine acid, unusually transparent, sp. gr. 1010, shows a considerable quantity of albumen, chlorides abundant, no sugar. Large waxy tube casts were detected in the urine, under the microscope. There is slight tenderness on pressing firmly over the region of the kidneys. Progress of the Case.—December 15th.—He passes from 100 to 130 oz. of urine daily. He has expectorated a considerable quantity of muco-purulent matter. His mouth and fauces were so dry this morning that blood flowed on dragging the tongue from the palate, to which it adhered by clammy glutinous secretion. There was a slight discharge of blood after blowing his nose also. December 18th.—Passed 176 oz. of urine on the 16th, 128 oz. on the 17th, to-day 82 oz., and drinks large quantities of water. Ordered to be dry cupped over the kidneys. To drink soda- water, and milk and water instead of simple water. December 20th.—Urine 112 oz. Ordered a tablespoonful of Oleum Morrhuas three times a day, and the following mix- ture : R Spt. AVtheris Nitrici Z i; Sol. Mur. Morph. 3 ss; Mist. Camphora- f ij. M. Half the mixture at bed-time, and the other half in three hours if the cough is troublesome. December 21st.—Had a good sleep after the mixture, but felt drowsy and sick all day. Pupils contracted at morning visit. Passed 112 oz. of urine. 22d.—Feels very well to-day. Passed a good night. Urine 64 oz. December 25th.— Has still a feeling of weakness and heaviness in the loins, and breathes heavily and with some difficulty. Expectoration purulent and considerable in quantity. Slight cedema of left foot observed this morning. Urine diminished to 54 oz. in the twenty- four hours. December 20th.—Passed 48, oz. of urine since yesterday. Has had no stool during last twenty-four hours. Complains of great sickness to-day, and vomited his dinner. Ordered Napthee Medicin. § ss: Tr. Card. Co. ? i; M. A teaspoonful occasionally in a glass of water. R Pulv. Jalapce Co. Z ss : mitte tales xij ; one three times a day. Ordered also 4 oz. of gin daily. December 2 7 th— Passed a very uncom- fortable night, with frequent moaning and stertorous breathing. At 1 p.m. his respi- rations became very slow and laboured, a mucous rattle was heard in his throat, and at 45 minutes past one, he expired. Sectio Cadaveris.—Forty-eight hours after death. Body a good deal emaciated. Thorax.—Very dense adhesions at the apices of both lungs. The upper lobe of each lung felt firm and dense. In the upper lobe of the left lung there was a cavity of tolerably regular oval form, and nearly the size of a hen's egg. The lower extre- mity communicated with a smaller one of an irregular form. These cavities were lined by a well organized lining membrane, having a cheesy-looking matter adhe- rent to it at many "places, and here and there the cavities were crossed by bands of condensed fibrous tissue. The pulmonary tissue around them was greatly condensed. There was much yellow tubercle scattered through the remainder of the lung, and several vomicae One or two small cavities and a good deal of tubercle were found scattered through the upper lobe of the right lung. About two inches below the 926 DISEASES OF THE BLOOD. apex, and nearly in the centre of the organ, was a cretaceous concretion, about the size of a pea, enclosed in a capsule of dense fibrous tissue. About an inch below this, there was a second concretion. The middle and lower lobes contained little tubercles. Bronchial glands enlarged, indurated, and loaded with black pigment. Heart healthy. Abdomen.—The liver was much enlarged, and was of unusual firmness and den- sity. On section it presented the waxy degeneration, well-marked, the surface of section being dry, of a somewhat mottled yellowish-red colour, with a peculiar trans- lucent appearance; lobular structure very indistinct. The organ weighed G lbs. 6 oz. The spleen was enlarged 8^- oz., and felt somewhat dense. On section it was found to be pretty abundantly studded with clear Malpighian bodies, resembling grains of boiled sago. The kidneys were enlarged, weighing 15.V oz. On stripping off the capsule, the surface of the gland was found quite smooth, very pale, of a whitish-yellow colour, and of unusual density. The surface was somewhat mottled, owing to some patches of vascularity, contrasting strongly with the generally anaemic condition. On section the cortical substance was found hypertrophied, and had a pale, translucent appearance. The medullary portion was moderately congested. Almost all the branches of the renal artery in each kidney contained whitish clots; some of them were firm, others partially softened. Some chronic tubercular ulcers were found in the lower part of the small intestine, and in the upper part of the large intestines. Microscopic Examination.—On examining microscopically a little of the softened portion of the clots in the renal arteries, it was seen to consist chiefly of granular matter with a comparatively small number of cells, having the character of pus glob- ules. When a section of the kidney was examined, the minute arteries were found to be much thickened. The cells and other structures of the kidney presented the usual characters of waxy degeneration. Commentary.—The polydipsia seemed to arise spontaneously in this as in the last case, but there came on subsequently pain in the lumbar region and other symptoms probably indicating the commencement of the renal lesion. After admission tlie persistent albuminuria and the waxy casts detected in the urine left us in little doubt as to the existence of Bright's disease of the kidney, although there was no dropsy in con- sequence of the large quantity of water whicii was freely passed from the system. The complication of excessive thirst, great diuresis, and Bright's disease, must be one of excessive rarity, if indeed it has ever been previously noticed. After death both kidneys exhibited a chronic state of waxy degeneration, a condition which in this case was proved to be quite compatible with the excretion of large quantities of urine. Death was occasioned by exhaustion from the pulmonary disease, vomit- ing, and impeded nutrition. POLYSARCIA OR OBESITY. Case CCXL,*—Great Obesity—Fatty Degeneration of Heart and Muscular System generally—of Liver and Kidneys—Hypertrophy aud Dilatation of Heart. History.—Anne Gilchrist, a3t. 42, a cook—admitted June 17th, 1857. With the exceptiou of an attack of rheumatism when 13 years of age, she has enjoyed good * Reported by Dr. John Glen, Resident Physician. POLYSARCIA OR OBESITY. 927 health until three years ago, when she ruptured a blood-vessel in the lung from over- exertion. Last March she caught a cold, and shortly afterwards observed a swelling of the feet, gradually extending up the extremities. Since then she has suffered much from dyspnoea. She has been of a full habit of body since the age of thirteen ; has indulged largely in eating and drinking ; besides spirits, having drunk at least a bottle of porter daily. She has always been exposed to large fires in the kitchen, and, in consequence of corpulence, has taken little exercise. Symptoms on Admission.—The woman is of an unwieldy size from corpulence. The circumference of the body at the umbilicus is 61 inches, of the calf of the leg 20 inches, and of the ankle 13 inches. She can lie on either side, but is very uneasy on the back. Slight exertion produces dyspnoea. The sounds of the lungs aud heart are normal. Percussion of the latter organ is unsatisfactory, in consequence of the uncommon size of the left mamma, and accumulation of fat. Pulse 82, regular and of good strength. Tongue covered with a thick fur. Appetite good. Urine scanty and turbid, sp. gr. 1015, albuminous on being heated. The skin over the abdomen and lower extremities was indurated and coarse. The scales of the house would only weigh 25 stone, and she was much heavier than this. To have a scruple dose of Bitartrate of Potash three times a day. Full diet and 4 oz. of wine daily. Progress of the Case—June 2\st.—Since admission, pulse better, and passes more urine—yesterday voided 30 oz. July Oth.—Has passed from 20 to 30 oz. of urine daily, and the legs have ceased to be cedematous. Complains of loss of appe- tite. Pulse 80, weak. To have 3 vj of wine daily. July 10th.—Urine again scanty, only passed 10 oz. yesterday." To have, a squill and digitalis pill three times daily, in addition to the powders. July 11th.—At the visit to-day was found lying on the right side, too weak to raise her head, and breathing with difficulty, the respirations being short and laboured. The urine was again deficient in quantity, and there was con- stipation. A drachm of the compound Jalap powder was ordered to be taken immedi- ately. In the afternoon, before the powder had operated, she suddenly grew livid in the face, a tracheal rattle was heard, and in two minutes she expired. Sectio Cadaveris—Forty-four hours after death. External Appearances.—Body of enormous size, owing to excessive develop- ment of adipose tissue. The head appeared to emerge without any neck from the trunk. Mammas enlarged, each above the size of an adult's head. The following measurements were taken :— Height...... Circumference of chest below nipples Breadth from shoulder to shoulder Circumference of abdomen " mamma? at base " upper arm " lower arm " thigh . " leg below the knee ankle Thickness of integument over sternum . » " abdomen Thorax —Heart much enlarged; it weighed 22 54 36 69 36 19 16 28 20| 13 All.the cavities were dilated, 928 DISEASES OF THE BLOOD. the walls retaining their normal thickness. The valves were healthy. The muscular tissue of the heart was pale and soft The lungs were healthy. The osseous walls ofthe thorax were not larger than usual, the breadth internally being 11J inches. Abdomen.—There were two ounces of serum in the peritoneal cavity. The liver was much enlarged, weighed 7 lb. 10 oz., and was of a pale fawn colour. The two kidneys weighed 13£ oz. They were of soft consistence, and pale colour. The spleen weighed 13J- oz.; it was softer than natural. The intestines were healthy, and, with the exception of a few cysts in each ovary, the other viscera were normal. Microscopic Examination.—The muscular tissue of the heart was seen to be in an advanced stage of fatty degeneration. The cells of the liver were crowded with large drops of oil, aud the nuclei of many of them were absent. The cells of the kidney were also very fatty. Commentary.—The circumstances in whicii this poor woman was placed were exactly those most favourable to the production of obesity. As cook in several noblemen's families, there had been no necessity for her undertaking much persoual exertion, and having a good appetite and sound digestive organs, she indulged largely in eating and driuking, whilst always more or less in a heated atmosphere. It is much to be regretted that her exact weight was not ascertained. When standing on the Infirmary scale, which only allowed us to weigh to the extent of 25 stone, it seemed as if she was at least 5 stone more. In a table of obese persons given by Dr. T. K. Chambers,* one man is said to have weighed 36 stone, but he was 6 feet 1 inch high ; two others, a man and a woman, weighed 28, aud another woman 26 stone. In the case before us, the increase of fat had certainly arrived at an extent seldom wit- nessed in the human subject, and with the result of gradually causing fatty degeneration of the internal organs essential to life. Latterly, from fatty degeneration of the kidneys albuminuria made its appearance, with cedematous limbs. From this, however, she might have recovered, had not the advanced fatty degeneration of the heart and liver so enfeebled the circulation as to render fatal syncope at no distant period certain. It is probable that the change of diet and absence of her accustomed stimuli contributed to the result, althougb every care was taken to counteract such causes of exhaustion as much as possible. * On Corpulence. 1850. P. 139. CONCLUSION.* The Ethics of Medicine. Gentlemen—After a lengthened period of study, and a series of examinations, intended to test the amount of your knowledge, you have received the degree of Doctor in Medicine, the highest academic honour it is in the power of any University to confer. The direct connection which has hitherto existed between you and your teachers here termi- nates, and all those restraints, which public opinion and legal forms have imposed upon the uneducated, are removed. The energies, which you have hitherto employed in acquiring the necessary preparatory in- formation, you may now dedicate to the practical affairs of life. In short, gentlemen, you this day obtain a high status in society, and with- out, I hope, ceasing to be students, you become members of a liberal and highly honourable profession. Such an event constitutes an impor- tant epoch in the life of every man, and is well calculated to excite not only deep feelings of reflection in yourselves, but those of lively emotion in all who are concerned (and who is not ?) in the progress of that art which is directed to the prolongation of life and the cure of diseases. It will not, then, be considered superfluous if, in obedience to established usage, before you leave this institution, a member of the medical faculty seizes the opportunity of offering to you a few words of advice, of point- ing out the importance of your future profession, and describing to you the spirit in which it ought to be practised. I. The first piece of advice that I shall take the liberty of offering is always to cherish a feeling of deep responsibility. A medical man is the earthly arbiter of life and death. He is the guardian of our race through the dangers of birth, and the perils of infancy. He is called upon to treat the different maladies which can afflict the human frame, under every circumstance of climate, age, sex, or condition ; and lastly, when all means fail to prolong life, it is his duty, if possible, to alleviate those pangs, and diminish those sufferings which accompany the separation of the soul from its present dwelling-place. If, then, we regard him as the soother alike of the entrance and the exit of this life, as the first and the last friend of frail humanity, and if we further consider him, in the social scale, as the superintendent of all public and private institutions for the * An Address delivered as Promotor of the Medical Faculty to the graduates in medicine. August 1, 1849. 59 930 CONCLUSION. sick and the insane, as the adviser of legal tribunals in the administra- tion of justice, and as the regulator of the sanitary conditions of armies, fleets, and, indeed, of nations, it is scarcely possible to conceive a vocation in which every feeling of duty and honour ought more to incite to activity and usefulness; to the cultivation of his intellectual powers and resources; to a life of beneficence and integrity, and, above all, to a sense of the deepest responsibility. This feeling is one which the most experienced and able practitioner can scarcely shake off, and which ought to press, with enormous force, upon those who are newly called upou to decide concerning the awful affairs of life and death. A fellow-creature having received some violent accident, or being attacked by acute disease, calls upon you for assistance. There may be no more experienced practi- tioner near ; there is none to consult with ; the danger is imminent, and you feel conscious that not only something must be done immediately, but that what is done may save or destroy. Then there rushes upon your mind a peculiar feeling of dread and anxiety, rendered more embar- rassing, perhaps, by the conviction that your future prospects may be influenced by the manner in which you conduct the case before you. Such a circumstance, as I have supposed, may happen to any of you at the commencement of your career, and it is then, you will perceive, that the only true support to be depended on, is a consciousness that you are enabled to put in practice all those means which the present condition of the science and the art of medicine has recognised as being correct. At such moments there will be impressed upon you the conviction that the good of your patients, and your own mental tranquillity, are inti- mately united ; you will see the advantage of having studied your profes- sion, not merely as an object of gain, but from a love of its intrinsic excellence—not because it brings you consideration aud respect, but because it enables you to do good and to relieve suffering—not with a vain effort at exhibiting your superior knowledge, but with that humility which is the necessary result of true wisdom. The object of medicine is to preserve health, prolong life, cure diseases, and thereby to forward the happiness of mankind ; and it is evidently the duty of those who practise it, to lose no opportunity, and to adopt every means of prosecuting that object to its fullest extent and in its widest signification. With this view, gentlemen, your past studies have been directed to the acquirement of various kinds of knowledge, the pur- pose of which has been not merely the obtaining of professional rules, but enlarging the mind, and cultivating the reasoning powers. The time has now arrived when you must concentrate the miscellaneous information you have gathered together, in order better to carry out that particular kind of practice which you in future intend to pursue. Any of the so-called accessory sciences may (should your tastes allow) be still further prosecuted, but not to the exclusion of more important matters. Your duty is to cure the sick and relieve suffering, and not to be distinguished as a chemist, a botanist, or a naturalist. Neither is it expected that you should have all the knowledge which each of your teachers possesses in his especial department, but that from the whole you should have obtained such a sum of learning, and such an available kind of information, that you may undertake the serious duties of a medical practitioner with credit to yourselves and advantage to the pub- THE ETHICS OF MEDICINE. 931 he. Such an amount of knowledge is within the reach of all; and should there have been any deficiencies or omissions in your past career, you are imperatively called upon to remedy them at once. Perhaps it is unnecessary for me to say your education is not complete; indeed, in one sense, it may be said to be only beginning. Hitherto, you have depended on others, now you must advance by yourselves—the informa- tion of collegiate life must be perfected and elaborated, in order to meet the exigencies of every-day affairs. You must prune away those imagin- ings in which the student loves to indulge, and direct your thoughts to the stern realities before you. For this purpose, you should seize the interval which may elapse between your retirement from the schools and the commencement of* actual practice, in arranging your past acquire- ments for ready use, and in extending, by every possible means, your experience in the observation and treatment of disease. By so doing, I consider you will be best qualified to meet the serious responsibility you have to undertake, and will thereby attain that comfort of mind and true respectability which the proper and enlightened exercise of our noble profession can alone secure. II. This leads me, in the second place, to impress upon you the import- ance of practising the art and cultivating the science of medicine, in a spirit of sincerity and of truth.—It is a well-known fact, that whilst the public can judge with tolerable correctness of merit in any other profes- sion, it is wholly incapable of forming an estimate of ability in medicine. The structure of the human body, the functions it performs, the laws which regulate it, and the derangements which affect it, are to mankind in general completely unkown. All that your patients will concern themselves with, are results—but so ignorant are they of the means by which results are obtained, so little do they know of the operations of nature as distinguished from those of art, that they are especially liable to be led into erroneous conclusions. In consequence, unprincipled per- sons, from time immemorial, have successfully practised on public credulity, and some specious but shallow theory, some vaunted nostrum, some peculiar accomplishment, or some singularity of manner, has each in turn been made the means of imposition. It is expected of you, gentlemen, that you are so well grounded in the facts and principles of medicine, as to be enabled, on all proper occasions, to put down ignorant presumption, refute false doctrines, aud expose artful knavery. You will remember that medicine is a progressive science, and that whilst the wise and learned who have cultivated it have done much, more remains to be accomplished. You will therefore readily acknowledge its imper- fections where such truly exist, and prefer a frank avowal of ignorance to a false assumption of knowledge. There is one great difficulty you will have to encounter, viz., that the rules and principles, which guide the profession, in the course of time undergo a considerable variation. The arts and luxuries of life, the physical changes of the globe, aud the differences of education and civili- zation to a certain extent, modify the constitution of man and the diseases to which he is subject. Maladies described as existing in former times are now unknown, whilst others are altogether of modern origin. It is of the utmost consequence, therefore, that the medical practitioner should 932 CONCLUSION. be alive to the importance of following the progress of his art, and not imagine that at any time he has learnt all that is useful, or that he can ever reach that point where improvement is not to be gained. At the same time, he must learn, amidst the multitude of suggestions, the num- ber of theories, and the opposing statements which will perplex him, to reject what is worthless, and only adopt what is truly useful. In all such cases, the best rule is to be on your guard against loose and confi- dent plausibilities, especially where such are advanced not in their true character as hypotheses, but as established laws which are to regulate your practice at the bed-side. It is sometimes allowable to give a cer- tain rein to the imagination, and cultivate the power of generalization which has led to the most important and brilliant results in science ; but if this be not controlled within its proper limits, nothing can be more mischievous, especially when the errors may affect the lives of mankind. Strive, then, so to improve your intellectual resources and observing powers, that you may be enabled to shun error and admit truth, especially avoiding all those easy and fallacious paths to knowledge, into which the interested endeavour to entrap the unwary. A desire to practise your profession in sincerity and truth, will also lead you, in cases which you have not particularly studied, or which demand special kinds of treatment, to require the assistance of some brother practitioner. No two persons prosecute their studies in exactly the same direction ; and the subject of medicine is so extensive, so complicated, and requires so much application, that it is almost impossi- ble for a single individual to become master of the whole. Vanity and self-conceit, it is true, have led some men to maintain the contrary; but where is the individual who is at the same time a good physician, a good surgeon, and a good obstetrician ? There are many, doubtless, who practise very usefully in all these branches, and you may be so circum- stanced hereafter as to do the same. If so, you will necessarily be often consulted in cases where you must feel internally convinced that you cannot do full justice to your patient, and then it will be right to bear in mind that, if you possess a greater share of information in some respects than others, they in certain particulars know more than you. Do not, then, be deterred by a false feeling of shame, or a desire for gain, from consulting your medical brethren; reciprocal services beget mutual kindness, aud it is at all times better to resign the treatment of a case you do not understand, than subject yourselves, by undertaking it. to a perpetual series of mortifications and disappointments. By exercising your profession, then, iu a spirit of sincerity and truth, you will be ani- mated by a proud desire to advance its claim to public confidence, rather than your own immediate interests ; you will despise the miserable vanity of announcing what is new, without a scrupulous regard to its being cor- rect. You will, while retaining the right of thinking boldly for your- sslves, not forget that observation is difficult, theory imperfect, and experience frequently fallacious. You will not, therefore, rashly substitute your own authority for that of those whose knowledge is more extensive, or commit yourselves to the ephemeral doctrines of the day, by which a few otherwise respectable men have lost their professional reputation. You will remember that the conclusions of youth are almost always modified by the experience of age; and that the wisest and most emi- THE ETHICS OF MEDICINE. 933 nent men of science have given the best proofs of a solid understanding, by the readiness with which they have acknowledged their own igno- rance. III. The third and last point to which I shall direct your attention is, that you ought to be strongly imbued with a sense of duty and of moral obligation. No profession demands that its members should be governed in their practice by purer principles of honour than our own. The medical man is received into the bosom of private families, where he is intrusted with matters of such a nature, that, if they were disclosed, they would be attended with the greatest distress, and would plunge parents or children into the most bitter and poignant agony. It is your office not only to regulate the corporeal, but, in many cases, the mental derangements and irritability of your patients; but who can govern the minds of others, if he is incapable of commanding his own ? Prudence, sobriety, kindness, and delicacy of feeling, are therefore especially enjoined upon those who treat the sick. It is true, you will labour among scenes of woe, and have to watch incurable diseases, and loath- some maladies; but he whose sensibility is thereby blunted, and who can look with indifference on the agonies of a fellow-creature, will seldom feel that anxiety, or experience that watchfulness, which is so necessary for detecting the true condition of his patient. Self-interest is the worst of all models for a medical practitioner, and is a vice which our profession may proudly claim exemption from. You, I trust, will never experience it, but rather those pleasurable emotions which result from lessening human suffering, without thought of profit, and from exercising friendly offices with that politeness and delicacy of sentiment which dis- tinguish every man of a gentlemanly and refined mind. Mixed, as you occasionally will be, with every branch of society, you must expect sometimes to meet with ingratitude, and be ignorantly undeservedly charged with committing errors. All men are liable to misrepresenta- tion; and although I do not, at such periods, advise you quietly to submit to insult, I strongly recommend great circumspection in mani- festing resentment. " Unjust suspicions may attach to an innocent man; the general consistency and integrity of his life will wipe them away; the imprudences of youth may be repaired by the circumspection of middle age; but if you once lose your reputation for professional prudence and honour, you will find, whatever be your attainments, that your influence is gone, and that you are, in all respects, lost and ruined men." In addition to the duties which you discharge to the public at large, there are others of no less importance which you owe to yourselves. Opportunities will frequently occur, where you may, by looks or words, seriously injure the reputation of some brother practitioner, when in reality he does not deserve it. The period of the disease, or the circum- stances which have occurred, may enable you to do what your predecessor could not. Every good feeling demands, that under such circumstances you should explain the cause of your success to the patient, and not allow him to suppose his previous attendant was in fault. Besides, the most scientific and experienced physician may sometimes err unavoida- bly, and you must never attempt to aggravate the consequences of his 934 CONCLUSION. failure, by adding to the patient's dissatisfaction. Conduct of this kind will cause the offender to be shunned, and sooner or later to feel that no success, and no wealth, can compensate for the absence of self-esteem, or the good opinion of the enlightened and honourable men of his own profession. Gentlemen, habitually engaged as you will be at the bed-side of the sick and the dying, you will have abundant opportunities of rightly esti- mating the insufficiency of mere worldly considerations. I think you will find, notwithstanding what is said to the contrary, that there is no class of society in which the true spirit of religion is more extensively diffused than among members of the medical profession. True, they shrink from an officious and public manifestation of it, and their habits of thought teach them to distinguish between trifling forms and essential truths; but I know of no calling more practically engaged in acts of charity, in an abnegation of self, a desire to do to others what we wish others should do to us, and an endeavour, if occasion require it, to afford all those consolations which a pure Christianity can alone impart. This has ever been the conduct by which all the brightest and most eminent characters in our profession have been distinguished, and I earnestly pray that such may be yours. And now, gentlemen, I and my colleagues bid you farewell, trusting that whatever part you are destined to fulfil in the affairs of life as medical practitioners, you will ever labour under a deep sense of respon- sibility, that you will always act in sincerity and truth, and ever be governed by a high feeling of duty and of moral obligation. Let us hope that you will regard your past teachers as your future friends, and that in whatever part of the world, however distant, your lot may be cast, we shall still be united by a chain of good feeling and mutual esteem, which, however it may be lengthened, can never be cut across. We desire that you will consider the reputation of this University as in some degree identified with your own, and, whilst on the one hand you take care never to sully the degree she has this day conferred, on the other you will, by constant good conduct, and b}r well directed endeavour, add fresh lustre to the reputation she holds among the academic institu- tions of this great country. TABLE OF CASES. diseases or the nervous system. Case I.—Acute Hydrocephalus—Recovery..... 3^2 II.—Acute Hydrocephalus in a scrofulous child—Recovery ... 312 III.—Acute Hydrocephalus—Phthisis pulmonalis—Death-Effusion into' the lateral ventricles—Non-inflammatory softening of the central parts of the brain—Meningitis at the base of cranium—General tuberculosis ..... ,, . IV.—General Acute Meningitis supervening on pleuro-pneumonia . . 319 V.—Acute meningitis at the base of brain—Serous effusion into the ven- tricles, with white softening of cerebral substance—Phthisis . . 320 VI.—Acute Meningitis at the base of the brain—Effusion of serum into the lateral ventricles—Effete tubercle in the pons varolii and lungs . 322 VII.—Chronic Meningitis—Serous effusion into the ventricles—Tubercular mass in left lobe of the cerebellum—Cretaceous tubercle in the lungs, with fibrous cicatrix ...... 325 VIIL—Chronic Cerebral Meningitis; induration surrounded by softening of a portion of the left cerebral hemisphere......327 IX.—Acute Cerebritis—Abscesses in the brain—Old Tubercle in various Organs—Chronic Peritonitis........329 X.—Acute Cerebritis—Abscesses in the brain—Pulmonary tubercle— Abscess in kidney ......... 331 XI.—Chronic Cerebritis—Epileptiform convulsions—Hemiplegia of the right side—Loss of smell—Blindness of the left eye; amyloid bodies in the brain.........333 XII.—Chronic Meningo-Cerebritis—Sudden convulsions—Hemiplegia of left side—Softening of anterior lobe of right cerebral hemisphere— Adhesions of arachnoid......... 336 XIII.—Chronic Cerebritis of the right hemisphere—Cancerous ulcer of the oesophagus and neighbouring glands—Fatty heart.... 338 XIV.—Paralysis of the abducens oculi and auditory nerves—Exophthalmia —Tumour at the base of the cranium—Partial Recovery . . 342 XV.—Paralysis rapidly becoming general—Old apoplectic cyst in right corpus striatum—Softening of pons varolii—Clot obstructing basilar artery —Pneumonia of left lung........345 XVI.—Apoplexy—Hemiplegia of left side—Convulsive attacks—Cardiac and renal disease—Old clot in the right cerebral hemisphere, with surrounding softening ..*...... 348 936 TABLE OF CASES. Cask Page XVII.—Two sudden attacks of Apoplexy—Hemiplegia—Cardiac disease —Persistent albuminuria—Enlarged and diseased spleen— Cerebral softening—Anasarca—Atheroma of arteries—Ob- struction of left middle cerebral artery . . . . . 351 XVIII.—Apoplexy, followed by Hemiplegia of left side—Recovery . . 356 XIX.—Apoplexy, followed by Hemiplegia of the right side—Recovery . 357 XX.—Palsy—Hemiplegia of left side—Recovery.....358 XXI.—Sudden Paralysis of face and left arm—Pneumonia—Bright's disease—Recovery . • . . . . . . 359 XXII.—Apoplexy—Extravasation of blood into the left corpus striatum— Pneumonia—Arrested tubercle of lung ..... 360 XXIII.—Apoplexy—Hemiplegia of left side—Hemorrhage into right cere- bral hemisphere—Diseased heart—Pneumonia . . . 362 XXIV.—Apoplexy—Hemorrhage at the base of the brain in a boy aged 14 years..........363 XXV.—Apoplexy, followed by delirium, and proving fatal in eight hour3 —Hemorrhages into the meninges ofthe brain . . . 365 XXVI.—Hemorrhage into the right crus cerebri—Meningitis at the base of the encephalon—Serous effusion into the lateral ventricles— Chronic phthisis—Vertigo—Paralysis—Spasms of the jaw— Delirium and coma ........ 366 XXVII.—Apoplexy—Hemorrhage into right optic thalamus, causing hemiplegia on left side—Progressive recovery—Two months afterwards, hemorrhage into pons varolii and membranes on right side—Death in seven hours ...... 370 XXVIII.—Five years before admission, hemiplegia, followed by recovery— Four months before admission, apoplexy, with convulsions and partial recovery—Pulmonary disease—Death by asphyxia— Chronic softening of right corpus striatum—More recent hemorrhage into the pons varolii—Cardiac hypertrophy, with mitral constriction—Hemorrhage into the lungs . . . 371 XXIX.—Cancer of the brain, spinal cord, liver, and bones . . . 378 XXX.—Chronic hydrocephalus—Paracentesis Capitis—No benefit . . 381 XXXI.—Acute myelitis in the cervical portion of the cord—General pains, resembling those of rheumatism—Fugitive paralysis in the arms and legs—Engorgement of the lungs—Death. . . 385 XXXII.—Slight paraplegia—Recovery.......388 XXXIIL—Paraplegia—Partial Recovery.......388 XXXIV.—Paraplegia—Incurable........389 XXXV.—Paraplegia—Chronic myelitis—Death.....390 XXXVI.—Paraplegia—Tubercular caries of dorsal vertebrae—Myelitis— Pulmonary Tubercle........392 XXXVII.—Paraplegia—Cancer of vertebral bones—Softening of the cord from pressure—Cancer of lung, liver, and lumbar glands— Ulceration of urinary bladder ...... 395 XXXVIII.—Partial amaurosis—Spectral illusions—Perversions of hearing, smell, and touch—Spinal Irritation.....399 XXXIX.—Delirium tremens—Recovery . . . . . . . 410 XL.—Delirium tremena with ocular spectra—Recovery . . . 410 TABLE OF CASES. Case ALL—Delirium tremens with convulsions and coma—Recovery . . 411 XLIL—Coma and death from excessive drinking—Opacity of arachnoid— Subarachnoid effusion—Fluid blood.....411 XLIII.—Poisoning by opium—Recovery.......413 XLIV.—Poisoning by Hemlock—Death...... 4.13 XLV.—Poisoning with lead—Painter's colic—Lead paralysis—Partial re- covery ...........418 DISEASES OF THE DIGESTIVE SYSTEM. XLVI.—Tonsillitis...........421 XLVII.—Follicular Pharyngitis.........422 XLVIII.—Stricture of the Oesophagus from Epithelioma.....423 XLIX.—Epitheliomatous Ulceration of the (Esophagus, communicating with the Lung—Pneumonia terminating in Gangrene . . 424 L.—Carcinomatous Stricture of (Esophagus—Cancer of the Liver— Pulmonary Emphysema and Tubercle—Pneumonia . . . 426 LI.—Dyspepsia........... 429 LII.—Dyspepsia—Oxaluria.........430 LIII.—Dyspepsia—Hypochondriasis—Oxaluria ..... 430 LIV.—Dyspepsia—Vomiting of fermented matter containing Sarcinae . 435 LV.—Dyspepsia—Vomiting of fermented matter containing Sarcinae . 438 LVI.—Clironic Ulcer of the Stomach—Recovery , . . . . . 438 LVIL—Chronic Ulcer of the Stomach—Cure......439 LVIII.—Chronic ulceration and perforation of the stomach—Peritonitis— Limited pneumonia with gangrene—Abdominal abscess—simu- lating pleurisy—Death ........ 440 LIX.—Chronic ulceration in the stomach—Perforation occasioned by a fall (?)—Recovery..........445 LX.—Cancer of stomach, pancreas, and mesenteric glands—Cystic atrophy of right kidney........448 LXI.—Colloid cancer, with perforating ulcer of stomach—Peritonitis . 449 LXII.—Acute congestion of the liver—Hepatitis?—Recovery . . . 454 LXIII.—Acute jaundice—Albuminuria—Recovery.....454 LXIV.—Impaction of a gall-stone in the common bile-duct—Jaundice— Death......., . . • 456 LXV.—Jaundice—Compression of the ductus communis choledochus from a cancerous tumour, composed of epigastric and lumbar glands— Occlusion of cystic duct—Enlargement of gall-bladder—Cancer of the pancreas—Biliary congestion of the liver—Cancerous exu- dation into various organs—Slight leucocythemia . . . 458 LXVL—Jaundice—Cancerous tumour of the pancreas, comprising the ductus communis choledochus—Dilatation of the gall-bladder, and passage of gall-stones into the gall-bladder—Cancer of the liver and kidneys.......... LX VII.—Enlargement of the liver—Ascites—Albuminuria—Recovery. . 463 LXVIII.—Fatty Enlargement of the Liver.......464 LXIX.—Cirrhosis with Atrophy ofthe Liver—Ascites .... 467 933 TABLE OF CASES. Case Pa ib. ; vesicular respiratory, 52; (avern- oue, ^3 ; amphoric, ib. j dry vibrating, ib. , sonorous, 54 ; sibilous, ib.; bellows, 58 ; exo- cardial and endocardial, 57 ; pericardial or 950 INDEX. friction, ib.; valvular or vibrating, 58; musi- cal in heart, ib. 540. Muscle, fatty degeneration of, 218. Myelitis, acute case of, 385 ; chronic cases of, 388. Myocarditis, 555. Naevi, diagnosis of, 780 ; treatment of, 737. Nausea and vomiting, treatment of in phthisis, 693. Neck, post-mortem examination of, 24. Nephritis, acute, cases of, 726 ; desquamative, 730 ; hemorrhagic, 733 ; scrofulous, 740 ; cal- culous, 742 ; chronic, 745. Nerves of special sense, definitions of irritation of, 403. Nerves, function and properties of, 113. Nervous system, examination of, 19; general anatomy and physiology of the, 108 ; struc- ture and arrangement of the, ib. ; reflex and diastaltic actions, Owsjannikow's views, 111 ; functions of the brain, ib. ; functions of spinal cord, 112 ; general pathology of, 115 ; effects of stimuli or disease on the functions of the, 119 : influence of rapid and slow lesions of, on symptoms, 120; influence of seat of disease on nature of phenomena, 119 ; production of si- milar phenomena in various lesions and inju- ries ofthe, 120 ; influence of, on nutrition, 121. Nervous system, diseases of the, 303. Nervous system, functional disorders of the, 399 : clas-i fication of, 402 ; pathology of, 404 ; causes of, ib. ; treatment of, 408 ; case of, 399 ; congestive disorders of the, 404 ; diastaltic or reflex disorders of the, 406 ; toxic disorders of the, 407. Nervous texture, mineral degeneration of, 235. Nervous trunks, effects of direct mechanical injury on, 121. Neuralgia, definition of, 403 ; treatment of, 408. Neural disorders, classification of, 403. Neuro-spinal disorders, classification of, 404. Neuroma, 153, 158. Nihilismus, 16. Noli me tangere, 177. Noma, 144. Nutrition, complemental, 258. Nutrition and innervation, general laws of, in health and disease, 99. Nutrition, function of, 99; division of process into five stages, ib. ; introduction of appro- priate alimentary matters, 100; formation from these of a nutritive fluid, the blood, and the changes it undergoes in the lungs, 101 ; passage of fluid from the blood to be trans- formed into tissues, 102 ; disappearance of transformed tissues, and their re-absorption into the blood, ib. ; excretion of these effete matters from the body, 105. Nutrition, importance of albumen, oil, and min- eral substances in the process of, 100. Nutrition, diseases of, 106; causes of, 107; principle of treatment of, ib. Nutrition, disordered, influence of on innerva- tion, 121. Oberhaeuser's microscope for medical men, 62. . Obesity, 159 ; case of, 926. (Edema, of the brain, 307 ; of subarachnoid cel- lular tissue, case of, 334 ; of the legs, from cirrhosis, 480; from cardiac disease, 544; of the glottis, 598 ; ofthe lungs, 730 ; from albu- minuria, 750.' ffigophony, 54. Oesophagus, case of stricture of from epithelio- ma, 423 ; cancer of, 338, 426, 472. Oil and albumen, importance of in the process of nutrition, 100. Oligocythemia, 846. Opisthotonos, definition of, 402. Opium, case of poisoning by, 413. Organs, circulatory, auscultation of, 55 ; sounds elicited by, in health and disease, ib. ; modi- fications of healthy sounds, 56; new or ab- normal sounds, 57. Organs, natural position of, 26 ; displacement of, remarkable cases of, 27, 628. Organs, pulmonary, auscultation of, 51 ; sounds produced by, ib. ; circulatary, auscultation of, 55 ; sounds produced by, ib. ; abdominal, auscultation of, 58. Ovarian dropsy, cases of, 706 ; pathology of, 721 ; diagnosis of, 723 ; treatment of, 724. Ovariotomy, case of, 706. Osseous growths, 190 ; seats of, 192 ; myeloid, 193 ; new, ib. ; in the eye and other textures, 194. Osteochondropbytcs of Cruveilhier, 186. Osteoma, 190. Osteoma, cystic, of femur and tibia, 168. Osteosarcoma, 154,188 ; observations of Good- sir and Redfern on, ib. Owsjannikow's views as to the structure of the spinal cord, 109. Oxaluria, cases of, 430. Painters' colic, case of, 418. Palpation, examination of patient by, 30 ; of aneurisms, 5S9. Palpitations of the heart, causes and treatment of, 557. Pancreas, cases of cancerof, 448,461; Bernard's views ofthe functions of, 462. Papilloma, 175. Papula?, definition of, 776; diagnosis of, 780 ; treatment of, 786. Paracentesis capitis, 381 ; thoracis, 625 ; abdo- minis, 706. Paralysis, definition of, 304 ; cases of, 342,388 ; definition of local, 404; of abducens oculi and auditory nerves, 342. Paraplegia, definition of, 403 ; cases of, 388 ; cause and treatment of, 394. Pathology, effects of advanced knowledge of, 250. Patient, method of examination of, 18 ; circu- latory system, 19 ; respiratory system, ib. ; nervous system, ib.; digesthe system, 20; genito-urinary system, ib. ; integumentary system, ib. ; antecedent history, ib. ; hints for carrying out examination, 21. Patient, examination of by inspection, 28 ; bv mensuration, 32 ; by fluctuation, 31 ; by pal- pation, 30 ; by percussion, 35 ; by ausculta- tion, 49 ; use of microscope in examination of, 59 ; use of chemical tests in examination of, 94. Pectoriloquy, 52. Pemphigus, diagnosis of, 779; treatment of, 785. Percussion, examination of patient by, 35 ; dif- ferent sounds produced by, 37 ; sense of re- sistance produced by, 38 ; general rules for practice of mediate, ib. Percussion of particular organs, special rules for, 40 ; of lungs, ib. ; of heart, 43 ; of liver, ib. ; of spleen, 46 ; of stomach and intestines, ib. ; of kidneys, 48 ; of bladder, ib. ; of aneu- risms, 588. Percussion hammer, utility of, 36. Perforation of the stomach, cases of, 440; of the duodenum, 735 ; of the intestine from hernia, 488. Pericarditis, changes which take place in the exudation of, 266 ; cases of, 514; pathology of, 527 ; diagnosis of, 528; complications of, 530; treatment of, 531. Peritonitis, cases of, 499 ; acute, ib. ; tubercu- lar, 501; cancer of abdominal organs resem- bling, 504; cancerous, 508. Pharyngitis, case of follicular, 422. Pharynx, diseases ofthe, 421. Phlebolites, 157. Phosphorus, in spinal diseases, 391. Phthisis, black, cases of, 699 ; nature and causes of. 7o2 ; treatment of, 705. Phthisis of colliers, appearance of sputum in, 81, 232. Phthisis pulmonalis, cases of, 658 ; natural pro- gress of, tendency to ulceration, and modes of arrestment of, 675 ; pathology and general treatment of, 684 ; indications for the treat- INDEX. 951 ment of, 685 ; cod-liver oil as a remedy for, 687 ; value of microscopic examination of sputum in, 80. Phthisis pulmonalis, special treatment of, 691; cough and expectoration, 692 ; loss of appe- tite, ib. ; nausea and vomiting, 693; diarrhoea, ib.; haemoptysis, ib. ; sweating, 694 ; febrile symptoms, ib. ; debility, 695; despondency and anxiety, ib. Picrotoxine, effects of, 407. Pigmentary degeneration, 227 ; general patho- logy and treatment of, 232; concretions, 239. Pigment, formation and varieties of, 227; causes of, 232. Pityriasis, diagnosis of, 780 ; treatment of, 787; parasitic, case of, 797. Piorry's pleximeter, 36. Placenta, fatty degeneration ofthe, 222. Pleuritis, cases of, 613 ; pathology, diagnosis, and treatment of, 618 ; chronic, cases of, 616. Pleurosthotonos, definition of, 402. Pleximeter of M. Piorry, 36. Pneumonia, acute, microscopic appearance of sputum in, 87 ; changes which take place in, 265; natural progress of a, 269; treatment by bleeding, 270 ; results of antiphlogistic treat- ment of, 271; results of dietetic treatment of, 272 ; results of treatment directed to fur- ther the natural progress of the disease, 273 ; bleeding, a palliative in, 276; treatment by mercurials, ib. ; chronic, cases of, 648 ; reply to objections concerning treatment of, 277 ; cases of, 630; diagnostic value of the absence of chlorides from the urine in, 643; general pathology and treatment of acute, 646. Pneumo-thorax, cases of, 623; remarkable death in a case of, 625 ; metallic tinkling in, 627. Poisoning by alcohol, 410; by opium, 413; by hemlock, ib. ; by lead, 418 ; by aconite, 585 ; by mercury, 899. Polycythaemia, 846. Polydipsia, cases of, 923. Polypus, soft, 155 ; hard, 156 ; in the heart., 546. Polysarcia, 926. Porrigo, definition and varieties of, 782. Post-mortem examination, 22; method and order of, 23 ; hints for carrying out, 24; knowledge required for, 26. Posture of patient, inspection of, 28. Pressure and compression, distinction between, 116. Probang, method of using, in laryngitis, 595. Prostatic concretions, 244. Prurigo, diagnosis of, 780; treatment of, 786. Psoriasis, diagnosis of, 780 ; treatment of, 786. Pulmonary organs, special rules for ausculta- tion of, 51; sounds produced by, ib. Pulmonary diseases, injections of the bronchi in, 611; case of, 609. Pulmonary artery, varicose aneurism of, 564. Pulse, characters of, 19 ; as an indication for bleeding, 262. Purgatives, use of, in intestinal disease, 478. Purpura, diagnosis of, 780 ; treatment of, 787. Pus. microscopic examination of, 78, 130 ; for- mation of, in pneumonia, 265 ; effects of mix- ture with the blood, 849; injection of, into the blood, 850. Pus, scrofulous, microscopic appearance of, 78, 130. Pustulae, definition of, 776; diagnosis of, 780; treatment of, 785. Pyaemia, case of, 847 ; theories regarding the nature of, 849. Pyelitis, cases of, 726. Pyrosis, 437. Quain's stethometer, 32. Quinine in continued fever, therapeutic action of, 879 ; in intermittent fever, 884 ; in hectic fever, 695. Rammollissement. See Softening Rattles, moist, 53. Recto-vesical fistula, case of, 742. Remedies, indications for the use of, 250. Renal calculi, 241. Resonance, vocal, 54. Respiration, motions of chest during, 29. Respiration, natural and exaggerated, 51; pue- rile, 52 ; alterations of, 53. Respiratory sounds, 51; alterations in natural, 52 ; new or abnormal sounds of, 53. Respiratory system, examination of, 19. Respiratory system, diseases ofthe, 592 ; rules for the diagnosis of, ib. Reticulum of cancer, 225. Rheumatism, general pathology and treatment of, 909 ; treatment of, by nitrate of potash, 910 ; treatment of, by lemon-juice, 914; dia- phragmatic, case of, 916. Ringworm, 787. Roseola, diagnosis of, 779; treatment of, 784. Rupia, diagnosis of, 780 ; treatment of, 786. Saliva, microscopic examination of, 72. Salmo salar, structure of the spinal cord in, 109. Sarcina ventriculi, 83. Sarcoma, 153; cystic, 169; compound cystic, of the mamma, 163 ; osteo, 154,188. Scabies, diagnosis of, 779 ; treatment of, 785. Scalp diseases, treatment of, 787. Scarlatina, cases of, 885; diagnosis and treat- ment of, 887 ; colchicum in, 940 ; bodies found in urine, in a case of, 90. Scirrhus, 133. Scorbutus, cases of, 920 ; epidemic of, in Edin- burgh, 921 ; observations of Dr. Christison and Dr. Lonsdale on, 922 ; Dr. Garrod on, ib. Scrofula. See Tubercular Exudation. Scrofulous pus cells, 78, 130. Sectio-cadaveris, method and order of, 23 ; ob- ject of, ib. ; external appearances, 24 ; head, ib. ; spinal column, ib. ; neck, ib. ; chest, ib.; abdomen, ib. ; blood, ib. ; hints for carrying out post-mortem examination, ib. ; knowledge required for correct examination, 23. Sensation, definition of, 113. Sensibility, definition of, 115. Sibson, Dr., his " Medical Anatomy," 27 ; his chest measurer, 33. Silver, nitrate of, action and use of, in laryn- gitis, 595. Skin diseases, classification of, 775 ; definitions of, ib. ; diagnosis of, 779; varieties of, 781; treatment of, 78o; scaly diseases of, 174; treatment of, 784 ; treatment of syphilitic diseases of the, 78S. Small-pox, cases of, 893 ; general treatment of, 894; ectrotic treatment of, ib. ; greater fre- quency of, 896 ; relation of, to varicella, 897 ; identical with cow-pox, 898. Socrates, his death by taking hemlock, 418. Softening, cerebral and spinal, pathology of, 305 ; exudative or inflammatory, ib. ; hem- orrhagic, 306; fatty, 307; serous or dropsi- cal, ib. ; mechanical, 308 ; putrefactive, ib. : necessity for microscopic examination of, 310 ; cares of, ib. ; cerebral, cases of, 333 ; spinal, cases of, 392. Solanoma, 187. Sounds produced by percussion, 37 ; elicited over lungs, 42; produced by pulmonary or- gans, 51 ; cracked-pot sound, 43 ; alterations of natural, 52 ; abnormal, 53; rubbing or friction, ib.; relative value of, in ausculta- tion, 54 ; of the circulatory organs, 55 ; diag- nostic of diseases of the circulatory system, 512 ; of aneurisms, 5S8; diagnostic of diseases ofthe respiratory system, 592. Spasm, definition of, 304, 403 ; of the jaw, case of, 366. Spermatocele, appearance of spermatozoa in fluid of, 87. Spinal column, post-mortem examination of, 24. Spinal cord, functions of, 112. Spinal softening, pathology of, 305; origins t and varieties of, ib.; necessity for micro- scopic examination of, 310; cases of. 392. 952 INDEX. Spinal irritation, definition of, 402. Spinal disorders, classification of functional, 402. Spirometer of Mr. Hutchinson, 35. Spleen, percussion of, 46 ; waxy degeneration of the. 214 ; hypertrophy of, in leucocythe- mia, 814, 829 ;"morbid anatomy of, in fever, 872. Sputum, microscopic examination of, 78 ; value of microscopic examination of, 80; micro- . scopic appearance of, in acute pneumonia, 87 ; appearance of, in black phthisis of col- liers, 81, 702 ; elastic tissue in, 80. Squamae, definition of, 776 ; diagnosis of, 780 ; treatment of, 786. Starvation, symptoms of, 121. Steatoma, 160, 166. Stetho-goniometer of Dr. Scott Alison, 35. Stethometer of Dr. Quain, 32. Stethoscope, 49 ; hints for choice of, 50. Stomach, percussion of, 46 ; hairy concretions in the, 244; functional disorders of the, 429 ; organic diseases of the, 438; ulceration of the, cases of, ib. ; perforation, cases of, 440 ; frequency of ulcerations in, 446 ; symptoms and treatment of ulcers in, 447 ; cases of can- cer ofthe, 448 ; structural changes in glands of, 451; remarkable case of emphysema of the coats of, 625. Stramonium, action of, 407. Stricture, 148 ; of intestine, 486, 488, 706 Strychnine, action of, 407. Succussion, examination of patient by, 32. Sugar in urine, detection of, 95. Supra-renal capsules, Dr. Addison's views of, 229 ; case of disease of, without bronzing of skin, 649. Sweating in phthisis, treatment of, 694. Syphilis, cases of, 899; observations on, 902; symptoms of, ib. ; diagnosis of, 903; propa- gation of, 904 ; pathology of, 905 ; treatment of, 906. Syphilitic diseases ofthe skin, treatment of, 788. System, nervous, general anatomy and physi- ology of, 108 ; general pathology of, 115. Tape-worm. See Tasnia solium. Tests, chemical, use of in examination of pa- tient, 94. Tetanus, definition of, 402. Therapeutics, recent changes in, 250. Thorax, inspection of, 29 ; mensuration of, 33 ; motions of during respiration, 29 ; post-mor- tem examination of, 24 ; view of viscera in, 26. Thrombosis, 356. Tissues, formation and su3tentation of, by the blood, 102 ; attractive and selective property of the, ib. ; re-absorption of transformed tis- sues into the blood, ib. ; Zimmermann's opinion and arguments, 103. Texture, morbid degenerations of, 210; morbid growths of, 148. Taenia solium, origin and development of the, 492 ; cases of, 495 ; treatment of, 497. Tonsillitis, case of, 421. Toxic disorders of the nervous system, 407 ; treatment of, 409. Trance, definition of, 402. Tracheotomy, in laryngitis, 599. Treatment, palliative, and curative, 251. Tricuspid valve, cases of disease of, 543. Trismus, definition of, 402. Trommer's test for sugar in urine, 95. Tubercle corpuscles, 79, 137. Tuberculae, definition of, 776; diagnosis of, 780 ; treatment of, 787. Tubercular exudation, 137 ; general pathology of, 139, 084 ; general treatment of, 146, 684. See Phthisis. Tumeur hiteradenemique of M. Robin, 172.] Tumours, classification of, 149 ; fibrous, 151 ; sarcomatous or soft fibrous, 153 ; dermoid or hard fibrous, 155 ; neuromatous fibrous, 158 ; fatty, 159; fibrolipomatous, 160; cystic, 161; simple cystic, 162 ; compound cystic, ib. ■ osseo-cystic, 168 ; glandular, 170 ; epi- thelial, 173; horny, 180; aneurismal, 181; cases of, 557 ; erectile, 183 ; varicose, 184 ; enchondromatous, 186 ; osseous, 190 ; mye- loid, 193 ; cancerous, 196. Ulcer, cancerous, of skin, microscopic appear- ance of, 93 ; cutaneous, microscopic examin- ation of, 92 ; of tonsil, case of, 421 ; of oesoph- agus, 424 ; of stomach, 438 ; of duodenum, 735 ; of intestine, 488 ; typhoid, 874, Ulceration, 144. University (Scotland) Bill, 11. Uric acid, microscopic appearance of, 88. Urinary concretions, 240. Urine, microscopic examination of, 88 ; specific gravity of, 94 ; detection of albumen in, ib. ; detection of bile in, ib. ; detection of sugar in, 95; detection of chlorides in, 96; diag- nostic value ofthe absence of chlorides from the, in pneumonia, 643; examination of in Bright's disease, 769 ; various kinds of casts in, 770. Urticaria, diagnosis of, 779 ; treatment of, 7S4. Uterine discharges, microscopic examination of, 85. Uterus, appearance of cancerous juice from the, 86 ; fibrous structure of the, 151; fatty degeneration of, after delivery, 220. Vaccination, mode of, 897 ; Dr. Weir's scarifi- cator for, ib. Vaginal discharges, microscopic examination of, 85. Valsalva's treatment of aneurism, 583. Valves of the heart, diseases of, 532. Van der Kolk's observations on phthisical spu- tum, 80 ; views as to the propagation of can- cer, 206. Varicella, identical with small-pox, 897. Varicose aneurism, between vena cava and aorta, 181 ; case of, communicating with the pulmonary artery, 564 : signs of, 567 ; pathol- ogy and treatment of, 568. Variola, cases of, 893 ; treatment of, 894 ; ob- servations upon, 896. See Small-pox. Varix, 184. Vascular growths, 181; aneurismal, ib. ; erec- tile, 183 ; varicose, 184; of new vessels, ib. Vegetation, dendritic, 179. Velpeau on the propagation of cancer, 204, 207. Vermifuge remedies, 497 ; male shield fern, 495 ; kamala, 498. Verruca achrocordon, 91, 176. Vesical calculi, 242. Vesiculae, definition of, 775 ; diagnosis of, 779 ; treatment of, 784. Vessels, auscultation of the large, 58 Villi, formation of, in pericarditis, 267. Vocal resonance, 54. Voluntary motion, 115. Vomited matters, microscopic examination of, 81. Vomiting and nausea in phthisis, treatment of, 693. Warts, 174. Waxy degeneration. 214. Weir's vaccinating instrument, 897. Winterich's percussion hammer, 36. Woorari, effects of, 407. Worms, intestinal, 492 ; varieties in man, 495. Zimmermann's opinion regarding the origin of fibrin in the blood, 103. Zymosis, definition of the term, 885. 0 ( NATIONAL LIBRARY OF MEDICINE NLfl Q320blb7 y $£j iw. 4.*v*« >»»»»« »V«V»*Xw ^Vt^Ji** •:■^%n^^c^^3W£3^^.. ."wf. ji.'„ SS .jj3T»5ft"j«r ^ H?i ■r-Utf ft, ■*'*■" "'"trl NLM032061676