IMAGE EVALUATION TEST TARGET (MT-3) Ai 7 H, :a j^'^'d? * i 3 6 V. 1.0 I.I 1.25 ■- IIIM ■ 5 ™l^^ •^ IIIM t 1^ M IIIM 12.0 1.4 1.8 1.6 Photographic Sdences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 r. Gardner]. Beschaffenheit d. Blutes u. Knochenmarkes Dei permcioser Anamie. Over-strain of the heart. Pathology of pig-typhoid. 21. Die Entwickelung von Blutkorperchen im Knochenmark bei pernicioser Anamie Pathological report, vol. i. [C/. no. 3536.1 Croup or diphtheria, which ? Obliteration of vena cava inferior. [With Congenital and progressive hypertrophy of rt. upper extremity. f y ^'■ Striated myo-sarcoma ol kidney Cardiac abnormalities (with 2 plates [at end of next paper]). i - c:«« Fusion cf two segments of the semilunar valves (with plate). Pathological report, No. 2. [Cf. no. 3537.] Systolic brain murmur of children Insular sclerosis. - S^^^y?'^ resolution in pneumonia. 3J. Heredity m progressive muscular atrophy as 5"o/-.^^-*^^.,^^''^^""y- Unseftedatend oj^'^f' ■ stx letters concerning fts., Whereases.] Remarkable heart-murmur, heard at a distance [Mtssmg.] Medullary neuroma of brain (with plate) infectious (so-called ulcerative) endocarditis (with plate). „, . CasesofHoagkin's disease, [38]. Obituary. Chas. F. A. Locke. 39- Clinical lecture on idiopathic or pernicious anaemia. Clinical lecture on fibroid phthisis. On some effects of the chr. impaction of gall stones . . . and on the " fi^vre intermittente h6patique of Charcot. Renal cirrhosis. [42 a]. Catalogue of specimens . . . brain and spinal cord. *^ 43- Intestinal diverticula. 14- 15- 17- 18. 19. 20. 22. 23- 24. 25- 26. 27. 28. 29. 30. 31- 32. 34- 3.5- 36. 37 40 41 42 i«-*it.. 44- 2nd SERIES (1882-91) Etiology and pathology of ulcerative endo- carditis. Brains of criminals. Obliteration of portal vein. Ueber d. dritten Formbestandtheil d Blutes bummer session clinics — 4 articles Cestode tuberculosis. Empyema and its antiseptic treatment [Cf 7a.] ^ J- Uraemic delirium and coma ^_. Parasites of the blood of the frog 53. Canadian fresh water Polyzoa 54- Parasites in the pork supply of Montreal. 45- 46. 47- 48. 49- 50. 51 52 i!^ ""■•'■■'V7'T7« 6i. 62. 63. 64. 65. ft *A^.%Tn/!?T^ '" "P^^"^^ tumour. [Missiv Jacksonian epilepsy i-chinococcus disease in Amerira. Endocarditis. [Another ed. of no. 3^0 1 Morbid anatomy of pneumonia. ^^^^'^ J6,^ v'^l ^"ft'-^."'y "f typhoid. *• -^ ^vol^*xf *xV'°"' ^^*^^°'°S^^^1 See. of Phila., f^?l^^;f2?,^So-°^ the heart. r.W "• °ad^;^^ C:1? ^,^ SSS^ (-essential 71. Cartwright lectures on the blood ^^■ Bicuspid condition of the aortic valves S'odtTuE" "'■*^^" ^°""^ °^ ----- Cerebral aneurisms. \Missine 1 Cardiac relations of chorea oT'Tr!^^^''' /"fa^'^tion. [Missing. ] l^rT^'- *^° lectures [M/fsL /?. published in no. ^=^62 1 i'^^isstng. Ke- 81. Cholesteatoma. ^^ "' f?" Nftr? 1^'^ angio-neurotic oedema. 83 Nitro-glycerme in epilepsy. iMitkne 1 H- Diagnosis of small-pox L''''"^"^-] 05- Glioma of medulla. S^ r^r.W'*^? ^"'^ appendicitis no 'S; Pf ^'^^ • • • f^"-«^- f*- Puerperal anaemia. 00' S!rf °''' ?* duodenal ulcer. 92. A lorm of purpura. PJ. Mortality of pneumonia. 94- Phagocytes. 9|- Pulsating pleurisy. 96. The license to practise. 97- Aquanimitas. ' '"hyrS"'^" ^"^^^^^^ ^-^^°P-g from the Idiopathic muscular atrophy oVDhllnma r>f ^^..^ j j*^ •>, '^-•1 o N o -1' '^ t Oh .-a ft hh .> . " " M D - S-" . ft I 0> 00 o' 72. 7J. 75- 76. 77- 78. 79- 80. u W (A o SO) „^ £«|-^^ ■ y « 5 " « +3 «N 03 4) . h " •• ^ Q;5So^ffl > COO Hepttblished in and appendix. I c . I a o I >-< 00 I > . ■ ^ a 99 -Sy^W^^-ySa equina. ^02. Hepatic intermittent fever '!< J-oj. Post-febrile insanity rn^' fr^/^'^^a'a^is m plitlusis. lot. Tubercular peritoni^is rnl' A ''• "fPhritis in typhoid. -t corut jftii? ^^^^"^-y- ■i'-ro. Sensory aphasia. iVirchow^ 5c(? no. 1663.] 3 rt o > cfl 0-33 rC O ■^ F 0-2 Cm O CO 00 o 4) P 3iO ffl f>. ft "^ «" . o o w« oj n c ■" ftS h2 22 o ^■^ ^ i. 0\ ft • o> 00 OJ 73 C 0) ,0 rs 5 o O " ;oo CO It I — J 3 /3^ C Ih" o !» *"* C 00 I N ft 4- o > VOt3 ^ S ftj ft ■go c CO ."S K ^ a 4 Ml . ex o t; »^ e C I' n ■R -•-' .2 -; • •^^^ to 0) "^ : .. +^ *^ nj ^ MooOQ coo " c S o O "J >-)0 to .~, J- CU IN 00 > > V Xi "^ n fa Pi O^ o ■T-rj. Doctor and nurse ON tfl -r/5. 119. I20. 131. 122. 123. 124. 125- 126. 127. 130. 131- 132. 133- 134- 135- with 3rd SERIES (1892-6) Remarks on specialism Ihe healing of tuberculosis. " ^ J^^^JT .°f congenital wrv-neck svstem:^ processes in tL central nervous Cold bath treatment of typhoid Teacher and student. '^P''°'^- luberculous pericarditis. S>ysfc*:°" Tn Plato°^°rV'J T""^ ^'^^^d-n. Art^rio.venous'^?ne°urisS'Efxm "" '^^'^ "p: v'aSeS^^TJK:;^! of endocarditis. -- Arsenical neuritis ^^orresp. inserted.] |ub!KiS=^P^^-*-f typhoid. TutefcutSs P^^""^^ ^^^^"uck lecture). 136. Sporadic cretinism in America .J7. Tuberculosis in children 138. Toxaemia in tuberculosis Typhoid in Baltimore. The army surgeon. OHver Wendelf HoiS: ^'' "°- ^^^^O Uimcal demonstrations on typhoid Cancer of stomach with verv ranTn .^ Teachmg and thinking ^ ^"^'^ ''°"''^^- sporadic cretinism, lyphoid m country districts. diseases) "^ ^-mer, text-book of nervous i-02. La veran's discoveries rr/.*^; ^63. Visceral compSfonf StfyThemf' ^'^.^-^ tivum multiirme. [ct/.^^^rjf '"- • « c . I -d^ • ON,„_C^ ■«J- Cj (D '^ °° "o -i3 - > 5 '-' "^ Ph W 00 "1 ON 'XI e bo u 3 7) "2 c > 0) -a c W "(NO) c o c d 13 m a; M m 3 -a -xi-' (U 3^ 144. 145. 146. 147- 148. 149- 150. 151- 152. 153- 154- 155- 156. 157- 158. 159- a H-I 00 O (X .2 t^ Co en r-< o 73 SB O c /■ "cS.rr""'^''^ -ith . . . adherent pe,. ■^75- 176. CJassifi t*^ '^'''^' (^897-1901) ^|5. Interna] medfcine as f °J ^^P^o^d. -f|6. Pneumonia ^ vocation. I feat™?- '^"-^ Plate, «■ Se%?„'Jf ■? "^"-bro-spina, ,eve,. 'P- Problem ^f * P"'^H'"0"ia. •o. An acute l^P'?'' '" ^e U.S. '■ Otaicaf LTSf ^'jatous condition. „ '," S?™°"am-lv?f„f™*<: trichinosis. ■'y William Pep„„ ""^=PP"- '• ct"1SeS'"|l- tWith piates., ■ ^i^^^S:^!^- '-cnrtin, fSi^F^-ttheii.. ?■ Visceral lesions of tL''"'"^^^. • Elisha Bartlett ^ "^*® ^tndy. ■ John Locke trf Hemiplegia „ W"""; "'^^■'\ ■ "Fa'^ Si'nT-- l88q-i8on c .J Analysis nf The s^tudy ^of tlT^\ ^^^^^^^^ " ' ^''' Perforation and '^"i°'^^- 2J0. 2 31 232. 233- 234- 235- [222 a]. Cerebro-spinal fever. 223- Books and men ?ff ?LT/'^ °* medicine in the igth century 225. Plea for more careful study of the s^mntom, ^,« °f perforation in typhoid^ [Missil^F 5th SERIES (1902-6) Diagnosis of bilateral cystic kidney. Amebic abscess of the liver Amebic dysentery. A^edUilS"' ^''°™^"^> *"--- -^j- Notes on aneurism. '^^' '''gTaphX-^'''' °^ American medical biblio- 238. Chauvinism in medicine. [Corresh in'^pyt.H 1 242. Aneurism of the descending thoracic aorfa 243^ Educational value of the mVdTcaf society ^44- Chr. purpuric erythema. ^^ ''^^' plateso'°" °* '"P'"°'" ^^"^ '^^^a- [With Stokes-Adams disease. Chr cyanosis, with polycythaemia and enlarged spleen ; a new clinical eSy The master-word in medicine. ^" lyphoid and tuberculosis. p5ob?em! '" '*' ''^^*^°° *° *^« tuberculosis 2^6 248. 249. 250. 252. 253- 254- 255- 256. 257- 258. 259- manifestations of the erythema Morton. 251. Visceral group. Ochronosis. fs'^iirrs^o^Sp-'' "■= -'— -is.. <„ -ri? '*y^ peace, and concord. The student life. Aneurysm of the abdominal aorta Convulsions in typhoid. " ;;; 'SrysSiL-r?;. -^'^ ^^-p-- ^n ^^^•"•SsSiusf^':^'5^i41^o^^^^^^^^ pp. 500-2. Cf. no. ig?.] ' '^'°' (1907-9) 6th SERIES, vol. 264. Cerebro-spinal fever f ?|- Il^e library of a med. school f^^' l^°y^^ Medical Society of Edinburgh "uSlh"'^^*^^ telan§eSas"e?with re- cumnp; haemorrh,nc... ^^j^h plat J ^ r if hi- ro. ;;^f John Keats. '^^' ^m'pfST'' '^''''^"'"'^'^"Pt^ universalis. Historical development ... of laboratorv and clinical methods in diagnosis. ^ Ochronosis. With plate Vienna after 34 years. Endocardites infectieuses chroniques '276 Whl°f''?S'*''Kr^''^^^i °^ *h« Arteries. &c. ' tublrc'u loSf " ^^" '° •" ^^^ ^S'^* ^Sainst '':• "'afets'^mSalef "^^^"* ^^^^^ ^-« '- Chr. infectious endocarditis. Kaynaud's disease ; &c. Evolution of internal medicine. Syphilis (with J. W. Churchman). The treatment of disease. [Review inserted.] uiQ and new. ■• Michael Servetus. [Cf. no. 886.] 271. 272. 273- 274. 275 278 27 g. 280. 281. 282. 283. 284. l 288. 289. 2go. 2gi. 6th SERIES, vol. 2 (1909-20) 285. Michael Servetus. ein Martyrer der Wissen- schaft. [Cf. no. 886.] ^ " 286. The medical library. . . [Cf. no 7206.] 287. The nation and the tropics Angina pectoris. [Cf no. 3575 1 Pupil symptoms in thoracic aneunysm Certain phenomena associated with cervical ^Aneu'rysm""" ^^^^^ ^^'^^ ^- ^"'*h)- Ini ^" "If'^oi-iam, Dr. J. Hewetson, 1867-1910 293- The hospital umt in university work Inf J?i^"gV^c^ie .emorragiche ereditarie. 295- Whole-time clinical professors. A letter to President Remsen. "^ [Privately pr.i 911 1 Transient attacks of aphasia and paralyses High blood pressure. Syphilis of the liver with the picture of Banti's disease. f ^i-uie 01 Specialism in the general hospital. ?fe medtaTciinr '"'^^ ^"^ ^^^'"--^• Burton's Anatomy. [Cf no. 4637.] „ Visceral lesions of purpura. 306. Bacilli and bullets. , 307. The War and typhoid fever Diagnosis of polycystic kidney. Cerebro-spinal fever in camps and barracks. Arterio-venous aneurysm Nerve and " nerves ". oy. Science and war. [Reviews inserted.] S" jXZf^I^^^ of internal medicine in America, school "^-^ '" '''^'"'' ^* ^^^ Public Cremators, transmuters and transmitters . Ijcc note to 110. 5444. J Illustrations of the book-worm Trf ?u ,^!}ti-venereal campaign. 318. The library school in the college. 319. Essai de bibliographie hippi|ue 7208.] ^ ^ ^320. Anaesthesia. [Another copy of no ^ 296. 9 297. \c298. J 299. a 300. ). ,301. (302. 303- 304- 305- '308. 309. 310. 311- 312. 315- 316. 317. o o en c ^ a ' g)' [Cf 1365.] no. 'o oj 13 O o> <*< ^» M c>» t*:i f^ (V-) tv.) rji, t*. {c L\rf J V: PUBLISHED MEMOIRS AND COMMUNICATIONS (To Jan-via: ^s- xat, issa.) WILLIAM OSf>:R,M.D.,M.R.c.P lond Jfospilal, Monlrenl. FOR PRIVATE CIRCULATION. 1882. \\ \ 'a 1 n rB ' ■jB IB ijBj a 'M. iM 1' ill 1 '1 ij 1 ^^ ^^H Ei ?^^H I Hf TITLES OI- PAPERS. '• On (•.•iiKM.Ii;,,! l>i,,(Mm;i,.a ■■■■ rr,fc;!:;:.r'''^^^ • s/ '^' ^••'''■''"••-iyf;,.,nMrlrs,,,,.|M(inM hiiliiu-i... ^'- Oh ,iK> !IiMo|,,,,.,,. ,,,,,,, ,,^,,,^,,,,.^ ^ ^ ^ '"». Mr, Ural ,(. .S'^/ZV/HV,/ ,A„„,,„/_ , s^,. // An I () " ""' ''■■"'"•I'W'fAJiiu.r's Lnnn-, ^"I. OiMhc- I„i,iallia.s],csors,nall-,,ox. • 1 'A. On hu.moiTl,j,s.i,. Smiill-|,„x. A. A form onnu.nnnlK.oK. Small-pox Clmcal Note, on SnuW-po.v." Montronl, 1876 AI. On Triclifnu Wpiralis. ,., , ,, ^^^«««ri/„« .yb«ma/ o/ Med. Sciences, 187fi / Yirr-. " ^ <^f<^riuarian, London, 1877 V XJir. Aneun«m oi' Hepatic Aru-ry (with Dr. Eo.s). <^rt«. .l/f^.^icrt? .f- Surgical Journal, 1877. i i z^^-. < ll/. ■y XIV. ]ntn.duo(or.v Adtke^s al tho Opmini,. of the ill, .Session ul 11,0 Modiral Fiinill^-, Aldiill (;n||i..,.o. ' x^^ TuM. ,.(• j>r ('<(>!. MrtUcii ,[■ Sunjlcal Jmirn/il, IS77. ft>Mvc !'ci'iiiri,,i|. Aiia'i,,i:i (will, D, * '■'"iiiL-rj rw/,. J/( ,//,■,// ,(■ Siinjicol Journal, IS77. X\I. C'.'i-^o (.ri'rMo-iv.qve Aiia'inia (will, D,., Ij,,||,. Tnut'^tftlomofCni. .1/a/. ..|x.yv/,///„«, ]S77, XVI!. l\.l,cr .lie i!c.>.hairei,hoit J.c. i;i„,o,s mA K,„m.|,o„- HKii'lcos 1,1 dc,' pi'()g,'c,s..ivei, pe,ni<.i.w., Aniiinie. - XVNI. ncv..hamnl,utd..s Blnlcmid Kn.M.|,enn,.:!c,w bei po,'- iiicioscii Aiiamic. ^^ ^ r.«^;Y,//,/,r// ^ ./. Mai. \Vi,,emhaflen, Xo. 2S. Ho, ,i„, 1877. XIX. Ovci'-sliaiii (iCilio Ileail. Can. Medwaliic Surgical . I jurnal, 1878. , XX. On the I'allK.logy -ifPio'-Typlioid. Veterinarij Journal, London, 1878. X.X'I. Knhvi,.ly. Journal of Anatomy i\t Physiology, 1880. XXVrr.^ Cases nf Caixliac AbnormalitioH (two plates). Montreal Clen. Jfosp. Reportf^, Vol. I, 1880. I y J fr'ii l(l.y» 1.1, •i-fcfs. 1 '.t'i .ik: / XXV ILL o n U '*' *"iiiii(i()i, ,,r I <'io 'Soniilnnai' Vjiiv "■-^ioii or (^\r,, OS (wifli plafo). "^yiiKJiiis of ^ XX 'X. Pad Monfrca/ Gen. ffosp. Re^ "\'Vy-'''"' %..,(, .Mon.r.al -V". /I (■'• XX > -^- <>„ (I, ^' «y.s(„ii,, I '^///( ilw Heimt,, V, •"■^'i'l inun:,ur .)r('|,i|,| '>'^rtH, Vol. r, 1880 I'-'l Hospital, f., 1880. eiK XXXI, .(.SOS >'' lll>l||;,f ,S( y ' XXXI '• *'ii iieliiyod I '"' •" «- 'iildroii. Joston M^j. ,, Surg. Journal, 1880 H.'-n|||/i,,|| j,| l> ''>"/•««/, 1880. ll'lllllOlli y XXXII () II llCIVilil y ii I ))rOi;| XXXIV. o '""^"•"<''i h- 'I,.' Fan K. M luiiilj '"""/" f^<(ncet, ISN'O. " ••' '^^^Miaikablc IJ "'• f^'- .V.>w Vork 1881. iioiii (Ik- ell, H'^l-wal «''^il-'mi(in,ir, lu-u,,! •■" a (li.si uiice v' '■ XX.W On ■'/'''/. 7Vw/r.s-,t CAz-re-//,- \, ^' XXXVI. Inl •' •■"■^''"r.\KMluliar_v .\ . ^-'iirDiJiu of Uj.; 'I (^viili plau bcti |.la ""^' '^" «':ilio(|, LJI //'t/%6vWc;y//, J^oruioM, 1881 '•^'••"ivo Ktj(lo,,,r.liti XXXVI I Cases .)!'llo,li,ki,,'., | irr/iivea of Medidue V, (with >'• v., I8,S1, N.V. x-'asf. H 4m« !. XXXIX <'lini(.'al i '''"•^^A^'/^cv,/.. ^V,;.c..^,/o«,.a/,lS8l. KXsc '^■""fv 'M, fdiopalhi,. or I '^'■"i''i .. ,j '"■""'•• '"ipac'tioii or (; <»'('hairot. t-'VK mtcrmitteiito I all •'^'^"- On Hoi.al '"^'^'""^ 7V«i^.s ,t- CrV<.'e^?e, t !it'|)uti(iue' CinI atoiicy, otc. "•sis, with -jontloii, [881. ^poi'ial rcibi'onoe ( o its ^LI'I. iVolOSOM I lUosiina! Divortioul: Canada Fmret, 1881 Annals of Anatomy i^Siu 'Wy, Vol. IV., Br uoklyij, 1881. V rT-&-hc oC^i & , '/-• ^u.,/ /uc.,^..,^. llJ M- (4^ £( r. '-U,!.. .if ^ ,^ „/( ' ^ I I ■ .c/,,Y,//, /" ^ .< .< ^„ /if/ ■' i"4, /,/,v.^ /■■<• ,y ,1,-, , . x^--A t^. /i i y •' -' / ■ ■ / , ' / / ^ ( 1 li . ,1 / / ^nc<^^J.y (h.^^ j„_^^ ;^ ,; tl •- c' ^\ ^•~^i^• IX lA w I [from the Pwockkdix «s 0. THE^RovA. Wtt, Xo. 158. 1874.3 MI - J /l- AX ACCOUNT OF CEHTAIN ORGANISMS OCCTRHTNf) TV THE LIQUOR SANGUINIS. KY WIUIAM OSLER, M.D. !*:« In many diseased conditions of th« k i . healthy individuals and in I „y ^ :tr""""^"-^^ ^ P-fectlv ga.^-n of the blood proves that, ^ add iiortrtr""'^^^ '''''''' ^'^^-«- exist pale granular masses, vvh oh on . !« ' "'""^ ^^^'"^»^«' there cularappearance (Plate V. fig. 1 ZT. "^'^ff °" P''^^^"* -^ corpus- h.t Ox rxaminmg blood who have not at ",n I? ^ "' °'^««'-v«'''- i" the these structures, and have been puH,. ^ ^""^ "'* '''^^''' ^^^ -^^h presence and nature. ^ '^ ^^'' *° "planation of their JS ■i ifi' ' '1 nil I li^B' < ■ --^^H ^^■i 1 ■ "S.''] " ■ vMHHj i -5 ,'B ■ I' = ^^1 t! 1 ■' ^fll 'm ■ 1 1 m:i Dr. AV. Osier oii Orgun'isuis [June 18, In .size they vary greatly, from half or quarter that of a white blood- corpuscle, to enormous masses occupying a large area of the field or even stretching completely across it. They usually assume a somewhat round or oval form, but may bo elongated and narrow, or, from the existence of numerous projections, ojfer a very irregular outline. Thev have a compact solid loo.v, and by focusing are seen to possess consider- able depth ; while in specimens examined without any reagents the fila- ments of fibrin adliere to them, and, entangled in their interior, white corpuscles are not unfr('(|uently met with. It is not from every mass that a judgment can be formed of their true nature, as the larger, more closely arranged ones have rather the appear- ance of a granular body, and it is with difficulty that the individual elements can be focused. When, however, the more loosely composed ones are chosen, their intimate composition can be studied to advantage, especially at the borders, where only a single layer of corpuscles mav exist ; and when examined with a high power (9 or 10 Hartnacic) these corpuscles are seen to be pale round disks, devoid of granules and with well-defined contours. Some of the corpuscles generally float free in the fluid about the mass ; and if they turn half over their profile view has the appearance of a sharp dnrk line (fig. 5, a & b). In water the individual corpuscles composing the mass swell greatly; dilute acetic acid renders them more distinct, while dilute potash solutions quickly dissolve them. Measurements give, for the large proportion of the corpuscles, a diameter ranging from one 80001 h to oue 10,0u0th of an inch ; the largest are as much as one 5000th, and the smallest from one lo.OOOth lo one 24,000th of an inch ; so that they may be said to be from |-| the size of a red corpuscle. In the blood of cats, rabbits, dogs, guineapigs, and rats the masses are to be found in variable numbers, Xew-born rats are specially to be recommended as objects of study, as in their blood the masses are commonly both numerous and large. They occur also in the blood of foetal kittens. Considering their pre^•aleuc(> in disease and among some of the lower animals, they have attracted but little notice, and possess a comparativel v scanty literature. The late Prof. Max Schultze * was the first, as far as I can ascertain, to describe and figure the masses in question. He speaks of them as constant constituents of the blood of healthy individuals, but concludes that we know nothing of their origin or d.^stiny, suggesting, however, at the same time that they may arise from (he degeneration of granular white corpuscles. Schultze's observations were confined to the blood of healthy persons, and he seemed oi' the opinion that no fiathological significance was to be attributed to them. By far the most systematic account is given by Dr. Riess t, in an * Arcihiv f. mik. An.it. Bd. i. t Rpiehert ii. J)ii Bois-Reytncmd^ii Arrliiv. 1872. 1874. article their p of the I have affectio ■c [June 18, hite blood- be field or , somewhat- , from the Ine. They 9 consider- l"s the fila- irior, white ' their true he appear- individual composed advantage, iscles may lack) these 9 and with free in the e\v has the individual id renders )lvo them, a diameter ;ost are as 3 24,000th of a red d rats the ^ specially nasses are blood of the lower paratively , as far as ffe speaks luals, but iggesting, :eneration mfined to I that no s t, in an 1874.] in the Liquor Sunyvinis. 31)3 affections of whatever sort, indeed in almost all oases attended with Wrw^ r/^uft^:,^ "-7,/^ Contr.ilblntt. |K7;i \, ■■ Vi»rlir "'» ,\r( IM. will. i^f^ I ! , i: ' i'. 1 , i Dr. AV. Osier ou Organisms [June 18, In size they vary greatly, from half or quarter that of a white blood- corpuscle, to enormous masses occupying a large area of the field or if. They usually assume a somewhat "'. or, from the '^. even stretching com round or oval form existence of numerr have a compact soli able depth ; while • menis of fibrin ai corpuscles are not It is not from ( nature, as the lar ance of a granu elements can be ones are chosen, especially at tb exist ; and wh( corpuscles are well-defined co fluid about the appearance of corpuscles cor them more di Measurement ranging from -i' '- much as one '" " r of an inch ; , i ^ corpuscle. • • - .^j-.^ masses are to be recoil '- * vi fe , ; ^ ,. coramonly foetal kitte • ■ W Conside > ■• , ^ ^. animals, t ' j . scanty lit ^ ' ' ''- Icanascc > ^, of them i 1 . ^ — (cuclude however " "■-'^ of gram.. the blood .>f heaiUi.Y ^ [rathological significance was to be m..^.. Bv far the most systematic account is given oy i^.. . * Ar<;hiv f. mik. Anat. Bd. i. t Reichert u. ]»ii Bois-'Rcymdiiiri" .W.liiv, l.'^72. 1874.] in the Liquor Sunyninis. ,^^:. .31)3 article in which he records the results of a long series of observations on their presence m vanous acute and chronic diseases. Ifis investig. ton o the blood of palienjs, which were much more extens e tal a " n.aye been able to underiake, show that, in all exanthems and c rcuic •.ff.ot:ons of whatever .ort, indeed in almost all cases attended with rbance o function and debility, these masses are to be found 1 e St, and that they are more numerous in the latter sta-^es of an t.on, after the acute syn,ptoms have subsided. The formed of These osihons IS undoubtedly true, as I have rarely found masses larger o abundant than I at on. tin.e, obtained from nu' own blood when "n idifon of pe,- ect health. These two accounts mav be said to .om- . every tnngot any nnportance that has been written concerning these ■ <<. he followmg observers refer to them cursorilv :-Erb * in a j)oth healthy and diseased conditions : he had hoped, in the begin- . of h,s research, that they might stand, as Zimu.erman supposes (see iusi 'Zrrr"" ^^f^^-^^^ -hi developn.ent of the red ^'■n. Hette heim t seems to refer to these corpuscles when he sneaks teV': blood of persons healthy as lei. as di^l^d, s^U n wltl 1 1 " " 1 --".---1 -puscles, whose measurements Ibit^nl . it?t ' eonsKleration; and they also speak of their CZT ::'""' 't'^ '' '^^^« masses, and reiterates his f S i,?;r""' T\ ^^'^-''-""-■>>f'-^'d„ had noticed them and ».ne conditions Banana might develop from them. Zimmerman W has H„bed corpuscular elements in the blood, which, with refeie" , , th Mies in question, demand a notice here. He let blood tlow dh"ec 1 ilo solu ion of a neutral salt, and, after the subsidence of th dou ed /ements, examined the supernatant serum, in which be found iieTr. tech ^1;'"'^^^!™'"' "'^"^'' ""'""-'^^^ ^--P--^- -' h weak on :^ b v^hich he gave the name of " elementary corpuscles." These he met' •ith m human blood both in henllh and disease and in the blood nf T ^.eranimals.andhefoundgradationsbetweenthesm^J:^^^^ less forms and tull-sized red corpuscles. He gives measurement othe Luller ones from one lOOOth to one 800th of a line ; the ra;;e ot I ♦"•«ho"-s Aivhiv, Ud. xxxiv. a ' «'c t Wiener mod. Presse. lafiS, ^•o 1.-? ! f;On;Pt^« Hend,,. Ixvii. 10o4. Q„otod i,. ' Ceniralblat.,' ,«H9 p ,fi S Ct-nlralblatt, l^;?;), i\„. ,s.j, ' -t.p. .jr>. II Contr.dblntt, 1878, Xn. ;10. I Hi I' 'itrhr .Ai Kfl r ;} t i 894 Dr. W. Osier on Organiamn [Juue 18, oOUth to oue 400th of a line), oud speaks of them also as occurrinR iu clumps and groups of globules. It is clear, on reading his account, that u. part, at any rate, he refers to the corpuscles above described, trradations such as he noticed between these and the coloured ele- ments 1 have never met with, and undoubtedly he was dealing with the Ja ter ui a partially decolourized condition. Lostorfer's * corpuscles which attracted such attention a few years ago from the assertion of the! discoverer that they were peculiar to the blood of 8.yphilitic patients, recimrefor their production an artificial culture in the moist chamber extending over several days. They appear iirst after two or three days, or even sooner, as small bright corpuscles, partly at rest, partly in motion, which continue to increase in size, till, by the sixth or seventh day, they have attained the diameter of a red corj)uscie, and may possess numerous processes or contain Aacuoles in their interior. Blood from healthy individuals, as well as from diseases other than svphilis, has been sho^v^^ to yield these corpuscles ; and the general opinion at present heJd of them is that they are of an albuminoid nature. The question at once mos*; naturally arose, How is it possible for such masses, some measuring even oue 40()th of an inch, to pass through the eapillanes, unless supposed to possess a degree of extensibility and elasticity su.'h as their composition hardly warranted attributing to them.^ Neither Max Schultze nor Eiess offer any suggestion on this point, though the latter thinks that they might, under some conditions produce embolism. ' During the examination of a portion of loose connective tissue from the back of a young mt, in a large vein which happened to be in the specimen, these same corpuscles were seen, not, however, aggregated together, but isolated and single among the blood-corpuscles (fig. 8) and repeated observations demonstrated the fact that, in a drop of blood taken from one of these young animals, the corpuscles were always to be found accumulated together; while, on the other hand, in the vessels (whether veins, arteries, or capillaries) of the same rat they were alwavs present as separate elements, showing no tendency to adhere to o^o another. 1 he masses, then, are formed at the moment of the withdrawal ot the blood, trom corpuscles previously circulating free in it To proceed now to the main subject of my communication. If a droi of blood containing these masses is mixed on a slide with an equal quan- tity of saline solution, i-| per cent., or, better still, perfectly fresh serum covered, surrounded with oil, and kept at a temperature of about 37° C ' a remarkable change begins in the masses. If one of the latter is chosen or observation, and its outline carefully noted, it is seen, at first, that the edge presents a tolerably uniform appearance, a few lilaments of (ibrin the vi( frcquc i of tint perfecl attaclu tlie ed, small, i are see (lu'se S( 'ilaiiien off I'ron hinited, joet froi borders, dark, sli rapidly ; margins themselv the cent] Iiresent making i become j merged ij seen in ir at this sti or even i meut goes torpuscles appear, pc delicacy (1 pass out o j)rocess re almost im occupied t last, after f in the field all that rei "lent from \\'e hav( and the rei * T]io mass "1 the foreign JH7-1..J Article in the Liquor Sanyuinia. 395 ' iTHi j„.rtmp« jidlieiintr to it or a f.-u- , i, »h« vicinity. Those lattr soon c.hil^t '"r?"'"'"' '^'"8 f'""" »' froqnently .„rni„g half ^ovri 1 ^^^^T' ^'■"""''^" 'novernents, of fino p..oi..tions IVo.u ^ ! . '^^^ •"" '' -^'7.'\- ^'>e P-.senee porfoetly straight, or ea.-h n.av mt 1 .^ T'' "■'"^■'' ""^>' ''« ^'^h^'r fl'f filgr.H of the mass aro nou- !..«« i '^^ , *"'''''^'* ^'^'^^n 'hat -^all, it ,„ay havo a rad LlL "t "s'' T" '"t"'^ "'•™"8^^' -' '^ are seen, a loosening takes 011' Th ^'""r^""^'"' ^'^'fo''^' '-"7 filaments 'iJaments above mlutionedoon be' ^ :'"""' """"• '^''^^^ P-i-t-S off iVom the mass, moving a.rfr.f V™^.'""^""^' '">d «ualJy break Ji"^ited, soon beeon,es n llnei ? ""' "r^' -'''''^ P''"'-'-^' "^ ^-t j-t fron. thexnass increa! '^ tV 1-.;'^ "' "''"""^^ "-^^^"^ P^ orders, but also, by altering tl / fo eu L hT" "p ""'j"* ^^'^ ^'^*-'*l dark, sharplv.lefined obieets 'kl7T\ ""'^'''' "^ *''« «"'•»««. as rapidly; and in a short ' thf t Wo '''f ""' ''^' "'""^"^^ ^^--d. ;;--gi- i« alive with n.oving or ms : r '^^ ^?" '^'■^^""'- ^■•o- the (Hemselves more and more peri 2^11 ^' .' ' ,""* ^'^^ '^'' ^^-^^^'^^ ^'^P^^ad tl- centre. I„ additio^to «"et o ''^ '^' ^^'^'^-^^-^ -ntinues in present in abundance, and ^ e T "e r"'*?' ""^""'"^' 8™""'- -« 'taking it difficult to define the i. li 7 'T. "^'"■^•^"^^ « cloudy aspect, become perceptiblv sma le^ Ire .^ ? '"r'"/ '^''-' '"-^ '-s now merged in the. vanning ;:jr;f'/^; ^'-I- indistinct and ^een in it, as well as free in t le f eld 7/ '^"^'^"'?""''"^ ''' '^"^ ^« be at this stage; usual] v, howev r it t.V/ ' "^'V""' ^' ''^'^™ *« arrive or even nu,ch less. The ^Het 'J; tie f """'''^ "^ ''"'"' '-^"^ ^ »>«lf. ment goes on; and wherea W T' ""'''""'''■'' '^'^ *^« develop- corpuscles were almost e^l^^^jrr'T"-"'^' "' «Pi"dle-shapfd appear, possessing two. three, L,. mo H^^ """ '""^'S"'- ^-ms dehcacy (fig. 5, /.). The,„ore active o«l; ^'T'''' "'' '^•^^''^"^^ pa- out of the field, and become osH 0^(11 uT''^ ""' ^"'^^P^-^^' process roaches its height ^^ithin ./; ''"'""^ "'« Wood-corpuscles. The aI.nost i^orceptibly t^I^;;; T^,^^:;'-;;;;f^f-- "- «- begin: "ccupied by the moving forms \m\ I 1 u" '""'' ^^ ^^"^« ^'^'"selv last after six or seven htur™t;.rts^;rr '"T" ^^*^^'-''^' ^^" "^ •n t e field, and a granular lo^t^Z!^ ""''""T ''' ^^ ^^ -- all that remains of the mass. 'The abovt r ''T''^'' ■''' «««^ i« ^*i f* S! ' I 39G Dr. W. Osier ,», Oryunisim [Juue 18, cl2luy..a by th. MxuUl fr.. .orpusdes at .,. .nargi,,,., wl.i,.h, previou.sIv U.oscen , begin a s,„.r,.vs ot jerky irn-gular .uov,.„H.nt, at on. tin... with hen- palo d.sk-Hurta,.,.s ..ppormost, at anotl„.p prosoi.ting tlu-ir cbiik J.oear p „,,, ^j,,,. ,,^ , .^ ,, ^-^^ fre.iu, nfly, ho.,., of xC,, un- .e-.. uUh n larger o.- MLiilIei- st-gLiout oi 'hcii- ci,-.M.n.f,.i-o,„.o thick.'.- ainl darker thrmi the oth.T (h'g. fl, c). Earliest. m.o pi-esent a dark st.-aight aspeet wh.,. tb.ev (u.-n over ((ig.o,..), auda.-o by far the long,.st of th. f.mns. .some nu-asuri,..^ as m,.el.a8 o..e 9U(.,h of a., ineh. Many .nt<.n.u.diate forms betw,...n"the r.).i..d d.seo.d ,.orpnsele« and those with long tails are .net with i,. the tl M(l, and are hgin-ed at fig. .'. ,f. Small rod-shuped forms are very nnmei-ons. most of whi.-h. howev..r o.» one aspect look corpuscular; buti,. olhers this ean..ot be .lefeeted o.' only w.th the g.-eatest dilllenlty; slight e..large.„en■«„„„„„,. ■TO? diftiTon,,. is »„„„ i,,,fi,.„i :.. „ ,■' ;, " "'P""'!!;" . IJUI an .■nJciK .mall ™rpuM.!.,ri :,'',''■'■ '"'; '""•"''"■■ f»™»r („l.„ ,|„ p-™t .he .a... „i,,i:-,iw "r;,',;.':" , f :'::"'" r'l r " salme so ut on or s.^rnm ,.rwi • ., ' rou omt. Uh adding wa„„ stag„7 1 . reLrt,* V ""■"' """"■ *''«'" '"""■■ "" ^o ™c. a, i5,uvii;':;::;™ : :,? xs;;::'-; -■ -" -i^' w-r e^i arf Eicss's »s,e«!o„ ,hM ,h« IH, t,. . f f 'r^-" "'eS""'™. whit. o„rp„sel«. be™,„e, ,„i.:Z„ ZZtTT'f same ignorance of the re-. son « »f fu • • "''" '-'O'lf'^ss tho know t. „i, what 11;;,:;° ; :^;;x: ," """""^ t''° ™ affections. ■ ' ^ '* "' *'^^ ^f^U'*«fi of fhrotnV. Finally, as there is no evidence tfint flio>:<. u i- •muity witl. anv other v.oo^n^A , '''"' '"'" '" '""S^"^^' <'«"- li^e power of r^It'tion no h 1 ' " "'^'^'^^''^ ^''"^^ '' ^^^-^-^ or of their relation to S.^^'"^^ "''' '^* ^"^^"^ ^^ ^'^^ ^i their natnre These observations Avere carried on in f}i« Pu,,.- i • i ^ , L^niversity College, and ,nv U,a ^s 1 due (fCf T , ""' '' Sehafer for advice and valuable assi'ance ""^'"°" '^"^ ^^'^• EXPLANATION OF THE PLATE. Platk V. Pie- 1. Couiinfin forms f>'' *!•- --1:1 -^ f^ i. • • I ! .398 Fig. 3. Fig. 4. Fig. 5. Fig. 6. Fig. 7. Fig. 8. Fig. 9. On Organisms in the Liquor Surf/uinis. Mn93 from blood of young rat (in sarum) in full development, after two houm' wanning. (Ocular 3, Objective 7.) Mas3 (young rat) witli blood-corpuscles alwut it, to show the relative sizea (Ocular 3, Objective T).) Some of the developed forms as seen with No. 1 1 Ilartnack. (See tei(.. ) ; Form watched for four hours. (Ocular 3, Objective 0.) Form watched for five hours. (Ocului- 3, Objective 9.) Small vein in connective tissue from the back of a young rot, showing the .cor- puscles free among the red ones. (Ocular 3, Objective 7.) Small vein from the connective tissue of a rat (in serum), showing corpuscle, and developed forn-s. (Ocular 3, Objective 9.) Ot vVllVV er two hour*' •elativc- si«e«. text.. ) ving the car- rpuscJiH and ChUr Fro .xli.iy ■ So-. . Vo i.JX". > y- & v'^ •' >^ e^ ^ © ^ ^ o ^ H Icf o ^-^ ■ o © Ilj i a. h n oi &■ <-' 1 O SI )\ '■ i V y ■♦ ^3 1 '>.c^j> cti? O' >^V'00 iM^'-l-vr-'?^^''8^^ o oo o \ ex o X. ^A,^,q «&^ o C "^ .o VVJIWV;. '.V t1.- "WTWiMfT (!c''^, :»*Tp Vh >. 'c yjL ON THE ^::S^^ PATHOLOGY OF MINER'S LUNG. By WM. OSLER, M.d. Licentiate ok ihk Royal Com E^iE OK Physicians, London. ml I fii! .ii n: < m- .'':-'>r-,'-:.b ■} ■;<>■ : >r"if.\ 'N THE PATHOLOGY OF MINER'S LUNG. BY WILLIAM OSLEK, M.D. Prof. Institutos of Medicine, McGill University. ""'" '•'"= "" »"^--C..in„sic.„ Socio,, of „o„„ea,, m'!,'"ce'itr" lu"'': " ' ^""^'"-^"^ <"^t-ce f,-„„ .-...cc;,::;:,:;i^°rrLt:eTr:.tr ti>= srst case ^a:l;„' r ;::, e°'"'"' •'''""^'°' built Scotcl,n>an,36year of at ■ ^^ ' '^°"°*'' ^^^'l iiHl instead of colliiwin,, „ • , -^ "" '" ™lume, lower lobe of teri.f,; !''"',, "'"''' '°™"<'- ^^e rrontand later ^y by ',:;::: '"T' '° "« ■""■« in old date. Left lun^and ,'„ ?'''' "Pl^^-'tly "ot of in .l.e p,«,ra, cavit-es o' :ra'° r'' ""''' 1"% ''°'""'' lungs presented over the"";, „T\trh ■•'"" ''°"' '>'"-ac.co>ot,r;so genera, .as i;;';ta;:,t:;rjt PATTlOLOCfY OK MINER'S T-UATr. natin-al hue of the organ remained. At the apices and in Iront tnc colouration was not so intense as in the posterior regions, but here it was exaggerated by the hypostatic con- gestion existing in these parts. Both lungs were crepitant throughout and floated in water. Cicatrice, existed at the apices. Several patches of collapse were noticed alon- the antenor free margins. Pulmonary pleura somewhat opaque and thickened to such a degree that even with a lens the' air cells could not be seen through it, except at one border where they were much dilated and emphysematous. At spots, probably corresponding to the interlobular septa the colour was darker than at others. On section the organs presented an intensely black colour, and the serum which flowed from the cut surface was of an inky hue. The nos enor lobes were sodden and cedematous, but still crepi- tant and floated in water. Here and there throughout the substance small patches of apoplexy-the largest the size of a walnut-could be seen. When squee^ed a fluid like ink could be expressed, which left a dark stain upon the hands R peated washing of a portion of lung diminished consider" ably tr.e intensity of the colouration. On the surface of a ponion thus treated different shades of nigmentation can pea to a h..!, '"? ". ""' '''''''''' ^^"^-S i" size from a pea to a hazel-nut, of an intensely black colour exist in lar^e can ,11 be detecte. in others they appear to be obliterated, and he section in this case is uniform, not porous On careful dissection I was able to demonstrate in nearly every them, and this can be seen in several of the specimens These patches when excised and placed in water X" J sank, even when air cells could be seen in th n M^nv sue existed just beneath the pleura and their situation w"^ easily told, not only by the deeper colour at these locaH "s^ ^ ^' ^'^'^^ °^ "^^ ^""gs, not SD much so, IIY WIM.U.ll OSLER, M.D. 8 however, as the apoploc.ic spo,,. Tl,= portions of l„„.v ZLTu , , "'•■"^ Srcy colour, studilccl with the Kemo, httges already n,entioretl. The fl„icl e.xpressed from these pieces was very darl< Th^ „■.■ n u win, n 1 ^'yu.iiK. iho air-cells when e.vaTiined with a lens appeared almost nniversally en,phy,emrto,K n ore especially those in the upper and .'nteri'or re "oi 3'of ct :""„fT,"T""°" " "'""'''^'"' ""^"■"■'- Certain'-li tc sectiono of the hings, generally situated superficially anncar denser than others, the air cells are visible but r;„' ami the amount of alveolar tissue in propcrtion to he a ' seeis abnormally great. This mav L due. of o ,r e e .her to cohapse or to an increase of 'the fibrous elcm nts the latter from examination of the air cells, and also after contparison o it with several genuine patches of eollap e which existed at the anterior free borders. Several small' cavtties. the argest about the size of a pe.a, con'ai 1.^1 were me „,th, probably large emphysematous cells, a °hey were qui e devoid of any definite wall, and the air v^^s Lies opened directly into them. The tissues of the lart bronch, preserved their natural colouration, but as thev ached their ultimate ramifications, when diminishec to'he ze of a crow.q„,ll, the mucous membrane became of .a d»»p black colour and the surrounding elements of the w^alh tit ve y generally pigmented. The bronchi were filled wlh a ft^thy mucus, but the mucous membrane was not 'l clc- The to».^„rf«,„,,/^ of the blood vessels-large and son was impregnated with the dark particle., and ^,e rl v^ ~ ITZT """>■>>-""•«' '"^ -'- of colouratio a ^he I 1 of ,, , , made";p:f"tT;e bl" c r;:;X'f .3,' tr ■ XI Hct "rf^*"™' ™',':"'-=-^' -" P----1 V L\^i\ Diack ^luriace on section Microscopical examination : first, of the dark coloured li! ri J,- 4 rATIlOLOGY OF MINER'S LUNG. scrum, which can be so readily expressed. A varicfy of cellular elements are here met with, and the colour is seen to depend upon black granules, partly free, and partly inclosed within the cells. A difference would seem to exist in this respect as to whether the drop examined was furnished by one of the dancer spots, or from the intervening greyish portions ; in the former case there are more free granules, in the latter they aregenerally inclosed within corpuscles. These carbonaceous particles range in size from almost imperceptible molecules up to portions the I-I2000 of an inch and over. The latter are, as a rule angular and do not exhibit the Brownian movement. In addition, pieces are occasionally met with of an clon-ated form, and of a brownish red colour at the edges, or, if^'thin ^^^ enough, over the whole mass. Some of ^^PH these can be seen with the naked eye, and ^^■^^ I measured several more than 1-250 of an i-ig-. x.oo. inch in length (See fig. i). Other very peculiar forms were noticed, which, from the regularity of their outlines, I believe to be structures connected in some way with the coal, but upon this point I lack the necessary knowledge to decide. The cellular elements found in the expressed serum may be arranged as follows •— I. Groups of flat cells each with a distinct nucleus, the boundaries of the cells, in many instances, being ill-defined or sometimes similar cells are grouped together upon a portion of membrane. Free in the field are others identi- cal with the individual ones composing the above groups They are about the 1-1200 of an inch in diameter, nucleus large and sharply marked, borders often indistinct, cell sub- stance granular, friable, often broken away in part, leaving, the nucleus exposed. The free nuclei of these cells also are present in numbers. Carbon granules are only occasion- ally met with in these corpuscles, and I think they must be regarded as the original cell elements of the alveoli, and perhaps to a large extent derivatives of them in a slio-ht catarrhal process. ^ BY WILLIAM OSLER, M.D. 5 meVbv^t'lf' ^^"°1, '"'■^. "'"'"• ''^^'"S"'^^^'^ ^^on^ the for- mer by their smaller size and less distinct nucleus Thov only occasionally contain dark granules. ^ III. Corpuscles in which the bulk of the carbon is con tained. and upon whose presence the black colo.^ of tTe" ^STet^^'-^' " r' ^"^^'^"^^^ ^'^^-"^- These ar v y variable in size, and may. on the one hand, approich th^ colourless blood corpuscles, and on the o h'er 'tt n to five or s,x times their diameter. See figur^ Ti^. Tri shape they are usually "round, sometimes oval oc- casiona y irre^-ular vnrw vo.-«i , . ' form Inside r^^ , '' ""^'P'^^^^'^^'S the spindle lorm. insKle all of these the carbon particles exist in extraordinary numbers, filling the cells in different dTre Some are so densely crowded that not a trace of celf sul' r?n:^::it^ TT' ""'''' ^""^"-"'^ ^ H- oft tt U: ; remains liee, or at a spot rear the circumference thp nucleus, wh.ch in these cells is almost always ccemr'ic i seen uncovered. The contained carbon particles "re '(or to„ctner, a reddish brown colour can be observed in each In a few of them comparatively coarse portions ol ^oal a e found imbedded stretching the cells to their n'nt ,"s At fig. 2 a and .) such cells are represented, and in the lattej the corpuscle has evidently accommodated itself to the shape of the piece of coal. One most curious pedn was observed : on an elongated piece of carbon three c SO that the whole had a striU-ino- re-mV-m-^^ < 1 , bell. I could hardly credit this at firs, until, by to." hit 6 PATHOLOdY OF MINER'S LUKC». !l the top-cover with a needle and causing the whole to roll cT.r, I quite satisfied myself that the ends of the rod were completely imbedded in the corpuscles, and the middle j)orti()n entirely surrounded by another. So strong was' the attachment that I failed to separate any of the cor- iJ'isclcs by pressure on the top-cover and other manipula- tions. Another corpuscle was seen entirely surrounding the end of a small rod, forming a miniature drum stick, the handle of which was twice as long as the diameter of the corpuscle. IV. Decolouiivcd red blood corpuscles, which are very numerous in all the specimens examined. Many of them a^^e aggregated together into masses, casts, probably, of the air cells ])ressed out of the apoplectic centres. V. Amyloid corpuscles, of which a few well-marked specimens were observed. We come now to the examination of the lun- sub- stance itself, and first of the small dark areas!" On teasing portions of these, unless done very finely, no structure can be made out, uniformly dark m-^sses present themselves. If. however, the elements aio more nnnutely separated a dense intcrpenetration by small dark granules of all the textures is observed. VVe have not here to deal with cellular bodies containing the pigment, for it IS free in the interstices of the tissue, and few or no cells can be detected. So thickly is the pigment scattered over the structures, that even an isolated fibril of elastic tissue IS with difliculty seen, on account of the granules attached to It. The air cells seem obliterated by the excessive accumulation of pigment and the great increase of the connective tissue, and hardly a trace of them is met with As before mentioned, the fluid expressed from th>..e parts contains only fine granules with an occasional cell. Thin sections show very well how intense the pigmentation is but yield very little information as to its distribution, for a uniform black surface is presented, which only here and there m irregular spaces is penetrated by the light. To- HY WILLIAM OSLER, M.D. 7 Zlf ;l^e borders, where the tissues are not so denseiv >"fi trated, some of the carbon is seen to be eo tie 1 vv^th.n round corpuscles, and also conHned in vx.y e. h' omewhat spuulle-shaped areas, but whether tLs Ta tS are conneetave tissue corpuscles or not is difficult o d d e From their extreme irregularity and the numb rot,; processes .t .s probable they are not. but only repre the arrangement of the carbon granules amoT' th. elements of the tissue. All the co-its of li T ^ • , and vessplQ in tu ' ^^^^^ bronchioles and vessels in these areas are impregnated in the same v^y, but I have not found any of the htter obstr ted bv accumulations of coal dust. "^^Liuccca by I" passing to the consideration of the histoloo-y of th^ less pigmented and by far the largest section of thi lunt •t may be mentioned that a considerable part U.e co ' ouration in this is due to carbon granules retain d within the cells already described. These exist in Ii V throughout the whole substance, Iri^^^^-y^rr; efo:;","- n"'"^: ^"' '" '''''^' p.-eparations V;:;; 1 ou set; the : ^^ "^"^'^^'^ °' '''' ^^^°"- --' ^^oZ tne course of he alveolar septa, occasionally. also, lyin<. free m the air cells. Nothing further need be idder r/ f description previously given of them " '^' I'ig- 3. (x 450.) Secondly, isolated particles of carbon are tolerablv numerous, even in situations which, under the n icr one look on superficial examination to be quite free The membranous walls of the alveoli are const ntly seen dottd over with black granules, though it is rare to see any o' pying the cells upon it. and in the snm. ,v,. th 'inter f ot the fibrous stroma contain them b ^l;/ ^ ^ TlL^ i h t 8 PATHOLOOY OF MINER'S LUNO. manner in which these snuili particles gain entrance into the stroma may sometimes be observed, as slri . n a trace of an air cell is found, but as a rule, all reams 'of them are obliterated by the overgrowth of the nbrous tis.<=ue \eryfew cellular elements arc found in these localities BY WlLLIA^r OSLEK, M.D. n and those present are small and do not contain many car- ttleT;:;r- .? '^ "'^^^ '^'''-'' >" -^ -^^-^t man yof tne Jess indurated nrp'ic tii^ ^,.11 1 i -^ - 1 , ""^^' ^'^■- cellular elements are nrescnt c u b the lact . at th,s specimen has been in spirit for ind s;,";?il ';"'"" "^ '"'""'■""" '"■^'"•""'"e- Cells, large dis i, , '"° """^ "■''"'"^''' °f "^-b"" or even ssr,ri :' »'■<=, """'=""-'- I" son.e instances a enclosed in /t f '""'""^ "^ '^='^'=°" "■-■■■= ^<==n °o e " " !f "'•■•'' "■""" ■""■•-■ """^ •■c-^="*hnce as\ 1„„ '?'°"'''' '^'"'f — 'ith irregular hard outlines black .w^i", r '",'"' ''*' --« "-"y small angnlar black pa, tides, also others much more minute In this or^arrraiT"*^ "' ''!'' ''^''^ ^""^ " -™™- -' ' ncheU^ '" r^ "'^^ "" -^SS'^S-^'io" of .5-:3o at- ached to a p.cce of lung tissue was noticed. None of these were oljserved within cells Ti, , i , , ""'"-"""'-^e cilities wl.i.i , ° ''"* «:"ipbysematous lo- cahties, wl„eh usually have a small bronchus in immediate ";i;at.7r'''i;'"";; ^^ """'"^- °' » "rlabirrml I ro w 1 ; r "" °',"-'" "•^'^" "'""■ -d "i-h hard 01 a cherry stone co„tan,ing five emphysematous air cells n eased ,. t,p ver,- finely, but was „,' able to fi d a yt I bke an alveolar membrane, only fibrous tissue evervwhlre ™eZt o /w'r'; '""'"r '- "'"- ™^™"-' wh:; r: ;! mentation was less profuse, definite increase in the fibrous e ements in the walls of the air cells can be s n In ,e^ o the isolated fibres of clastic tissue which i " he a , " g runs across the alveolar wall and serve to s. e "l , Ire th rtJr" "' """'•'•«••'— perfect netwoA^No ait cnese to he mis^nk-p'i \^ntu = air eells immediately ^1^=1^1° i, "vf' 7 '' '"™'""S the variably emphysematous xLe,,'"'"' ""=== ''"= '"- little affected, only I'e^e and 2r! ^ ' """"° "■''='f '= >""' ance, due to the aLrtll! r^r^^'^u^-^ ^'^P- ;".;:. "rrr rtr T,"- "--■ "" ""- lar elements: ".rCs „' tptm^ il ?' '"= '^^"^ «"'- brous tissue. Where the L . ""'°"= ""= "" -.bjacent air cehs e L'a'e d" T'"" T"'' '"'" "- sionally the alveolar u.^1 ' , te ,tha" -e' "' ,"'' '"''■ »f pigment upon it. Cells e:,n i '^ r,: '^^f ''^ common in the alveoli whirl, h. i ^'^° ^^""y monic process, and t ^d Xt^h^TMe™'' l" ^''r"" part.yf.eandp^^tl^^in'ict^li:;:.:,^^;::'.';'^'!-"'- filled with a finn rr,-.,„.i... _ , . '"^""^^"'^'^"^ vesicles are \v hich contain carb granular substan ce alveol ar •on and are ident; septa. Small angular particles of carbo and cells, man).- of cal with those in the n are com- |l !'■ |1: fh' ■ I i' i » i 14 PATHOLOGY OF JIIXER's LUXO. mon in the field, but no coarse ones, like those in cases i and 2, were met with. An interesting: fact, which will be referred to hereafter with reference to the probable origin of the pigment in this case, is that extravasations of blood were seen in the siib-pleiiral region, and usually in the vicinity of the dark areas. On several occasions I saw at the ed^'es of small teased portions of an intensely black colour the reddish brown remains of an extravasation. The small pigmented areas in the lungs presented nothing remarkable, .they were chiefly in connection with blood vessels. From the description of the two first cases it is evident that we have here to deal with the early stage of the dis- ease known as Miner's Lung, or, to give it che scientific appellation, Anthraccsis. I say the early stage, meaning that the degenerative process can hardly be said to have- commenced, and had not these men died of intercurrent afiections, they might have lived for years under favorable hygienic conditions. No doubt, however, the point had been reached where further exposure to the impure air of the mines could only have resulted in bringing about serious lung trouble. Ultimately, as the records^of /^j-^ mortems show, there arise extensive areas of consolidation- carbonaceous Pneumonia, as it is called,— with numerous cavities containing an inky coloured fluid, and at last death takes place with many of the symptoms of chronic Phthisis, a peculiarity in some cases being the expectoration of a dark colored mucus. In the cases under consideration the intensely black.consolidated spots may be regarded as the first step in a series of degenerative changes. Such gen- eral infiltration of the tissues by a foreign matter canno't be without a strongly irritating action, the final effect of which would be a proliferation of the epithelial and connective tis- sue elements, with the result of obliterating the air cells and the formation of firm indurated areas. The larger these become, the more the cellular elements participate in the process, so much the more likely will they be to soften at Mie centres, and finally form cavities. The indurated spots I5V WILLIAM 0.>^LER, M.D. j- in our specimens were remarkable by the abserm nf puseular elements, and the same Jm ^o^^Z^ Z' n la.ger areas ; still, even in these, as occurs in Ci C of the lungs a molecular degeneration goes on n t e CO tre w,th the formation of a cavity. In the lu . 'f 11 n.d,vKiuals who die of this disease these cav^i'Ue are no doubt often bronchiectatic, are described, surrou ed by nulurated areas, while the comparative ^lea it :"nV:"re"^"r'/' ^^^'^^'^^' cmphysL^atouI' S -^ aTc iL. • , "^ "^'"'■■•'^ leaving died of intercurrent en,pI,yscma.ous. I., so„,e i„sta„ccs tire con i/jai'^'^ ttle effect, for cases are mentioned of miners exposed J years to the same influences to wl,icl, others succ n b a ° y t who were but slightly alTected, PredispositionToiu ' 1 s ase ,s an ,„por,ant .actor here, and it L bJhZl hat where this e.vists, they die at a nn,ch earlier a J°m those wthont this hereditary weakness, whici, need no however, necessarily be a true tubercular diati,e is dcec' n read.ng over the records of tl,e ^,sl ,nor,e,„, , , ,! l' dsease one ,s struck by the absenceofanymenton ith of true tubercles or caseous masses, and in neither o, hi Path'ological Sodefy'f™ :":::";- ""= ^"^^-'^ "- ™.ati,,g substanceL the al^Hhelli 1 •IiriL;,;*" represented the final change which these had under.r„„, Aga,„st any such view the cases here recorded sp ks ro, „ expect just in this early stage to find traces of it ; lii i li y I i'" i mI I ■i r ' ^ : ! .L 16 PATHOLOGY OF MINER'.S LUN(f. but instead, we find at the outset of the disease what is spoken of as occurring at the close, fibroid consoHdation • the difierence consisting in the extent to which it has ""one and in the absuncc in the former of secondary chano-es. In its essence the whole disease would appear to consist in an overgrowth— a h_vpci-plasia — of the fibrous tissue of the lungs, induced by the chronic irritation to which they are subjected by the inspired particles of coal dust, a veritable Cirrhosis, or, as it might appropriately be called, the black Cirrhosis of miners. This certainly is the most natural view to be taken of these two cases, and accords best with their general and histological characters. From the fact that in many instances small bronchioles are seen in con- nection with the fibroid masses we may infer that about them the process begins, and spreads to the surroundino- alvcoli, In other places the advcntiiia of the blood vessels, and the interlobular connective tissue furnish starting points. We are still in the dark as to how all this takes place, how the air cell:^ become converted into firm, hard areas— fibroid substitution as Dr. Bastiau calls it,— or why, again, in the same lung, some of the intensely dark spots are solid, while others are emphysematous. Before referring to the other specimens, which do not, I believe, come in the same class, a few words mu be s?id upon the general subject of lung pigmentation. J3riefly, two sources must be admitted, an internal and an external •, in the former, the pigment is transformed ha^matin, and the affection is termed Melanosis; in the latter it is inhaled carbon, and the resulting disease is Anthracosis. It is only within the last ten or fifteen years that unanimity has been reached on this point. Up to this time many of the lead- ing German and French pathologists refused to recognize the latter source. Even Virchow as late as 1859, basino- his observations on portions of miner's lung sent him from Edinburgh, came to the conclusion, thouoh he describes angular particles of carbon from the same^cases that a transformation of the colouring matter of the bluud BY WILLIAM OSLER, M.D. 17 in repeated small hemorrhages would account for the whole P.gmen . The English observers (and with them sever I H-ench), one and all, as far as my reading goes, from Pear son who ,n 1813 first described the affec^-on, t ok a nZ practical and common sense view, and attdbuted to it oely an extraneous origin. Having many more oppo ' unmes of obserwng the conditions under which miners worked and knovvmg the foul, sooty atmosphere of the n^mes they were led to connect cause and effect, the dust vvuh the disease, and so arrived at the truth ycirs before the Germans, to whom, however, the credit is due of hav- ing placed the fact upon an histological and experimental basis They demonstrated the presence of dotted cells and other structures characteristic of vegetable tissue in the coarser particles obtained from the lungs and also proved that the lungs of animals might be mad'e of 1 dark color by exposing them for a length of time to a sooty a mosphere. I have been fortunate, also, in these cases to obtain positive evidence of the external origin of the pi^ ment. At fig. 5 a portion of coal is represented which t ^'ig' 5. ()C3oo.) Fig 6. exhibits the characteristic appearance of scalariform tissue 1 h.s was a very thin flake with distinct cross bars, three of vvhich occupied the whole breadth of the piece, while one weic of a brownish red colour. By manipulating [ man- aged to break it across just below the third bar, and was then able to obtain the transverse section, which is given at Pi 4;fil!' qil 18 PATHOLOOY OF MhNEIi'S LUiVG. fig- 5 {^), 'ind makes it more than probable that this was a portion of a scalarilbrm duct rendered prismatic by pressure,, a common strncturc in ferns, and also plentiful in cannel- coal. Another piece, seen at fig. 6, with two round holes, represents a portion of a dotted cell of fir wood. To consider now this subject of Anthracosis more closely, and endeavour to obtain an insight into its rationale. A comparison of the lungs of a child with those of an adult, or, better still, of an old man, shows that the natural colouration of these organs undergoes a change as aire advances, the rosy tint of childhood givingway to a marbled slate-grey, interspersed with patches or lines of an intensely dark colour. Similarly the lungs of an animal present a marked contrast to those of an adult man ; and there can be no doubt whatever that in great measure this change in colouration depends upon the inhalation by him of the products of imperfect combustion of fuel of various sorts, gas, &c. '1 his has been called physiological Anthracosis, in contradistinction to the more extreme condition met with among those who work in mines, and other situations in which the air is charged with soot and coal dust. Against the entrance of these noxious matters into the lungs the nasal orifices are furnished with numerous hairs, which, to- gether with the mucus of "hcse passages, retain a consider- able quantity of the dust and coarser particles met with in the air. After a lengthened sojourn in a smoky atmosphere how common it is to see the nasal secretion quite black upon the handkerchief. Still, even if the particles escape retention at the orifice, as they all do when the breathing is carried on per on^, a further provision is made for their expulsion when they reach the bronchial membrane, the cilia of which are in constant motion, producing currents which set externally, and slowly and surely convey the mucus with the contained granules towards the larynx, whence they are readily coughed up. In ordinary inspira- tion the volume of tidal air docs not probably reach further than the larger bronchi, and the coarser particles in this fiV WILLIAM OSLEF, ^'.D. 19 orlvi ! ']''>; '''f' '''' ^>'^'^-«'' '-^t all do so by the force of grav Uy bu u. the stronger respiratory efforts, just such as miners by the very nature of their work must constantly make, many atta.n this situation, and. as here no provision s found for their expulsion, nature provides that they shall at any rate be placed in less injurious localities. In what way th..s IS effected how the small angular particles which can be seen on the alveolar walls penetrate into the interior. sZT.T fT ''''^""' ' satisfactory explanation. Shaip angular bodies are said to have a habit of workin-. into soft textures, especially if there is any impelling forcc^ however slight behind ; but what of the infinitesin.al par- apply to hem ? Certain it is, however, that once fixed in he alveolar wall they resist all attempts at removal, and hey may be seen, as at Fig. 2, in all stages of proo-rcss towards the interior. In their further distribution the^ot ow exactly the course of the lymphatics, and the tissues i heir immediate vicinity ; where these are most abundant there the Pigment is in the greatest quantitv, as about he connective tissue of the vessels and bronchi', the inte bbt ar septa, and. above all, just beneath the pleura. Once n- s de he _lyn.phatie vessels a large proportion of t le gr nules ,s carried on to the glands at the root of the lung and IS here permanently fixed in the cellular elements ovei fifty. This fixation of the carbon granules in cellular bodies IS very remarkable, and must be regarded as an effort oftue economy to render harmless what might otherwise be very irritating substances. In the greatei part of tie rf \ T r' "" '" ^^''^^"""^ ''■'' -"^-"-^ -thin large cellular elements, belonging to the amcx^boid class of connective tissue corpuscles, and in the other cases they were by no means uncommon. These were unusually lar J twice or three times the size of the colourless blood cor- puscles and very abundant, as if the supply had been equal to the demand. This pathological infiltration of corpuscles "1^ ) l\ I r 8" jii 20 PATHOLOCtY OF M1NP:r\s LUNO. With carbon appears to interfere just as little with the per- formance of their functions as does the physiological, so common to many connective tissue corpuscles of n°an ind the lower animals ; for in the air cells which had been in- volved in a pneumonic process, anc among the epithelial elements with which they were filled, these same large cor- puscles occurred, evidently having migrated from the sur- rounding tissues, in^vhich sections demonstrate them to be plentiful. To show the remarkable aptitude of cells to take up granules of various sorts, and, also, .u demonstrate the rapidity with which the lymphatic glands are affected, I per- formed several simple experiments, of which I shall mention two : — Experiment I.— Into the axilla of a two days' old kitten m 111. of a strong solution of Indian ink were injerted and into the right lung of the same animal a similar quantity was injected through the pleura. The kitten was killed twenty hours after and the parts carefully examined In the axilla there was a spot the size of a marble of a 'ark black colour, composed chiefly of connective tissue and fat On examination of teased portions it was seen that the par- ticles of Indian ink were either free in the interstices of the tissue, or else contained within the numerous .nicocytes white blood corpuscles, with which the tissue was inundated These were specially abundant alon- the course of the puncture, ar.l i„ this situation all the leucocytes were loaded with the dark granules. The spindle shaped con- nective tissue corpuscles did not contain any. On removing the sternum a dark lymphatic gland was seen, and close to it a much smaller one. Nearer the manubrium was another black spot, apparently only an ag- gregation of dark granules. Where the point of the syringe had penetrated the thorax the layers of the pleura were united by a dark round band about two lines in diameter. Under the dark spot on the pulmonary pleura was a portion of inflamed lui.g substance the size of a large pea of a dark red colour. E.xamination of the dark spots on the pleura BY WILLIAM OSLER, M.D. £1 and the intervening band showed tissues everywhere infil- rated with small and large cellular elements, in which the bulk of the p.oment was held. The small corpuscles in ap- pearance and size correspond to colourless blood corpuscles winch modern pathology has demonstrated leave the ves- sels m large numbers in the early stage of inflammation. Among hese some were sparsely, others densely, crowded with oark granules. The larger cells were more than twice .he size of the ones just described, and belong to the group of connective tissue corpuscles. Many were rounded or oval .n oulhne, and these contained the greatest number of granules, whde elongated, spindle shaped ones rarely con- tamed any. Changes in outline, amoeboid movements were seen m most of these corpuscles. In a portion of the pul- monary pleura which was under the microscope a small net work of lymphatic vessels was rendered beautifully clear by the number of dark granules inside them. Unfortunate- y I was unable to .ketch it, as on changing the object-o-las3 or the purpose I accidentally let it falfup^on the lick ad tTsTo ■' r "r '"'"^ "^^- ^"^ ^"-- phenomenon was seen m teased portions of the inflamed lung of cells contammg red blood corpuscles A considerable numbe of these were met having from si., to ten corpuscles in their mtenor, others presented only a diffuse colouration txpermient V.-Into the right thora.x of a four* weeks- old kitten mx of a solution of Indian ink were inrec ed and he animal killed thirty-six hours after. A dark spot on the costal pleura corresponded to the point of entrance of the need e but the layers of the pleura were not adherent. The lower lobe of the right lung presented a dark firm masj about the size of a walnut, occupying its interior, and scat^ tered round it were several other small dark spots involvino- both p eura and lung substance. The sub-sternal glands were slightly coloured, and those at the bifurcation of the trachea were dark superficially. Examination of the dark mass in the lung showed the air cells in a condition of in- Hammation, and everywhere crowded with leucocytes in ! Si ; i 1 in all "II 99 ^ATHOl.OOV or MINKH's LUNO. side winch almost all the Iiuha.i ink granules were con- tained. So numerous were these cells that even in very thin sections hardly anythin- else could be seen. At the mar* gms of the healthy and inflamed portions larger corpuscles occurred, which Avere also fdled with the dark granules, and a few were noticed containing red blood corpuscles The lymph corpuscles of the glands, sub-sternal and bron- chial, especially in the superficial region, contained numcr- ous pigment granules These experiments serve to show how quick!. irritaMn^. materials are taken up by cellular elements ; and it is in precisely the same way that the carbon granules which reach the parenchyma of the lungs arc fixed in the connec- tive tissue corpuscles and so rendered harmless In ex- periments 2, 3. and 4 the substernal glands were also more affected than the bronchial, as in these cases the ni^rnicnt vvas chiefly about the pleura, and adhesions having^laken place between the layers, the lymph bearing the Indian ink granules was conveyed in the vessels of the parietal layer to the glands under the sternum. _ In cases three and four the pigmentation is not so extcn- sive and there IS not the same certainty as to its source. In the absence of any history it is hard to say whether in the former case we have to deal with a condition produced by the inhalation of dust, or whether it is an excessively pio-. niented piece from an old man with chronic lung affection. The general firmness of the piece, the thickened pleura the existence of caseous masses, and the absence on micros- copical examination of large particles of carbon flxvour the ' the latter view ; and if so, the pigment is to a large extent melanotic, i.e., proceeds from the lucmatin of the blood. Of course m all these eases a double origin may usually be at- tributed, for the process of physiological Anthracosis goes on constantly, whether there be disease in the lungs or not • but we have learned to regard the pigmentations occurring in the indurated areas about cavities or r.n.nous m-ses as specially of blood origin, in as much as they' are met with . ItV WIIJ.IAM OSU-AI, M.I). O'i in young children, in ,vl,„m an ;\n,hracosis is out ol ihe .11 >. ages of t,an.,forn,at,„„ fr„„, ,.el|„w up to a iet black . .1.0 ast ca,e I think „„„ is slili less „„n, f ,| b ' the, „'„?f;l" ■""','"''.''■" "' '"^ '"^■™"' '" -'°''- .cina, to Hh.ch situation it ,vas in great part condnecl a .tiuttion, moreover, shown l,y Virchow to be special ypne xtravasatious but, above all, the detection of iZ! vasations in and about some of the pigmented areas Wl t,," ;r'"r'"r ""-■"" "'^' "- '^ " "-ran i pro • W ther this had any connection or not with .he dcran ": men of pigmentation in the skin, as vvassuggested may be questioued. Melanosis as it ordinarily occurs i, a very t.on I or the former to take place there must be cither long continued congestion, amounting almost .0 stagnati n h tr mat: "T'T"' "'"'" ""''""' -'^^^^l-es the colon i ng matter of the corimschs infiltrates the tissues and ere gradually undergoes a graiuilarprecipitatnf:^^^^^^^^^ the httle particles known as melaiv.,. If i„ , ,;' "' -ning cellular elements , I., .k o, ine'hrat'r ' d s" way into them it may occur in them only ; but if the extravasation takes place in the region of a fibrou t s le Ike these indurated areas in the lungs, the eoloti iig J; p. sby .mbibi.ion among the v,arious Clements, and ve find It there .as a granular precipitate In the normal orocess, as it goes on for example in the '■""'""'""". .no cells obtain colouring matter from the sels. One pathological condition, met with in thepl.-mented Sarcomas, adheres to the physiological method, fortl" e iVr 'ati!-;: u:"; ""'' ','-"""'• '" «™' "''"■ ■™"' "-e plasm rrigat.ng he tissue, but according to some observe s also from small capillary li.-cmorrhages. It is interesting in this connection to refer to the cor- puscles containing red blood corpuscles which were found '1 24 PATHOLOGY OP MINER'S LUNG. in the lungs of several of the kittens experimented upon. Here we have to do with an intravasation, or rather an in- gestion of the coloured corpuscles within others. Many deny this, but as far as my observation goes there can be ' no doubt of the fact. In these corpuscles as many as si.\ to ten were seen, in others again the outlines of the red corpuscles could not be detected, as if the cells had absorbed only the colouring matter. Nuclei and granular protoplasm were also seen— strange constituents, if, as some suppose, the appearance of a cell is caused by the separation of the fibrin round a group of red corpuscles. I have sketches in my possession of amffiboid cells from newt's blood crowd- ed with blood corpuscles of the guinea-pig, which were abundant in the scrum with which the newt's blood was mixed for examination ; and it is not at all unlikely that other amoeboid cells, even in the tissues, should do the same thing. This is not a common way for cells to be- come pigmented, but th?re can be no doubt that these would rapidly have become so, and would then have been undistinguishable from many of the larger corpuscles con- taining Indian ink granules. To sum up — I. The histological examination of these two specimens of miner's lung favours the view that in the early stage the process is confined to an increase in the fibrous elements about the bronchioles and vessels, and in certain emphyse- matous areas— a genuine Cirrhosis, or, as some would pre- fer to call it, an interstitial Pneumonia. II. A considerable proportion of the carbon is contained in large cellular elements, which are specially abundant in the less pigmented, healthy portions, and in these it pro- bably remains without much injury to the lung parenchyma Another large part of the pigment lies free among the ele- ments of the tissues, this being specially the case in the in- durated spots, in the thickened pleura, and at the junction of the alveolar septa. III. The extraneous origin of the carbon is proved by the detection in the lung of portions ol fossilized vegetable tis- sue in the form of scalariform and dotted ducts AY VALEDICTORY ADDRESS TO THE in ^thkim mh ^m^tx^, McGILL UIJIVE'RSITY. DELIVERED ON BEHALF OF THE MRnrPAT ...^ ANNUAL CONVOCATION HELD IN pTe WU M.T'' ^^ ^"^ "AX^I^ OK THE ONIVEHSIT?, o"/ W^ED^J^SDr'^" THE 3 1ST MARCH, 1875 ' BY WILLIAM OSLER, M.D., L.RCPL LECTURER CV INSTITU i OP MEDICINE. ^Fro,n tke Canada M^^ an, sj^l ' Journal^ '^-^ ^ ' Gentlemen OF THE GRADUATiNrTr A «c tu , ' ' duty devolves upon me nfnffL ^ ^^""^^^ Pheasant Faculty of Medidne ^nnf .. T I-"^ ^°"' ^" ^^^alf of the cess a'nd gld'^^sh'es'fSfThettur: °Vor7 ^"""^ ^"^■ have been occupied in mastorinl fl , ""^ ^°"'" >'^a^s you fession in the LeSure room r"^ ^1 ^'^'?^"^' ^^^O"'' l^ro- andnowhavint^aSe^crthefere.^^^^^^^ the long looked for de^^ree h;,« Til r ^"^ University, title obtained. The time has Lrf.i'f''"^"'''^^' '^^ ^^^^^ed your p?orrnauLTar.'L'b:^n'o'" ^° '^^^ ^'^ ^'"^ ^^^^ have, as it were onlv h ? V . / , "'•^^"' complete ; you Gent]emen,wh& it ^^tole honlTl^ ?'''"' '"^' ^^' "^^ ^^y' foundation has beenla d unrfe ^^'f ^^^^ ^"^ Promising of others, it re£ wir/o' f,^;^^^^^ ^"^ '"^^^^ctiof shall be. The credit nf , 1 V^ n^^^ ^^^ superstructure Professionto which i is o/rn' ^,"""^"' '^^ '^^"«"'- ^^ that your advancement in hf'dC'i^d^' and pleasure to belong mark out and follow or youSve Y ' '""'"'" ^'^^ "°^ tent to rest on your oars Th! ^°" P^^^t not be con- formulas of the faw are o a cert?"°"! ^^ ''^^ ^^"^^h, the stereotyped. N^ o Idicine ? f^^^"' inalterable, are gressive science, day by Z ;eceiv n/7'"i'"'"^'^ ' P'^' ODenino- un new fi-i ] r -^ receiving fresh acaui.s tfon- duty, al fl as™ y^i^t' to Seft™' '1" j"' ^ ^o" During the first few vears „hni^ ^ , "'!'' *" P™S"="- ' will have ample leisim- ,!; , ™'""« '""^ P^ctice, you various branSof yo r ^''ofSn'''' TJ" ""-""Kh'y *" 1-st .echcal li-L.re^tuiri^lftthTse'-l'S;"';: |i^1 L L 1 btudious habits. 11 happens too frequently that after the severe work of the final session, books are^throm aside and rarely reopened. A glance at the bookshelves of anv professional man- Cleric, Lawyer or Physician, ^11 enable you to judge better than anything else, the estimate he has ^ formed of h.s :alling. Let it be also an ambition to add your m.te to the store of medical knowledge. Every one can do something ; and the routine of general pract ce af fords many cases worth reporting or "commenting u'n Our Medica Journals greatly need the cooperafon^o To p. ofession throughout the country, and in thus record n- your experiences you will benefit yourselves, and he tS raise the standard of Canadian Medicine. Hitherto Gentle men, your relations have been chiefly with your 'teac lert and with each other ; now these relations are d an ?d and you will have to deal in the future with patients a rdfelbvv practitioners. On the first point it would not becle me to say much. Remember, however, th.t every patient unm' whom you wait will examine you critically and^ form an e d mate you by the way in which you conduct yourself at the bedside. Skill and nicety in manipulation, llSier tn the simple act of feeling the pulse, or in the performance of any minor operation will do more towards estab i" hin? confidence in you, than a string of Diplomas, or 'he renu^ tation of extensive Hospital experience Foriner y iiX days of apprenticeship, the medical student was brought daily in contact with patients of all classes, now itTs foo often the case that Hospital practice is the oni ' varl ty seen ad U.e sudden change to private practice is found rather' trying. Time soon remedies this, and every case success fully treated adds to the confidence you fbel hi vour mln powers Fortunately, the first patients aS an^' the poor, who are less exacting, more easily nleaspd Tmh"^ con.iaeration. It has been well said, "No one should cnanger Let the spirit of our Medical moralist Sir Thomas Browne, whose Religio Medici I would commend to your perusal, actuate you. He says " Let me be sfok myself, if sometimes the malady of my patient be not a dL ease unto me ; I desire rathe/to cure his infirmides th^^ my own necessities ; where I do him no good me hinks ^ s scarce honest gain, though, I co.ifess, 'tit butThe wor hy salary of our well intended endeavours." Upon your rela^ tions to follow-practitioners, allow me to ofier you a few words of counsel. It is a fact well known to you all that the great opprobnum of our Profession, especially in he smH towns |s the constant rivalry and distrust of one anotherTus played by its members. That men whn-- hJ^i, , o r„ bind then closely top.h: "LVvvLse'' t?e ;"\"?ct much in common, should thus disao-ree is a m^tw f f to be regretted ; and. I would urg^r^^l^^^^^^^^y let me hope, prosjoerous career, to do all tha't may lie fn C; power to lemove this scandal from our midst. A littfe watch fulness when commencing practice may prevent it enti'w m your own circle, and you may thus have your brother ac titioners as friends not enemies. The evil I ro ^^ ■ .> PT^ . V CU A ^. (w. c ■ /z- 'U 1 ^Um 1 /^ OU /u 1 /r - OU f 1 'k 7U > V - /7v /i / f- Oh A ^ f $1^ ^ v UNTIL ELEVEN A. M. Z. i --> y s J i -/ L. ■T i;4 ^/ y ^ 'She , the and >ed. igs. no /." the u_-vvA i4. a.^<_^^^ o' 7" .y . .^ 'lor, ^1 ■^'U- /^ce '^^^' a of I fy- oh A.,u^/, / / / ^ '^^*-*- /W^ . ^/^ 1 T-" . •est 6 ex- the ^^ lied ^ i) ^ ^ ^ 7 the J/fP, any I • •: M i i 1 " even cont and injui Too year mine thef T] ther< Cou; I be vine does whei sess( the ] profi bvc( ducti has < men befo] men Ontj yet ( medi orde: mucl the pare( men. thee our comi Onta McG Univ ditioi whic In go.y andc your ing; ■/ ->•'> '•^'•"/-'l,; ? -^ , / / / / .1" ??^' /'■"■7^' Shakespeare's Physicians!" ' ^^'^°"' °"^ °^ " He was In what he did profess, well found." C V.I'-'' o^. ? / •»T -»?-» ' es of CANADA MEDICAL & SURGICAL JOURNAL. ORIGINAL COMMUNICATIONS. <:«x. ^/ Scarlatina miliaris. By Wm. Osler. M.D., Prof Institutes of Medicine. McGill College. C. S., ast. 9, had been convalescent for over two weeks rerainir'^H''^''- "T' '"^^' °' ^"^^""P^' ^"^ ^^^ only remaining m hospital on account of two ulcers in the le/ nurse till 4 am. watching a dying child, and as on getting Z^ f ^■''* '^^ complained of a few pains in her back, and looked very pale and unwell the nurse sent her back to be/ She was not sick at the stomach, nor had she any shiverings ' •chant had r" ^''- ''' '^^'^ '°'"^ ^^^^ -"' -^ - change had been noticea in her health. About g a m the mirse observed that she had become of a bright scarle'tc'olor At the visit, at 4.4S p.m., there was intense hyperemia of the skin, the whole surface being of a brilliant red clur •and on touching gave the impression of pungent heat The redness was diffuse and uniform, only here'and the'e, on close examination, a punctiform character was observed temp.Tor."' "" ' '°"^"^ ^''^'^^ coated ; pulse 140; temp. 104. Tongue coated. Eruption remains, being even addeV ThTk,'"'.""! ^'''^'°"^^ ^^^^"- ^^" -'ere t added Thickly scattered over the whole trunk, upper ex- ■with a 111 ^ . ' "'^^^y ^™ '' '^' ^o'-'^h' ^"d filled with a yellowish creamy fluid. Over the nape of the neck and oack they are so closely set that hardly any I ■ i3 i]_ l^_: .• ^ MU : i K ^J \ ^ ^ '^- ': 1 \ ._: ; ! 'I- "" ' • i }M } I ■ ■■ ' i 1 50 CANADA MEDICAL AND SURGICAL JOURNAL, intervening skin can be seen. On the dark brown cicatrices left by the varioles they exist in groups. On the arms they are not so numerous, but on the extensor surfaces, especially about the elbowjoint some of them have coalesced to form large bullae, which are filled with the same yellowish-white matted Only a few of the vesicles are evident on the legs, but on close inspection small clear subcuticular papules are seen, like the vesicles in ?n early stage of development. Legs and feet are somewhat swollen. S.30. P.M.— Pulse 148; temp. 102.4. Tongue very much coated. Bowels opened once freely. Feels heavy and IS not disposed to take much nourishment. Face suffused but general redness not quite so marked. Vesicles on back and chest appear firmer to the touch, and on squeezing a portion of skin their contents do not flow out so readily. They also exist in numbers over the scalp and are very thick on the forehead along a narrow strip just at the roots of the hair. Only a few are present on the face and th«se are larger and more of the nature of bulL-e On the trunls,and thighs they are most numerous, and on pass- ing the finger over the skin in these regions the sensation ot closely set fine papules is experienced. The legs are cedematous, bright red in colour, and— especially about the small ulcers, which have now scabbed over-have a glistening aspect. Fauces and pharynx look quite natural, and are not at all congested. Urine normal in quantity, not very deep in colour. Sp. gr loi ; Examination of the contents of the vesicles show them to be made up entirely of pus corpuscles, mixed with a con- siderable quantity of granular matter. 3;^,/._8 30 A.M. Pulse 128; temp. 99.4. Tongue has iost Its white coating and is now of a dark red colour, some- what swollen and with papilLx prominent. She had a very good night and made a fair breakfast this morning. General redness still evident Vesicles drying and disappearing on tne chest. None have appeared on the legs, which are much less swollen to-day. Back and thighs very rough to the SCARLATINA MILUUIS.-BV DR. OSLER 5, on chest and e'remWe! t, ! """""• ^"* '''"'ing Some of the mffiary ve ict 7^ T""" "'""' ""e back ftomthetrunk eavLthl 1, ™ ,'""''' »" disappeared large ones exist „„w?„, he baT"'^'::''' '" ^"''- ^-eral filled with a purule nT Zd t , °, *° ''""'''*• "Wch are still remain upon the exti? "7'^'™". 'h°ugh larger, and ankles have To t thd ", LT '"'"=' "^ ""= ^™^- F<=e so much swollen A few!,'^,'T'"!'PP=^'-='"" and are not legs. Over the whtk lib th" ° T' ""' "P™ *e eoalesced, and the contents\r„ IThi^?^™;"''"™'^ matter,_a miniature of what Lsnm.r ^ "^ P"™''"' cases of confluent small oov P .'°"'"™« seen in bad back of the neck, aTegLr^h::-;:™'""'."" °^ '" *= abundant, and in drying have left it ha i' "f" T' General symptoms continie good b "'',Pa'"f"l- nrme contains no albumen, Sp. gr ',o, . '""' '"'" ' 4ue m°;.^i:'b-gts,ot':^/*'^r'- •™^- ^^-^ ^ nent. Throat natural. Skin ^tUlir" ""' ^^ P™"'" about the back. Desquamatfr,^ f Iwerrem.c, eSpecially scales beginning oTfte ch™, 0%?^' """^ =>"" """ and about the axilla the cru!' °" ">= ''ack of the neck be readily picked off IT-^alT"'''''"'' ^"^ "" granular, and on close inspectbn .he l""? '"" ™"='^ """ little vesicle can be seen A f I""* '''"""'•'"' "'''^ach sist about the h^KLand 17 "vriT ^"" ^"" P^^" normalin,ua„t,,S,gr.,:f- ralbu^-"-'""-- ' aisa;arin7'a'rdt;rL^^- ^''"=-— • Rash feels quite well. i '^fe't-ssing. Says she 5 th, 9.30. A.M.— Pulse SS • temn 08 - tj , -ales and fine crusts, whic-h are r^pfdlrbetmiS^rtctd 1 li- i!.:. hA;,! m "i ' i 1 i 52 CANADA MEDICAL AND SUROICAL JOURNAL. and falling off. On the limb the scales are smaller, thin- ner and more furfuraceous. 6, p.m. Pulse 84 ; temp. 98.3. 6th,— Pulse 92 ; temp. 98. Desquamation proceeding rapidly, crusts almost all off the back and neck. .Appetite good, 7th.— Pulse and temperature normal. Thin flakes of epidermis are peeling off the arms and legs. On the trunk the scales are smaller but exceedingly abundant. Theba.k is still very rough and covered with small, fine scales. Urine natural. 8th.— Desquamation beginning on the face, and crusts can easily be picked away from the roots of the hair. Appetite good ; asked for meat. 9th.— Feet and legs covered with membranous flakes. Body quite clean. 1 2th— Desquamation nearly completed. Urine abundant pale. Sp. gr. loio. No albumen. Microscopical examina- tion negative. i6th— Had a bath which has removed the rest of the scales. Several small pustules — Acne — have appeared about the face. 20th.— Quite well ; ordered to be discharged. Remarks.— A local eruption of miliary vesicles occurring m Scarlet fever is not uncommon enough to demand notice but such a plentiful crop as was present in this case is rarely met with, even in epidemics characterized by this peculiarity. The pustular nature of the contents of the vesicles, from the first, their curious confluence on the scalp and the existence of pemphigus-like blebs on the limbs' brmgs the case into the category of those described as Scarlatina pustulosa. Not a little confusion would appear to exist as to the forms of Miliaria, and their relations to Sudamia, Hebra Neuman and other German authors describe three forms • mbra, alba, crysalina, of which the two former constitute Sudamia, while the latter is regarded as Miliaria proper. Again miliary vesicles, as described by the above authors. ooAar.ATrNA .nL,AR,s.-„y „.. „,,^, ^^ tular, In E„g ish Ckftl ev » "=v.r became pus- -rbid and .LJ^ ' bT ctererenf ^s T"''^' according to the latter or« i '-'""^"^'^"lent. Sudam a, o-ed b; swea,i„"r;iS':^ s^rir',*' ''™' necessarily produced by sweatlnl k , P"™''^". not a. .he heigh, of a febrik aff^c rVheJ","™^ °''^" correspond to Hebras M 17' ,"'= ""''"y vesicles Sudamia. Kox strikes a^.i, ' "''"'='' ''= '•«'">"^ a^ he cans Miiiariat'flte" S^da^ a"' ^h ""'" "^™ doubt that, given suitable ^ ."'""^ ^^^"^ can be no Of the Skin with"co::r,t rr;r^-tr "'""^"'^ increased supply of nabulnm ""Smented temperature and plasm, which Sftt In f' r™" P""^'" °f P™'°- develop into pus or „ c e ° st "^ th'" ^•^-='*^' -"M '0 Co outside the bod^ in t^' irl^ ^^ ^ ^^J^ -de pende;X:;L';::::;iig a3rh° "r '"='='°''^'' ^"'- the outset. The Tst mot,M° '™ "''=" ''"""'^^ f™" carefully for an;.":!:; af ^^^^ rab'tV,' """"' none could be detected On VhT i ^ "' *= '™"'' clear. sub.cuticularpaTues°des wfSh fr^"^' ""^■" or other did not develop but it ™! ^ v™"'"""''"''^ wa^in this way that :i:;'^!,;:ro:,^ratet"-''"''^'''^ rardy otevSTIiT' '"•"" '" '"'^ ^-=' -^ ™e very .he '^^rori'zzzz':^ f-'"' '"^-"» »' a good light, and not even a tn^.? r " """^ ""^^ '" from first to last, °' ""Sestion was seen An interesting question arises : where are w, »„ l ,. r .he source of infection ' Th- .^.n ! '"'' '" sepa..ted by a considerable SrvaTorhe''^"?" '^ as well as from the house, » w u ^_ **°'"^' "ards scarlatina is rife'l^r atl'!, I'^-./.^^'f" P'-- Porson to withstand dilution to suS'T d. ''"T"'" ren-ams active after passing .hro^ht ^dX'wth ■k ■ ! ;■ 54 CANADA MEDICAf, AND SUKOICAL JODRNAT,. separates the Small-pox hospital from the neighboring- buildings, can we attribute a minor degree of vitality to the small-pox germs which must be wafted out of the ventilat- ■ng shafts in counties; numbers to be distributed in the neighborhood ? Experience has taught us that we cannot. Another, and perhaps more likely, source of infection must not be overlooked. On the nth and 12th ult., I attended lor a ftf;//>^r^ a case of Scarlet fever in the immediate vicinity of the hospital, and on the evening of the 12th I went direct from the house to the hospital. At this period she was almost convalescent. The stage of incubation is so variously placed by different authors, ranging from three days to a month or more, that this may have been an instance of pro- longation of the period of latency. With an impoverished condition of blood the Scarlet fever poison may not have met with sufficient quantity of that " mysterious some- thing," different for each exanthcm, upon which the germs are supposed to live, grow, and at last, happily, exhaust ; and hence a lengthened period of incubation,' with retardation of the eruption. -Removal. — New By. John Bell, Case of Mtiltiloadar Ovarian 1 Tumour. Method of Ligaturing t/J Pedicle A.M., M.p. / / On the 14th of June, I wasNrequestcd b/ Madame M. to see her daughter who was suffering from >Ktumour in the abdomen. ^ saw her the i)4xt day, an, C: ^gnosed the tumour to b^ ovarian and ci'stic in its n hv ^ and recom- mended its removal. ^-^ / The patient, a French Can/kdian, recently! came up with her family fi-om Riviere du I^oup, en bas. she is 21 years of age, single, of medium 1^'eight, of well-deJeloped figure and frame, with pale or rathter sallow skin. jUntil the last few days she had been able td walk about witf comparative comfort, bu*" no"' chp c^o.,^,. i„„„4. _r 4.1- - ^r \ 1 • ■' ^ ■•i-v.iaa |nu3i. ui tuc Lunaiymg aown Her appetite has been habituilly poor, and thire were but niSTOLOOV OP LEUOOOYTir^MIA-BV DH. OSLER. 439 a grain of pepper, that looked like cicatrices, but no corres- ponding mark coukl be found on the mucous surface The greatly enlarged spleen, firm and mottled all over with vvh.tish spots, occupied a large part of the left side of the abdom.nal cav.ty. It was tolerably regular in form, elongated hke an almond, and presented the usual notch in Its an ter.or edge, together with several smaller sinuosities owards Its lower ends. It measured about 13 inches in length. 6 .nches in breadth, i; i..,^.. m circumferen ^ hor.ontallyatthem.ddle of the perip:...-y. and weighed - lbs - oz. The vems and s vlrMic art. ry were propor- onally increased m calibre. Dr. Os„.., l.aa kindly examined the mmute structure of the spleen -. .oil as Lt of the other organs and tissues, and I believe has prepared n paper :bt;:Zr ''''-''" ^"^^°^>'^"^ an/inLtratinL^i;: The liver was considerably enlarged, and its cut surface rrmar^Th"" '"' ^"°°^'' ^"^ °^ ^ ^^^^ -^^ ha" normal. There was no means of weighing it. The kidnev^ —Hfrn^^^-' ^" ''- -^ appLan?e wIttT exception of being flattened out from pressure, the left one m particular being very much expanded. Som; parts of the cortical substance were paler than others Some of the mesenteric glands were a little enlarged Several of the retro-peritoneal glands were also increased m size and slipped readily from their investing tissues m re'Se1h'° ""'^Vlf' ^^^^^^^ appearand and be more friable than usual. The brain was not examined. I, Beaver Hall Terrace, ) Jan. 26th, 1876. } OSLER M.D L.R.C.P., London. Professor of Insti- lutes of Medicine, McGill University. Beginning tl,e description ,vith the blood-the tissue most remarkably altered in this disease-it may be nofced n the firs, place, even with the unaided vision,'a peculiar creaL; i Hi 440 CANADA MEDICAL AND srRGICAL JOURNAL. look in the slides prepared for examination. This is very characteristic, and when seen in blood taken from an adult IS in itself evidence of an excess of colourless elements. In sucklings the same appearance is seen after feeding from excess of fatty matter in the blood. In a specimen sent me for examination some time before the death of the individual the colourless corpuscles numbered at least one- third of those in the slide ; the majority of them in appear- ance resembled the ordinary colourless elements, many, however, were smaller, others a little more granular than usual. One feature, not at all usual in ordinary corpuscles was the presence in most of a single, clear, vesicular nu- cleus. Blood taken from the heart and splenic vein after death presented very much the same characteristics ; the colourless corpuscles from the latter situation varying great- ly m size. The general experience in Leukemia is that the colourless elements of the blood are somewhat larger than m health. No such conclusion can be drawn from this case as was evident by an examination and com- parison of sketches of two sets of healthy and leukemic corpuscles, drawn to scale. Though some of the latter were Jarger than normal, others again were much smaller, and the average size in the two sets was very nearly the same. Apart from the increase in number, the presence of a single vesicular nucleus in most of the corpuscles was their most striking feature, and one not common in either leukemic cr healthy blood. When first examined a nucleus may not be seen in normal corpuscles, but after a time, especially if re- agents-acetic acid— be added, two or three may develop and the same number is spokeu of as occurring in the colourless corpuscles of leuka^mic blood. Peculiar crystalline bodies, which will be referred to here- after, were found in the blood of the specimen first given me, and also in the blood from the splenic vein and heart An unusual teuuency to crystallize, not often met with in human blood, existed, and from tb-- cn«-im-r -—,-■•' during the life c-" the patient the Haemoglobin separated i IvM HISTOLOOY OF I.EOOOCri„^„u_.v DR. O.L.K. «, out in small square .ablets and in l„„g rectangular prisms In a shde of blood from the heart, which was surrounded w,.h 0,1 and la,d aside for a week,.some enormous "able's and prisms crystallized out. "oieis In the heart were several large clots of a peculiar green- .sh.yellow colour, like masses of semi-solidifled pus Tom^ of hese were seated on dark grumous bases, others were uniform throughout, while one was capped with a lavrrof transparent gelatinous fibrin infiltrated'with serum' o„ examination the greenish coagula proved to be colLtion" of leucocytes entangled in the meshes of the coaguS fibrin ; while after hardening, the cut sections presen ed a remarkable similarity to lymphoid or adenoid &si,. con- sisting of a reticulated network, in the interspaces of whTch the cells were enclosed. One or two decolouri^ed clots were met with in the splenic vein. Spi.EEN-Teased portions showed numerous small cor- puscles, very like those met with in the pulp of healZ iri'l T r "'* '"''' '"S" cells,'leucocytes in tolerable abundance. Nu.leated fibre cells existed in g eat numbers, constituting in many specimens the majori?; o the formed elements. Normally these occur abiut the sma ler vesse s and in the connective-tissue framework of the organ but not ,n the proportion found in this case Red blood corpuscles and much fibrous tissue werel^so present. No traces of the Malpighian corpuscles remained Sections taken from different lo.aIi.ies demonstrate tha the hief change in the organ had occurred in fibrous ele ments which were everywhere enormously hypertZLied bemg both relatively and absolutely increased Tht' sections of a healthy organ, (such as'yous under ot of the microscopes,) show little else than a dense a Jre ga ion of small round spleen corpuscles, and t o5y a he thinnes. portions, and with high powers, that th» dell cate fibrous stroma of the pulp can b= d,..;.,ed "l .! . case exactly the reverse holds good. NoVonly the'cMrse bands which, as in the normal organ, dip into the subin e I 4 :%\U^ ^i i 1 i i u ■I f: 442 CANADA MEDICAL AND StJRGIOAL JOUBNAJi,. are hypertrophied, but also the excessively fine adenoid network forming the matrix of the pulp ; so that with a low- power we see a tissue composed apparently of nothing but fibres crossing each other in all directions, and having little, if any, resemblance to the structure of the healthy organ' From the remarkably irregular course of the fibres and their arrangement, a peculiar appearance is given to the sections which will be best understood by an examination of the specimens. Light and dark columns of fibrous tissue are seen crossing each other in every direction, four or five often radiating from one poiiit. corresponding generally to a transversely cut splenic vessel. Thin sections highly mag- nified further show the extent of development of the fibrous tissue, and the relation of the cells to the reticular net- work, explaining, moreover, ! he light and dark areas which give such an extraordinary appearance to the specimens when examined under a low power. Extending from the larger trabeculae coarse and fine fibres proceed which uniting enclose rounded or irregular-shaped areas, and from these others originate forming similar spaces. The nodal point of these fibres is usually somewhat triangular in shape and a small nucleus is not unfrequently seen, so that in' places they are or appear to be formed by the union of the processes of stellate fibre cells. Such an arrangement, I may remind you, constitutes the stroma or fibrous matrix of ail lymphatic structures, and is known as an adenoid tissue Normally it occurs also in the spleeu pulp, enclosing the cells in an exceedingly delicate reticular network very diffi cult to make out. In this case the deucate stroma is greatly hypertrophied, and constitutes with the coarse bands dip- ping m from the capsu' Mie bulk oi the organ. The relation which the cells bear to the stroma is very easily made out the latter simply encloses them in its meshes, and accord- ing to the width of these one.two, or more cells are included In most instances the meshes are so small that only a sin-^ gle corpuscle is. enclosed, which appears, moreover. rlnc.K, embraced by the fibrous net. In other instances two or more corpuscles may be counted in, a single areola Lt nrSTOLOOY of LEUCOCYTH^MIA-BY dr. 081.EB. 443. The dark and light columns referred to above are found to depend on the presence or absence of corpuscles in the meshes ; m the former case they are retained, hencT the darker appearance ; in the latter they are abs;nt, and in consequence these columns look much lighter. A pre Z'tlTlu" r'T'''' '' "^^' ^^^^ •" ^he lymphatic glands' n which the hght areas constitute the lymph pa^hsf while the dark columns, termed the follicular cords are fill d with the ymph cells imbedded in an adenoid ma ix The ly-phatic vessels aft.r penetrating the glands ulti'. mately open into the lymph paths, or clear columns, and the lymph in passing through disengages or washes Lway cofuir " ^h<= -ntiguous follicular cords or dark Substituting in the sple.n the blood-vessels for Ivmph- atics there is a remarkable similarity-nof only in general ceHs a"n'd%h ' " ''' 1^'°" °' '""^ ^^^^ current' o the na V ^mnh^T' r'!"'"''^"'^" ''''' °^^- ^^ -" -bi- nary lymphatic gland ; so much so that Frey, Moller and o hers describe it as a blood-lymph gland. L^ 'g ' their description the " blood from the arterial capillaries s emptied into a system of intermediate passages, whXe directly bounded by the cells and fibres of the ^e'work Tf hdr'oti^^";;'^^' ^r^"^" ^^"^- ^^^^^ their origin. The colourless corpuscles are supposed to develop from the cells of the pulp, and are washed Tut by the constant current of blood passing through the or^an ifthTb VTr' --ber of these elements met wUh m the blood of the splenic vein. Some even believe that these colourless elements may while still within the spleen ' pu P develop into coloured corpuscles, but of such a pro. cess we have no definite knowledge. This being the case It would appear easy to explain the etiology of thts diseaTe hypertrophy of the organ, increase of thefellular elements' more rapid formation of coInMrlp«c,..,,„Hp , ,' »;„_„/-., . , , - •••i"'=cie3, una conauc- T.^n M° ""^ '"■'"'"'"" ''^*'= "'"od current would be steps ,„ the process. Unfortunately, there are insupera- 1 !i U4 CANADA MEDICAL AND SURGICAL JOURNAL. ! • bie difficulties in the way of any such explanation. We know of half-a-dozen hypertrophies of the spleen— more genuine hypertrophies too than are met with in Leukemia in which the normal proportion between the elements is 'maintained, yet wholly unaccompanied by any increase in the cellula. elements of the blood. To say that in the simple hypertrophies there is retention of formed elements while in Leukaemia there is a rapid increase, and as rapid separ- ation of colourless elements, incapable of developing into red blood corpuscles, is simply , to admit our ignorance of the intimate pathology of this obscure affection. Again, there is a disease Anaemia lymphatica, or Hodg- ^ms Disease, characterized by enlargement of the lymph- atic glands of the body, generally without any accompany- ing hypertrophy of the spleen, and without any increased the colourless elements of the blood ; and yet this is equally pernicious and runs a like fatal course. Further there is a variety of Leukemia, excessively rare indeed' marked by hypertrophy of the lymphatic glands all over the body without corresponding enlargement of th- spleen. I mention these affections, so like in some re-^ ,pects, so unlike in others, just to illustrate the difficultie ^^islrderT °^^'^^''^''^'"^ ^ "^'"''^'^^ Pathology of lymphatic ^Passing to the consideration of the liver we meet with ' changes equally remarkable. On section of the organ, and also through the capsule, irregularly scattered areas of a >.h.te or yellowish white appearance were seen, nowhere. ' distinctly isolated, but merging into the surrounded liver : Bubstance. Portions taken from these areas and teased in •sal.ne solution presented a great accumulation of round -colourless corpuscles, ordinary leucocytes, very similar to those met with in the blood, many of them with the same clear vesicular nuclei. They presented considerable variations m size. The proportion of these corpuscles differed according to the locality from which the oeice w.« '^ken ; from the central portions of some of the larger I HISTOLOOr OK LEUCOCYTH^MIA-BY DR. OSLEB. 445 White patches they formed almost the only elements in the min;i ". tn?. ; '"''■ ^^"^ "^'■^ ^^-^"* - abundance mingled w.th the former. Irregular cells filled with yellow granules constituted the sole remains of liver structured some places, while in others the cells were not so mu h degenerated, but a little irregular from pressure. Many possessed double nuclei. Some irregular shaped connec- •ve fssue corpuscles were found in these specimens. In the more natural looking liver areas the cells were found - a healthy condition, not at all fatty, and with very Httle granular matter. In these portions leucocytes we7e also found but in greatly diminished numbers flufd'lnrin^r'' '''" hardening the organ in Muller's to 2^- "I "^ -'•e exceedingly instructive with regard to he d.3,,bution of the leucocytes. Thin section's of hea thy umniected hver. when cut transversely to the central veins of the lobules, show elongated Uds or columnso hepaticcellsconvergingtowardsL openh'gso the central ve.ns.with very little intervening space be ween contiguous columns. Similarly in a section parallel to h" central vein these columns appear cut across and are seen to unite with neighbouring columns. .. a empty spaces br;:: -h' ^'%'"f - ^^^-^^^^ ^^ ^^^ vesXeSg fi trltTon ofT' ''" ^""""'^ "^^'- ^" -^--ve In filtration of leucocytes existed between the columns of or an n ' "' ''' ^^^^"^^ "^ ^^e disease in the organ. In some situations they were few in number and the surrounding liver substance was little effected in atroph.ed cords of hepatic cells. A still further change was seen in many places ; atrophied remnants of liver ceS occurred interspersed in a tissue made up of leucocy surrounded by a finely granular or fibrillar matrix. Ind'e^d ZZL7%T '^--^^^-^^ together, and so scanty the remnants of hver substance, that in <=no^c ,> j-rkp-^ i--. Sarcoma. Of aU organs the liver is the most frequently m i ll: III! 446 CANADA MEDICAL AND SUftOiCAL JOUKNAI,. ' '5-'; afifected by leukemic growth.:, and occasionally is founf^ much more diseased than the spleen. The leucocytes, tilling the spaces between the columns of liver cells a usually regarded as white corpu.scles which have wandered rom the blood-vessels, and certainly the conditions in the liver are most favorable to such a process. Th; Mood in the porta! vems has already traversed one set of c.iDiilaries and must circulate in the intralobular plexus under extP nelv lo.v pressure. We know that the colourless elements .f thi- blood have a great tendency to adhere to the sides of t'l ' vessels,especial]y under diminished blood pressure, and rerv readily migrate uncugi,. They .r. sticky adhesive bodies when in the vessels, an. .dhere to one another and to the walls w.th great pcrtin. . ty. That all the leucocytes in such a liver are to be rega-aed as vagrant white corpuscles may be doubted. It is much more probable that by a proces- of fission they have niultiplied enormously in the leukamic tracts, causing atrophy of the liver substance. Indeed these aggregations of leucocytes may themselves have been foci Z ?.' '.T'', '"'^ development of others, which, passing into the blood current, served to augment the colourless- eieraents. llTDNEYs.-The portions of these organs removed for examination did not show any marked alteration in struc- ture. Here and there groups of leucocytes were seei> between the tubules, but the process was limited, and no extensive growths, as often met with, were found Lymphatic GtANDs—These did not appear much, if at al^ enlarged, and those removed (mesenteric and lumbar) did not give evidence of any hyperplasia of their cell-con- sMwl. «"^which, so far. I have specially examined showed a great increase in the nbrous elements with a corresponding diminution in the cells. Some remarkable crystalline bodies were found in the blood ana liver, forming colourless spindle-shaped prisms of very beautiful and regi i. shape, varyin. much in ." ' I can offer no explanation ,:; cheir nature, not having ^r.d have been fonj iZ^ ZT^nJ':^":!^ T'"- but whether the ones here referred tnh "'" *''^^^=' with either of these I cannot" '" "' """""°" Profe^orofMediea, Julprudence, McGi,, fniClv had nlr^eenToved/o: rJrTf / '^^y'f"-'' child l7ad had several att/eks of vomi f„ ' ,t J "'' ""^ only,,^f stercoraceous cLracteri h I, i 7^ °'^^=''°" suffer Uuch in other res„X.i •"" ^ad no/ seemed to slcin wU „f fspwts, and nursed fair^ „ell Th^ •ended,! and .he'Sl'tit'irtivT, "'"i' *^- *hreelr.ers orn7^fclX'L^±,!r 1 sencelfthcTnkHnil .""'""'• ^'^h 'h^ pre- a bogl stL'SatifenTarr'' "5^'"'"'« '' '°<'°' BeinU no n,eans JfrS: Ma pSTl'f fh was notfebsent. I did Lf ^. . Portion, of the rectum natural Jassag^/brClurd'rr sr?"^"" *= be to op( n the bowel \ the lefr T , ^ ^' P^^" '^^"'d as to thelproprietv o U Ll ^ "' ^"^"'^^ '^^ ^"^stion decided LyThe aLkioU r r^u' '" ^^a^ direction to be thrown orthecase bvfc '^'^"'"' ^ ^^P^^*^^ -ould be ing in thelroin '^p^^^^-'^ ^^^^ f e artificial open- Conseq, lently. on th^ following day L with th. • ble assistance of my friend, Y^r XKiLl 7 /''""' •P-orm ti operation jf .olo^omy; in^'as' n^^.^^ r I l!i[ \'-\ I I i 'iL, 448 CANADA MEDICAL AND SUKOICAL JOURNAL. be, the sigmoid flexure. The child having bfeen chloro- formed, I made an incision an inch and a half in length/ extending in an oblique direction upwards and, outwards from the middle Ijne to a point about half an indh beyond the anterior superior spinous process of the ilium, dividing the skin, and cellular tissue or superficial fasbije till I reached the muscles, which with the transversalis fascia, and peritoneum vyere successively divided on thje director! The distended bowel lay immediately beneathj ready to' hand. The gut', was transfixed by two curv«l parallel needles, half an inch apart, and each threaded wiith double ligatures of carboli^ed catgut, after which it wi opened and the edges attached to those of the wound /in the in- tegument. A large quantity of meconium of/a greyish^ yellow colour was immediately voided. , The substance of the coats of the bowel was found to be very easily lacerated as if softened, from the effects perhaps of previous inflammation from the distension. The operatfon, although tedious, was one which presented no very great difficulties in its performance; Some bleeding from the lower extremity of the wound was arrested without much difijculty. At no time after the operation had the child a single bad symptom but nursed and slept as if nothing had happened. The skin rapidly lost the dirty sallow hue it previously Presented, and at the end of a fortnight the little fellow becat/ie quite plump and healthy-looking. i \ I Repeated explorations of the bowel, first with elastic bougies, and subsequently with a whalebone probe, intro- duced through the opening in the groin, conjoined with the finger in the canal cu/ de sac, lead to the conclusion that the rectum is absent for a portion of its length, as thq probe thus used cannot be made to pass downward for morei than about three quarters of an inch, and cannot be felt by! the finc^er. The most remarkable fact in the case, perhaps tiie only one excepting of course (the success of an operation soj frequently fatal, IS that this child should have lived for a foftnight (as it did) previous to ^he operation, in a condition of compara- CLINICAL NOTES "^tii ON SMALL-POX I- THE INITIAL RASHES. 'vj^ 11. HEMORRHAGIC SMALL-POX. "0. in. A FORM OF ILEMORRHAGIC SMALL-POX. ^ BY WiLhUU OSLER, MD OF T,„. Ix.sTiT.rEs OP Medicink, McG,l. UmVEHSITY, MoXTREAr,. '"^l m f;|, j: .11 i:'in atanc •jals, initia Engli two t coded books make in the «xten( Tho var Mm of cedinir G rej tina-lik •On ' f On! ton] I- THE INITIAL liASIIES '■'0 or three |i„e, 1 ll, t,,!,"?'"'''''''? " "'"'"y '"^'^i '» bo»b o/aiL? Cw r '"••iL"P'*"<'- ™''- (See text "LKLn, vvooLi, Watson, Niemovor Rirlr^u- ^ ivr make no mention whatovor of th.m rUonn-it t' \ ^'""^ "1 the special WO.-K r.n fV , (.i^enni^tt, farnxM-). Even oxtonded '" '^" '•^'J^'^'' ''- '-^i- - ---cely more of ^:;ir ""^^'^ ^^^ ^°^^°^-« -'^ - ^ -.on precursor • On Varioloid DiseaseHTpp^sT^^i^i r On amali.pox, p. 97. t On Eruptive Fevers, p. 49, 'I I f pi «"fW ^ THE INITIAL RASHES OF SMALL-POX. Marson* states, that in varioloid the eruption " is very often preceded by roseola, which lasts two or three days — the r. exanthematica." Foreign Physicians appear to have paid more attention to them, and very good accounts are to be found in some of the recently translated works f Many of the older authors believed them to he independent affections, and, according as the eru[)tlon was diffuse or mottled, spoke of scarlatina or measles occurring simultaneously with small-pox. Sydenham was evidently acquainted with them, and refers to the difficulty they may cause in the diagnosis. " The afore- said small-pox," speaking of the discrete form, " breaks out some- times after the fashion of erysipelas, sometimes like measles. From these they are difficult to be distinguished even by the practised physician, provided that he goes by the external appearance only."f In some of the cases collected by Murchisdng of the sup- posed coincidence of two fevers at the same time, the mistake has been made of confounding the initial rashes with indepen- dent diseases.— (Illustrations, 3, 4, 5, G, 7, 8, 9, 10.) Our definite information on the subject dates from the publica- tion by Dr. Theodor Simon of Hamburg (whose premature death last year was a severe loss to the profession in Germany), of a series of articles in the Archives f. Pormatologio und Syphilis^ Bds II, III, & IV, on the "Prodromal Exanthems of Small-i ox." Other papers on the subject appeared in the same journal from the pens of Drs. Knecht and Scheby-Buch, and less important observations have been published in several of the German period- icals within the past four years. The probable reason why such scanty reference to them is found in the records of the older epidemics is that they appear ♦ Ilcynolds' Syf-tcm.— Article Small-pox. t TionsReau.— Clinical Medicine (Syd.nham Society) Vol. 2. Hebra. Skin Disenses, (Sydenham Society) vol. 1. Ziemssen'8 Encyclopedia, Cnrwlimann. Art Small pox. X Works of Sydenham (Sydenham Society) Vol. 1, page 127. S Med. Chiriirgical Review, 1859. \3 N. r. ^^' M 1 jf 4^ J- ■5 vi' • * * .0 r ^ 1« o G- ■'-I ^ +-■> G •H c ^ c +■> c r c c- ^ *«J ' V-" c r.,.. o ■»^ ■j' fc_ 1 r g c *^ , • ^~" o -' ^ S c^ -r^ f, r~< ~^ i^ c- J^' ■s--' c r ' .— ■>> ^0 .»-^ "■ c; "■ f 1-, ■ K-' >. •* +3 ^, o r ■■ r -^— J C c T,' "- +-■> e •H CO' •rt T' M t-y. <^' *• r +3 • r— ' c: ^! r; K ._. •r-l ^ (■^ c- 'X t-' +■■> M ^ ^ (/; c W " r <^ *-1 r-t ■H f^ « 9 u r S-. •— 1 -:-l f*.. ■p -■% c ~r ■ t-i f^ ,1 > c r 4-^ c4 > a:' o t— C £ 00 v^ \ c V J ?=^^ •^ ^ i 1 ! i I i - ! : ^3 I -i V f. ^ V V ,^ \ — J ^ ^< ^ . ) f ~^^^ V i \: i r ' \ .J* s^ 1 I V x: J v5 .4 < f i V f i r i I f V •v J < i ^t. ' i ,^ 4 - > J V i i V 'i ' •^ J v* J , ** v„ 4 - i v^ VI J ^ „ ^ ^ ^J Si ^^, -J -' r"' ^^- — s V-'i A, with g ing, af] Two scarliiti may be of the < coverin and sho good es est frecj the basi! superior I'^oupart Another (the cru I'c'gion, ii of the rilj imd in tl The simp petecliia?, areas. V is cornraor accordinnf the extens bnrhood o feet, on th ankle aion, My expc the Hmited were unacc reported by sence or a on the othei hifimorrhairi eryt!u>;;iatoi of the natijt r '"' .5 J 'si i - '- THE INITIAL HASHES OP SMALL-POX. 3 ing, affoiding uimierous instances, others very few. Two forms of those rashes are to be distinguished, the diffuse «cariatnufora, and the inacuh. or ineasl, eithe of h"h I ay be accompan.ed by petechi.e, and occupy a variable extent ot the cutaneous surface. In som- instin J/m ^"^'" '^'^'^'-"* ,1 . , 3uiu^ iiibcances tliev are •'ctumtiI covernig the who e bodv as n ml^ i.. ., ^^"(^lai, 1 , •' ' '^ '^'c? Iiowever. thev ,in> liim'i-nfl and show a cdded prelerence for certain loo. it^ Til' good especally for the purpuric rashes, which occu ^ J t e re,uence nj the abdominal region, occupying a tri^nl base of which is formed by a li..e drawn from ^no anterb .penor spinous process of the ilium to the other, the sides by 1 oupart's hgaments, the ape.x corresponding to the , bif Another favorite situation is the inner surfl^c^s of the tZr (the crural tnangle of Simon). A third is the later thdie egion, in a strip extending towards the navel, along tl, of he nbs. I he above are the usual sites for the pun, uric ra he ftiid in the ma prity of caso^ th^.r n. . • l""!'"'^'^ >ashes, Mu • , J J' "I cases they occur m one or a of them He sunplc erythematous and macular rashes, unaccompani bv potechi. are often much more extensive, spreadirr^ter areas. When limited, in which case the presence^ o nurrl My experience has been that thev ire pJ.;«fl„ • • were ,maccom,,a„ie,l by petecl.iu,. I„ very m-,,,, If ,l, .^ ' repo.teJ ,„ «:,„„„ „,., K„ee,, ,.„ ...iii^e „ l^r sonce or absence of cutaneous extravasation, s.l k i*^?' wrt-t:i;:i"-r-™^^^^^^^ «...h.....4, ?7''',V-' "."^^'-o^^ petechiic occur uoon nn «.^«.e:tu^Xt^u;i^:is-:f----a III i -'a 1 (■'' B j ■ ( 4 TUB INITIAI, RASHES OF SMALL-POX. Case I.— D. R, set. 14. Admitted November 28th. Vac- cinated, one good mark. Revacciuatod 8 days before admission, three points, which had taken, wore just passing into the pustu- lar stage. A diffuse cryticniatons rash of a dark-red hue existed over the abdominal region, extending upwards in the lateral thoracic areas, and downwards upon the thiglis. Face much suffused, extremities unaffected. On pressing with the finger upon the skin of the abdomen, numerous petechise were evident, most abundant in the groins, and inner surfaces of the thighs. Temp. 101^. Slight delirium. A papular eruption over face and arms. 29;^m[^p:>:^^r. ««. 0^ inner s,.ra.. on,::;' ^'ivLr'Too" "'^ r "■°™'; bourse of Dl.p„^„ p,„, ° living a°; !Cy, P ;'"''";?"■ , Eocl,j,„„.,, aj„,, „,,„,„^„ No complicatio,,.. ■ ''«"^™"»n rariy. Ra,,iJ ,ocoverj. "nJe'rcticiftr "■":,"""' '■^-■^'= °f «>« »"*io.. »it..atio„3, vi. t \J?,r™ ,°'"-°°""'''"' '''° '"-' -""I "o'inns, to,el e vi; t """""l" ""■' '»"'"' '''""« »porficialol„,m r,'7'' ""'■'""' "f "'" """I"- O" "ocoming so, 1, " " , ^7"°' "■'"■° ""' "' """ "■'"■"". had faded. ' "'" "^"""""'g <'»y. "ho" «.<■ orj.tl,c„,a e»3epcar.-d, whereas, if purpuric in character traces of them will remain for days. In some instances, a fading erythema was noticed on admission ; in others, no history of any could be obtained, though the petechial wore ]'re-:ont. The fnllnv.iiv cases illustrate this : THK INITIAL UAsr.ES OF SMALVPOX. 7 Cask V \r n ,„(. i^- -.r visible on the face inrl nh. !> " ''^ ''' ^'''' P'^^Pu'es sides, groin, ande. 't! T'"^" ^^^^^'"^^ «" ^^''^^^^ ^n the hypogastric rcion X'^^^^'^ ^^'* ^ .^ 'f '.'«' «^^Pocially Course of Disease Favorihio P .• cation early; recovery rajl ^^ '" ^'''''''° ' ^'''''■- Case VI T. C nt on v ■ ^ , .nu.cles. None „,,„„ =,,3 ';,;,, t' -- '^ -■-•. ™«..i srj-tl.Braatoiis rasli nor no„l,l ;; . ., ■'?■ '™'' "' "" »f the paUon. .LaJor w'tt^j'""'"™''"™ "-'»'™«"'^ Admitted Pooembo,-' -iT , "■7^ "«""«>te'l, one good mark, vesicular .a e":'"^™- a^.^f ^'t'; ^^T '1 '". ''" tnitial »^n,pt„,„. „,i|,|. Nun,.™,, ,1,, '" "".°° "'" "'*■ groins, an-ange,! chiofl, ZZ\Tf ' "'T""° '^'' '" "'» extending interna,,, o.^r' ' . e n^:!' fT'""' ""' aoug,,,o,no,,hat larger, existed In ,™, , li. th '",'"' ''■;"' extond.ng towards the nave-,. Accord 1 t'tl "' fte patient, on the second and tl.^d 1^ f , , I ,el r"'" °' » rasi, on the ,„wer abdominal re^-ion ''• ""■'''° """ Casr VIIL— R. W Tf 'XI A- • mark. Admitted Jan 10th TnU;„} . " 7""-''' ^^^ =i<^i.ierent ^™p«o«onraee,,,ntto:tir::Lrrdru^^^^ i. 8 TUR INITIAL RASHES (IF SMALL-I'OX. sent over the wliole tniiik, and, in a limited de;^roe, over both elbows. Accompanying this were abumlant petcchiic, espe- cially numerous in the groins, tlie lumbar rc.n;i()M behind, and the posterior snvt'nc-s of the tlie thighs. Jan. Uth. Erythema had disappeared entirely. On tlio buttocks, back, and extensor surfaces of the arms and thig!is, the pustules wore collected int'j small grou] s. CoursL' of 2)/.svv?.sv'.— Pustules did not maturate fully ; des- iccation early. Ifecovery rapid. This was the only instance in which the initial rash was present on the extensor surfaces of thii joints. Occasionally the initial rash is lato in appearing, and may follow rather than jirecedc or accompany the eruption. Case IX.— II. A., iict. 28. Vaccinated, five good marks. Admitted April Snl, with a disseminated papular eruption. Initial symptoms had been tolerably severe. Afiril Wi. At morning visit an erythematous rash, accom- panied by numerous petechiic existed over the lower abdominal regions, and groins. Erythema not intense, petechiix; small, and closely set together. April 5^//.— Rash had disappeared. Course of Disease. Pustules developed well. General symptoms good. Purpura had faded by the seventh day, leaving light brown discolourations to mark the places where they had existed.. The initial rashes in the foregoing cases, with one exception, (case IV), occurred in the discrete form of variola, and though recovery, as a rule, was rapid, none of the cases could properly (unless, perhaps, case VII), be classed as varioloid. One of the last patients admitted into the Hospital afforded an instance of an initial purpuric rash in the mildest possible form., of small-pox. Case X. W. A , xt. 17. Vaccinated, two good marks.. Admitted June 2nd. Eruption scattered, pustules few in num ber, not more than 30. On admission an abundant r urpuric «ruption, acco.npanied by a sliglit degree of erythema, existed ■i THE INITIAL KASIIES OF SMALL-POX. 9 over the lateral thoracic romon. fho nM Burfaces of the thir^hs Pnf , «Mo:.non, and inner ■" tl'O Kn,i„s „orc of hr-c ,:,<,"" ^'^ P"r,,„r,c ,|,„t3 P»uparfs li...„„o„., „ , :, ' f """'' "'"■■"^ r'»'»llol to I o''""^"w, at a ( istancc fi-nm 1" i" i V •solatcd ones extended over thorn to t ! . '' "^^ "^ ^'^ tlH.hs,whiIeothers existed on 1 L 1 ^7 """" "' '" Ctf Mrs^ of n- rr '^^ ' '' ""^ ^''" '""«'' surfaces. ^,7' '-^ ^^sea-^e.-Up on the 5th day. Admitted April 7(1, ll;, T ^"'^<^"»tod, one bad mark, examination „„;,/;• '7'"f°'™ ''■■"' '-" -lemto. 0„ tics ,vl,icl, nresentld h^ '7 "''°" "'" '■""'' »'"! '^■■"■■<=™i- linearly, i„ otC fol; '"h'^V""' "'"° ^'"™ "»"«'"' SroupBd togotlior boin,, m„', k j '"'"'' "'":>' "•'^'■° "'"ofly ;*iie on tb^ o,j::rof .:;':::::::::::" ""'"■":^"'*"'' 'weal wheals of tbo alTectL I„ bT TJ"";'' '"'™'""' ankle, and back of .,,„ f,e ™, were o la"f '■''"°;' f "^ bettor than anywhere el,e ,/ , ° '™' "'"' *°»'''l eruption. The ClLl "'"'"■"eristio feature, of Iho i'^Kh.^, and :br:e:\::iirbtd"'- rT"'" " -^•^' -" "ocurred. A few nanale^ J , ™'™"^ '^ ^'"^ »'"<"-eak and abont th„ wit? ""* "" "o"""' »" 'he iaee, .rul"' '"'-^^'-™ Persist,, though not ,o marked on the of ^nlt""a S"„X' '™' *t'"'"^' »"^ «-»'" P-' -™iu« visit no tr'aee rurL:™!::'?" T"°^ ^""^ ia number, not more than 60 ° "'""''■ ''"='"' f" ..e^:" t,f "" "" '"^ ^«"" -J «-i„ed in the hospital ^W„presse_3„™,^^^^^^^^ n I tl 10 TliE INITIAL BASHES OF SMALL-POX. i I occurrence of genuine urticaria as .a prodromal exanthom in small-pox, believing that most of the cases described as such should he refeired to tho macular or measly rashes. I think there can l)e no doubt about this case, tl^o wheals were too characteristic to allaw of mistake. A genuine case is also reported by Starck, (Arch, djr Ileilkunde, Vol. iv.) in which tho urticaria a[)peared and disappeared in different parts of the body in the course of the disease. Simon calls attention to tlie fact that the simple macular and diffuse rashes are not unfre(iuently accompanied by sensations of heat and itching, which in the case of the former might cause them to he confounded with urticaria. Tho freijuency with which the prodromal exanthcms occur is ai)parer>tly subject to considerable variations, de{)ending, perhaps, on tho type of epidemic, which has exhibited marked changes within the present ■" iM';:-y. The epidemic wliich has raged in so many parts of rln i'....i-iu since 1870 has been of an unexampled severity, o\vin,u. isi ;i% v'aj part, to the large proportion of hiiemorr- haglc cases, and haa 'ju'an further marked by the very general prevalence of the prjdrom;d exanthcms. That no reference is made to them by ,so many of the old authors, and that such scanty notice is found in the more modern works, can oidy be cxplaiiicd on the supposition of their infrequence in former epidemics. In 108S cases of small-pox observed by Knecht, (Arch. f. Derm. u. Syph. iv), prodromal exanthcms occurred in 104 or ' about 10 per cent. In 141-> cases of Scheby-Buch there were 237 instances of these rashes, or ICy} per cent. In 81 cases under my care there were 11 instances,/. <;,, about l-> per cent. Sinu)n does not give the percentage in his cases, but from tho number recorded in his series of articles on the subject it must have been large. The localities most commonly aftected are the anterior abdom- inal surface, and the inner surflxces of the tliig'is. Ttius, in Schcby-I5ucirs 237 cases these regions were affected in 190 instances. In the few instances which have come under my notice, the lateral thoracic areas were more fre<|ucntly the seat I T"K IN.Tr.M, riASlIES OK SMALL-fOX. H enj.tl,c,„at„„„i,c" ° J ! f °Vr ' """"■ '''''° ««"«™l wore o„lj- U i, ,1 N ,; '" f '^-'''"'''» -""»'™ ""■■'« latter g,J ' "r T " ""'' '"" '^ °°'"° ""''<"• "-^ "»'!™ rt'o inirial rasho, « „ ° ' ■ °"°'""' "'"' l^™"™'"" 'alne of tl,o as .0 it, p,-*:,,!:: I!: """"• °'""^"' -^ '■"'-■'"o- -> opi..io„ oases ,vcre of anv ,1' f *'""'' ""'"-' "^ "'" "''»"' Wal,.oa.l/be ■:, r ,:'" '" '"■■f-o -«•'«"--; .:.at ««'i»rily of cafes if i »PI"'^>«"'<"= of (,1,0 o,-„p.i„„ l„ t,,„ ",o,-o o»,. „ . it • ™»-!>",<';">7 1'" of ,liag.,„,tio im|K.,-,a„oe, -„• sU::"!;; i.r :;':;;;:;' zjif :'"'",■ "■"?'•• *^"-^""' oxaMl,e,u situated i„ 11, .„.;„...", I*' ''.• ."'o J'»'"»,-,-l,a^-,e rash O' much <^i'jatt'f d " tlu tnaii;; of t'l-^ Hn.rl. mm i. i • erj-thematous, and • Loc. Cit. a lagnostic value than tl case of fever presontint petechial lio simple an eruption of K'Wl ''^'^' ^'mori supposes bv hvnor'p- m,a of 1,= eord, which alfects injuriously iZ vas „|L Ive" pas n, do„„ from the ntodulla. - If," i„ ,,i, „„„ „,„,,,„_ ;:^; lollmvs, wh.le ,f nn.led to certain groups we notice eireu.nserihod J hemas : and, as the chief site of th,- :,H'ectio„ (hyper JiaV) of the spmal cord ,s in the lowor dorsal and lumhar re.-L.s we p:r:':;tz:;5."'""''''''""^''-"">""«"«''°*»'°- II. IlyEMOimilAGIC SMALL-POX. _ True h.«morrhagic small-pox occurs under two conditions ^ •n one the characteristic symptoms come on earlv, either with or followmg close upon the pro.lromata ; there [.re exten cutaneous extravasations, -with hemorrhages from the muc surfaces and death ensues with a terrible certainty in frortwo to 8.x days. This is the purpura variolosa of auti 1 tL pe ech.al, malignant, or black small-pox. In the ot e 'e progresses as one of variola vera, and it is not until the ves T ^r or pustular stage that hemorrhage takes place into the poX and m some eases from the mucous membranes. This whicht' almost as invariably fatal as the former, has been cfltd ^y some H-ftfl 'i B IG HiEMOimilAOIO 8MALL-P0X. writers, variola hccmorrh'i gica pmtulosa, indicating that the hicmonh igcs occur at a hiter period of the disease. The epidemic which has raged in this city for the past five years has been remarkable for the prevalence of this variety of the disease ; and the present paper is based on 27 cases, 14 of which came under ray own observation, chiefly at the General Hospital, wiiilo the remaining 13 were under the care of my pred.'cessjr. Dr. Simpson, to wliose kindness I am indebted for permission to utilize them. The clinical history of the disease is well exemplified in the reports of the following cases. I. — A. T., aged GJ, unvaccinated. Admitted at 2 p.m., July 14th. Had been ill since the afternoon of Monday, the 10th with fever, severe pains in the back and head and vomiting. Patient seen at 8.40 pm. Tulse 144, tolerably firm; tem- perature iOf)^ ; icspiiations 2G, the rjthm broken by an occasional (loop inspiration, or a series of shorter ones. Pupils dilated, ^llgilt delirium. Tongue thickly coated, white, edges red. General cutaneous surface of a dusky red colour, especially marked in the face, and by careful inspection an exceedingly fine papular eruption was discovered, most evident on the face, less so in other parts. Scattered over the whole skin wore numerous ecchjmoscs, from 1 to 3 lines in diameter, and of a dark red colour. They were most abundant about the neck, in the submaxillary regions, scattered on the extremities. A thickly set group existed over the left biceps. Ordered quinine gra. x, at [\oO. Yory restless all night, raving and shouting ; tem- perature at 3 a.m., 104 1, and at this time he had a second ten grains of quinine, shortly after the administration of which he vomited a little blood. l')th.—9.V) a.m — Pube 140. not so full ; temperature 104*^ ; respirations 18, and still irregular. Is sensible, but will not take nourishment. Ordered a cold pack. At 12 a.m., temperature 103«. 5.30 p.m., pulse 144: tempet'aturc 104.2« ; respirations 32. On the back are many elevated wheals, and on the summit of these sra : groups of vep^oles exist. The fine punctiforra ext j avasations almost universal on the skin of the trunk. Lips iri^MORlUIAOIO SMALLPOX. J7 gr X, at J p.m. To have morphia if sleepless. draughts of morph.a (} gr. each). l'ul.,c HO, «ak but regular; temperature lO.i.2" ; respiratious 18, morl" Great rest essucss and jaetitation. The seattc ed papulefarc umforml^ hemorrhagic, and the wheals on the hack and ide »h,cl, 3,e,ter,laj. wore only hjpera=mie, are now purpuric, li vasatmn and the free portions are of a duskv-red colour ben h th co,gunc.,va. The urine passed through the night fhto, 'J °' '"""^- "»' 1'^''°'' " considorahle amount of b 00,1 per rectum, and also a small ,,uantity of bloody urine ab^Zt ' ''"•'"■• ?^"-»™-«»- appeaf deeper a,Krre' • According to the nurse he became easier after 3 pm. passed more blood from the bowels aud bladder, and died a'sSoTl 1 avmg been iu hospital a little over two d.,ys. Du rata o^ illness about six days. i^urjuon ol question"'!;!! r ''" '■'''™" " '"" ""'=""P'° "f "'" *=«« in h, f™m H.re 7^' 7'" '" " """■"' "-'■"'""" fo™' killing One of the worst eases which came muler my notice was of us descrtpfon, and, as I saw it very freque!,lly fr„rtl 1 logmnmg to the close, I will give a short account of it. I ound lit if: ?t f ' " ''™'' ''"■■'«'i".3">-g Englishman. lull ar "d I" e f , "'! """"'""'"'^ "f '"'"»=« P»i" i» «■« '-' luiuhar and pr.ocord.al regions, and incessant vomiting. He r :: !.c':^,''°:t« "'° "■""'' "- >'-i--'i«i.'°f->i"g ..„ 1, , , ' "' """ <"' "»aking this mornin" he feh -nwell, had a headache and nausea, anl was unable To attetd r- 18 TliEMORRUAOlC SMALL-POX. 4^ r- tt> %: to hla business. He believed it to be biliousness, to attacks of which ho was, at time^', subject. On the left arm were two scars of an old vaccination. 2i>th, 9 a.m. — Found him in the same condition, havinf^ passed a very bad nijiht. The vomiting and fains continue. Temperature 101*^; pulse IIC, full and strong; iaco llui-hed, skin of chest erytliematous. The prascordial pain was specially grievous, and I gave him an injection of J a gr, of morphia in this region. 12 a.m. — Is a little easier, but the retching continues. 4. 15, pm. — Skin of the trunk very hyperaemic, and a few isolated ecchymoses were noticed along the lower margins of the chest. 9. p.m. — Scattered spots of purpura exist also in the groins. Condition much the same, retching not quite so frequent. Pulse 112; temperature 102.^"-'. 2Gth. — Passed a restless, uneasy, night. Skin of trunk much congested, that of extremities less so. Ecchymoses have extended, and are more numerous. In consultation with Dr. Howard in the afternoon, my suspicions were confirmed, and the diagnosis of small-pox made. On careful inspection a few small papides were discovered upon the wrists and forehead, near tlie roots of the hair. Still complains of the dull, aching pain in the back, and the vomiting continues every 15 or 20 minutes. In the evening he was removed to the small-pox wards of the General Hospital, and placed under the care of Dr. Simpson. Shortly after arriving there he vomited a little- blood. 9. p.m. — The skin of "the trunk is now almost univer- sally purpuric, and the extravasations are extending on the -f.iCl-^' extremities. Pulse 12-l,^soft and compressible ; respirations 20, interrupted, every fifth or sixth inspiration deeper than the others. Complains a little of his throat ; soreness duo probably to the constant retching. Still complains of the dorsal pains. A hypodermic injection of morphia was given m the lumbar region. 21th. — Passed a rostless niirht. ILBm.aturia and melaina towards morning. Ilsematemesis at intervals. Considerable n^MORRnAOIC SMALL-POX. 19 needle. General symptoms a little improved. The lumbar pa.ns mueh reheved. Cutaneous h^monhages are oxt nln' on the extre„m,e,s. Pulse 140, and small ;%espiatior 34 temnerataro 100 oj ti i 'i-^'i-iuauuna c* , mJ, a, 1 • "^°'"»'-'*'»S™ f'<«» 'ho bowel,, sto Diach. a,>,I m-unry passycs contiiiucj lliiou.-h the div anrt a sj„„,„„„,s bcca„,e agg-avatcd. « „ „,._°ru „ ]4o' a"d?:'™"'""\', '■?"'"'"=' "'"' -' "-"■ '»* ..;r:hrr^::.ir;;:e:^;ri-^ .0 exti..as .fons did not eomo on in tho initial stal ru^^ur .n^ . d.ve!o,m3ut of U.e pocks.- V. ^....M«^/^;Z;^ ^ e following .. a bnei" hi..tory of one of these case^ : " ' A :r; r ^^""^ ^^' ^^ "'""-^"''t scotch girl, unvaccinated Admitted January 81s)- 187^ e .i '» unvaccmated. Huiy dist, 1870, from the general wards, where % I J If! i!;:' 5' , I 20 HiTIMORnilAaiO SMALL-POX. Ill ^ she had been under treatment during two weeks for some ill- defined affection. Only six weeks previous to this she had been discharged from the Hospital convalescent from typhoid fever. In the general wards she had suffered with the usual initial symptoms of the disease. On admission, temperature 103.3** ; pulso 116 ; respirations 22. A deep erythematous rash exists over the whole body, most intense on the abdomen and thorax, unaccompanied by ecchymoscs. A papular eruption is present on the face, thorax, and arms, and is just appearing on the legs. Patient dull, heavy, and does not respond to questions. Feb. \»t. — 9 a.m.— Temperature 102'^ ; pulse 110 ; respira- tions 26. Has passed a restless night ; delirious at times, vomiting continues at intervals. Erythema persists. 6. p.m. Pulse 112 ; respirations 32 ; temperature 103.4". Towards the afternoon the nurse states that a small amount of blood was vomited, and she also passed a little from the bladder and bowels. The eruption has extended, many of the papules have now vesi- cular tops. The erythema is not nearly so bright. 2«c;., 9 a.m. — Temperature 102.3"; pulse 100 ; respir- ations 26. The hnematemcsis has continued at intervals through the night. Slight hiicmaturia. The bright erythematous rash has gone, the skin is now of a dusky livid hue. 6. p.m. Tem- perature 10;).4'' ; pulse 60, and intermittent every fourth beat, but is tolerably full ; respirati(ms 28. Cutaneous extravasations noticed for the first time, chiefly about the vi^siclcs on the upper part of the chest, and on the logs. In many the haemorihago has occurred into the vesicles. The hijemnrrhagos from the mucous membranes have continued at intervals. Zrd, 8.30 a.m.— Temperature, 101"; pulse, 112; respira- tions, 24. Most of the vesicles on the legs are now hajmorr- hagic, and the ecchymoses have extended in the abdominal region. The vomiting is still a very troublesome symptom. 5.30 p.m. — Pulse, 120, not irregular ; temperature, 102" ; respirations, 24. On the face and arms the pocks are develop- ing slowly, and only a few in these parts are haemorrhagic ; melaena, hfiematuria and metrorrhagia (slight). Takes nourish- ment well. H^MORHnAGlC SMALL-POX. 21 ith 9. a.m.--PuIse, 120 ; temperature. 101.2" ; respirations, 28, says she feels better; vornitin. l.as stopped. Blood in the ur.ne passed through the night. Pocks are no devel pt 1 k dark, atKl the majority of them are hemorrhagic. " 6. p.m.-PuIse. 124 ; temperature, 102"; respirations, 3G The peouhar vanolons odour very evident this evening. 18 sfent'n ■"?''' ">' ' *^'"^"^''"^"-' l^O" ; respirations, top, and of a dark colour; skin between them livid and -vered .uhmmute extravasations. 6 p.m. Pulse, 112 v^^ weak and ,n ermits every tenth beat; temperature lOP" i^ very dull and heavy, and does not care to take nouris Lent ' N mueh change noticed in the eruption, the mniority 'rrocl s ooU,ke elevated hemorrhagic papules, no uLbi.fcatior; ifa^ from tt ' '^'" '''"'"S she lost a good deal of blood from the vag.na. got much worse towards mmmv^ and died .t 7 a.m„ on the 9th day of the disease. "' '* The details of the above cases furnish a tolerably accurate picture of the clinical features of this truly terrible iiasH?^ sha now proceed to make some general remark TpoV^ Wtoms, diagnosis, etiology, and pathology. ^ ^^^«^^.;.._gatisfactory evidence is wanting as to the period ZulL V ''"' "' " '^"' ''^''^ ^■^™' ^" -' 12 to 14 daj Zulzer, however, states that it is shorter, havinc, determined -9 eases to be from 6 to 8 days. In th; majoHty of ^^^^^^^^^^^^^^^ U IB unaccompanied by any symptoms-perhips Jight 1^ lu "nee" iriT ^ '• "t," '"^'^"° ^"^ ^"^^^^^ ^ ^» ^■ Fn l-\ r';" *'^' '''' "^'^^ ^^P^^ted of the young The symptoms of the initial stage are those of the nustuL form ; incleed, the disease may be regarded as an n tensified and prolonged in.tia stage, combined .ith a remarkable fndeny to cutaneous and mucous hsemorrha^e^, ^«"uency -;2ll^!!!!lP!!!i^^ triple com- • lifiliner klinische WochenBchrift, 1872. "^ ' ~ 22 Hifi.voRnnAGic small-pox. ' I bination, which we look upon as almost pathognomonic of small- pox—are the prominent 8^-mptonis throughout, even after aio characteristic extravasations appear. The fever is iisually moderate, varying from 101" to 103" ; only once did I ohsorve a temperature of lOo". It is frecpiontly ushered in with a rigor, or scries of chills. 'J'hc jiiiin in tlie back is perhaps the most distressing symptom to the patient, and persists longer, and is more constant, in this than in the pustul- ar form of the disease, continuing in some instances to within 12 hours of death. All of niy patients com] lained of it, and when asked to localize it placed the hand over the sacrum. Praccordial pain was also common, in one or two cases much more severe than tho dorsal. Headache is rarely absent during the first days of the fever. Vomiting constitutes a very troublesome symptom, and, in my experience, proves exceedingly obstinate, much more so than in ordinary small-pox. It was very unusual for patients with the latter disease to vomit after the apfiearance of the eruption, while, in cases of the hnsmorrhagic form, it continued for 3, 4, and 5 days. Dry retching was frequently combined with it, and seemed particularly distressing. Early on the second day, or even in the most severe cases on the evening of the first, a bright scarlatiniform redness spreads over the skin of the trunk, sometimes extending to the extremi- ties, but not often involving the face. In some instances this is not universal, but confined to the lower abdomnial or lateral thoracic regions. It is difficult, or even impossible, to dis- tinguish this general or localized erythema preceding hemorr- hagic small-pox from the similar condition which, as an initial rash, so frequently ushers in the ordinary or modified forms of the disease. For a time simply hyperoemic and disappearing on pres- sure, the character of the rash quickly alters by the occurrence of numerous extravasations, which begin commonly in the groins and lateral thoracic areas. At first punctiform or macular, and concealed by tho general redness, they soon increase in size, and on tbe trunk form irregular patches, ranging in size from a six-pence to a penny, while on the extremities and face they remain discrete. In 3(3 hours the ecchymoses may have devel- 'MvMuKRiuoio SMALI.-POX. 23 wacK siuall-|,ox to ll„.< varioly ol' (lie ilisoasc even to f.ol fi ?' ^ '"^-^ '^^ ^'''i^'^'f "^ impossible variety . Z,^ "^ "^c "i^.elf of their presence. la the other Zv ti. ;t ■ ;''^"^'"^'"'"^' *''^ -"l'^-" ^--^ out as usual, the extravasations occurrin'^ eitl.or in f).„ , • i tular sta-e '^ '° vesicular or pus- symptoms "stuutcs one of the most, prominent ™ da*, „„a „i.ed^„u„ .„:"^:r ';,:;,r "■ "»'™™' " ting in the chamber-pot. ^ ' ^'''°'^ '°^°"^^ i^/<^<;-m-/iagia instated to be cx-ccedincrlvr.r.m,v, • " r -"^ "»'i-j i» o„e o„. of i:t':ir °° ■" ™"- Mood ,jl t:. :s,:„ - j:'-"^ --" wuk 24 lI.EMOUUMAOIC SMALL-POX. These hpcmorrhages from the mucous membranes do not always occur. In five of my own cases (Nos. 1(5, 18, 20, 22, 28,) they were absent, and yet tlicse were among the most severe and raj)i(lly fatal cases ot the disease, death ensuing on the 5th, 5th, 6th, 7th and 4th days respectively. In two, (Nos. 22, 2';i) pout ynortem examination revealed extensive haemorrhages into the mucous membrane of the stomach, intes- tines, and urinary tract. The puhe in the first days of the disease ranges from 110 to 120 boats in the minute, and is full and compressible. Gradually the arterial tensioa is increased, the pulse becomes more rapid, 120 to 140, small, hard, and irregular, and at last uncountable or imperceptible. The rcapirations are unusually increased in frequence in the early stage, witliout any discoverable disorder in the lungs, and are out of proportion to the intensity of the fever. Li the case of a negro whose respirations the morning after admission were 32, and the temperature 101", after examining the lungs and finding nothing to account for the acceleration, my suspicions were aroused, anc on careful inspection I was able, even on the dark skin, to detoot the lucmorrhagic condition in and about the papules. This symptom alone directed my attention to his dan- gerous condition, wliich might otherwise have escaped observa- tion, as there were no haemorrhages from the mucous membranes. An interesting, and by no means urifrequent phenomenon,was the disturbance in the respiratory rhythm, first drawn attention to by Drs. Cheyne and Stokes, consisting in a series of superficial respirations, sometimes almost imperceptible, followed by a deep inspiration. This was noticed chiefly during the last 24 or 30 hours of life. A short hacking cough was not an uncommon symptom. Many of the patients complained of sore throat, which, in some instances, appeared to be duo to the constant gagging and vom- ting, in others to afoul, horribly foetid, diphtheritic pharyngitis. Consciousness is com.monly retained until near the end. In only six cases was delirium a prominent symptom. A hypenxis- tuetie condition of the skin, incntioncd by Zulzer* as common ■was not noticed in any of the cases. H^MonanAQio small-pox. 25 In the true petechial form the patients seldom outlive the sixth or seventh day ; ^vhore iho h.v3morrhagos do not come on untU the vesu^ular stage, they, of course, last longer. The cases upon wh ch this paper is based died on the followin-. days • Ion the 3rd day; 2 on the 4th day; 5 on the 5th day; 6 The disease in both its forms, is spoken of as invariably fatal, of r r 't7 "^ ''P'"'"^° ^" ^"'^ '^-^-^"-P^-- d^^Par tment ot the (jeneral Hospital. Diar^nosis.~.Jn an epidemic of small-pox characterized by he presence of h=«morrhagi, .ioties, there is rarely any doubt the na ureof a case of fever presenting extensive cutaneous oxtiavasat.ons, and, perhaps, mucous Inemorrhages. Given however an individual case, when no epidemic .a; raging, and' the matter would not be so easy. ° We must be careful, in the first place, to remember that the initial rashes, which so often precede the milder forms of the dontical in appearance with, those accompanying the true pete- hial variety. It might be impossible to decide definitely for 24 hours on the nature of a case of this kind. In the latter the erythema would probably be more intons;, the ecTyZosel more extensive, and the general symptoms more agJvaed The bright rosy-red, rash appearing on the second day mi^ht be mistaken for the eruption of scarlet fever, unless the mode of onset of the disease had been carefully watched ^Ihe djagnos,s between hemorrhagic scarlatina-fortunately a ra tee-and petechial small-pox offers still greater dif^cult.es Close ,„ ection might discover in the latterVpules ab u he fo^-e ead or wnsts, and, I think, the characteristic odour of nw'^tf r ^"" ''"'''''' ^" '''' -™'^' --Id -d ia ariiving at a conclusion. Cerebro-spinal meninmh"= ;c. o.,-..-.f!.,._ i! . , ,. , . ase which, in some of its forms, is apt to be confounded with i pams in the head and back in the latt nirpuric variola. The ^'i- simulate those of 26 n/SMORRHAGIC SMALL-POX. im n meningitis, in which disease also cutaneous ecchymoses not nnfroquently occur. Indeed, I liave the permission of the phy- sician in charge to state that in case 25 on the list the error in diagnosis was made. I remarked to him at the post mortem examination upon the similarity of the pathological changes to those iu ha^morrhagic variola. The mother, who had nursed the child, a short time subsequently took small-pox, and died. With true Purpura hx:morrha(jim —the Murhm Tiiaadomn WtrUioffu,— this variety of small-pox has many points in com- mon. In both there are cutaneous and mucous hemorrhages, but in the former the extravasations begin on the lower extremities, the skin is not so hypencmic, the fever not so high, and there may be oedema about the joints, diarrhoea, and ascites. £tioh(/>/.—Fi-om the table subjoined some interesting facts with reference to the general etiology of the disease may be drawn. It is most common between the ages of 15 and oO. Thus of the cases there were — Under 10 years, 3 ; between 15 and 20, 4 ; between 20 and 25, 9 ; btween25 and 35, 6 ; between 35 and 45, 3 ; above 50, 1. ^ Young, vigorous, muscular persons form the majority of the victims, and this remarkable fact was noticed also in the late epidemic in Germany. (Zulzer, Ponfick). Several of my patients wore above the average muscular development, most of them belonging to the artizan class. The predisposing causes mentioned by Aikman,*viz., sudden change of residence, debilitating ner- vous influences, unhealthy dwellings, were not speciallyobserved. Men appear to be more frequently attacked than women. With regard to vaccination the table shows that 14 were un- vaccinated, while 13 showed marks of a by-gone vaccination. In none was there a history of re-vaccination. That is, the whole of these cases were unprotected, for I hold that we have no right whatever to say that a man ib vaccinated because he has cicatrices on his arm. The proof that these 13 were not vac- cmated lies in the fact that they died of the worst form of small- pox. No properly vaccinated person, one in whose tissues the impess of vaccina persists, can, I maintain, take smali-pox. _SunilarlyJZu1z(TWsos,J]5^ gears, • Glasgow McdicalJourml, 1871, p. CO. t Loc. Cit. HEMORRHAGIC SMALL-POX, 27 ttiat pe.sons .v,thout ccatnces of a fomer vaccination form the ^-pnty, or even all, oft he number attacked lar lnZr'7 '' ^"""^^-^-^^ --« l^-^s been unusually woH 1 • T ?"• "'' '^''^ ^'^'-^ ^"^ '■» «ther parts of the ^0 Id , nuloed, ,t has been the most virulent type of small-p x known since the beginning of the century ^ In the small-pox department of the Montreal General Hospital there were admuted from Dec. 14th 1873, to July 2 st S ZilZ:^ "^'^" r'''^ ''' -^^- ^^- tbese 2^4 die f the' variety u^dei^ consideration, or 9.23 per cent. Va,J t^- Death. 81 h (ith 8lli REMARKS, f 97 35 M. Ifj M. 30 M. 4 36 F. M. If I>olii'iiitn. Ilmiiiateiiiohis. JW>|fitaxis.Mela;iia.llaMiioptv«is ])i'liriiim. Miila-im. ^ No papules eviduiit. Died 3i uoiirs aft(!r admissicn. Kpistaxis two daj-8 before. islifrht c(inviiltiioii.s. ilioiiiaturia. Much Delirium, var. ham. pust. iNo niiicou.s luL'Ui()rrhagy.s. J><'liriuni. Melrena, frequent. iifninateniL'si.s. Mehena. lW)i.staxi,--.ilela'ua.Ilreiuateme8ii( Nai lirotn. pustul„srt. iirciuop- IVMs 01(1 luug disease. IIreiii(U„ria.Mel(ona.HH>moptysi.s iW'i'^taxis. Hfcmoptysis. Hajuiatuna.HiKuioptysis.irelfflna \ . liaMii. pustulosa. Uajinaturia. litBuiatemcsis. No unu'ou.s hremon-hafres y. hicni. pustulosa, Ua-maturia ilreuiateuiesis. No mucous bicnorrhagoR Hfcuiaturia. MetrorrhajfJa Dt'luiuui. No mucous basmorr- Jiasri^s. Uiuniaturia. najinatemesia Mel- ,i ^ r i . . "^tves. parts abont , „■ vcL , !„!c b '" ° ""^ '"'™'"''''' ™' was f„„nd in tb, eJbnof tl, ""JT' """" " '"""' ""««'"""' appearances were ^^H: ^^ riZf^J"^- Snob are tboebiefpatbological change, in tblttc" » an t, ,, ^,^^,^ ^^ .LL'it:; „' ■ ;';:s rr:'dcr:„xt:;- tb^irrab? ^Tr~ peculiar, and stands in ntlcj c „"! t^'Zl *'"'' "'"' Mf II :J!l 1 1 i m III i 1 1 BO ITiEMOURlIAaiC SMALL-Por.. and friable, and in that state of cloudy swelling common to pro- longed fever. So impressed is Ponfick wifh the pathological and clinical differences between these extremes of small-pox, that he is inclined to group them ns distinct diseases. But, just as transitions are met with clinically between the macular hicmorr- hagic form and that in which extravasations take place in the vesicular and pustular stages, so also, I think, in a more extended series of post mortem? appearances would be found intermediate between the extremes, and where the disease had lasted any time the same pyrexial changes would occur. Indeed, Cursch- mann* states that he has noticed them in vmiola hcetnorrha gica pustidosa. On the intimate pathology of this disease I can offer no sug- gestion. We are, as yet, profoundly ignorant of the conditions of its genesis, and do not know whetlier it dcoends on the in- tensity of the poison or the extreme susceptibility of the patient. JMost histologists are agreed that in those purpuric disorders the red corpuscles pass through altered or thinned and not ruptured vessels, but as to the causes of this general diapedesis, as the process is called, we have no data upon which to form a judgment. The treatment of the disease is eminently unsatisfactory, the patients almost invariably die. A few instances are recorded of recovery from variola haemorrhagica pustulosa. All the usual medicines i dicated under these circumstances were tried, gallic acid, ergot, turpentine, acetate of lead, &c , without the slightest benefit. Quinine was used in large doses, and in three cases I used the cold pack. Since the closure of the wards I have met with an article in the Glasgow Mediml Journal by Mr Aikman, formerly assistant medical officer at the Ilampstead Small-pox Hospital, in which he recommends strychnia in lar^e do^e?, and states' that under this treatraant many of thesj cases recovered. He gives as much as a drachm and a half of the liquoi- strychniae in the twenty-four hours ia severe cases, combined with iron and qnassia. • Zienissen'8 Encyclopedia, Vol. II., Art. SmuU Loo. Cit •pox. p. 387. W- A FORM OF ILEMORRIUGIC SJULL-POX. are, T.,:,;tl„ ;;-: ::™™ 1^-7 -■• POO„HaH«e,„a„J hiemorrlia-os into «™l ^ . ., '^ T'" '" «l"'™«'«ri^='l by lower half';?, I, \ J "' "'" <""''^—'>"'liy tho^ of the of i ' a it t t7", *° r'"'"' ''"=°- '^''"^> -'-" follo„i„,ML rZl "'T"™ "',"' '"""'^ '"="'":'■ 1'*"= "o was cne tourth case observed : June 8.h"'E™„,iI''r'"'""''; "'"'' l"''"'""'" """''• A"'»itted ruiseiUb, full and strong; temperature 99^ "^ i^,awoMito™tin^,::„;;:*^^^^ „• -1 ,. . 'vF^'<«"iia nave become puruur c -inrl n a.m iar oondu.on ,s observed about several on tl o am P Le yo ; temperature 99.50. "'^® limcrWltTs'"",' '° "° "r ''^ ™ ^ "Wedelinousat "uiL,a. rujse 8« ; temperatare 99 2" eve":^-:a:\fL::;k!::i':-r™'r-"'''» teeJ, and of a semi-opaque, somewhat translucent !t" h' i\ , ' ' ^:. i )1 32 A FORM OF IIi?!MORRHAOIC SMALL-POX. r' aspect. No true pustule is present, with the exception of a few about the roots of the hair,— but the face has a rough nodular appearance. Over the legs, arms, and to a less extent the trunk, there are numerous small, dark-red spots, about the size of a pin's head, which on superficial examination, looked like purpura, but on closer inspection prove to be small papules into which extravasation has taken place. On passing the finger over them a slight hard elevation can be felt, and in some asmall aemi-opaque, vesicular top is observable. Other larger ones, the size of a split pea, flat, with vesicular tops, and situated upon haemorrhagio bases, are common on the legs. Here and there over the trunk and arms true pustules occurred but they are small and have not hyperaemic bases. The sjmetrical clusters, mentioned as situated on the legs, are elevated into bulla filled with a sero-sanguineous fluid which gives to them a bluish look Upon the walls of the bulla- the remains of the septa of the original vesicles are distinctly seen. The separate varioles of the clusters on the tibiae have not coalesced, though they are filled with a fluid of the same chai'a':>tor. Another large bulte filled with a sero-sanguineous fluid exists on the radial side of the ball of the left thumb. The bases upon which these various clusters and bullae are situated are hosmorrhagic. Examination of the contents of the bullae and of the larger pocks of the legs showed a large number of normal-looking red-blood corpuscles, and numerous granular leucocytes, many of which were grouped together. The sharply-defined, dark-red spots scattered over the white skin gave a remarkable appearance to the eruption. General symptoms good. Tulse 86 ; temperature normal. 14^/i.— Desiccation proceeding in most of the pocks, and those of an haemorrhagic character present small dark scabs,(represent- ing the contents of the vesicle) situated upon a base of fading extravasation. A few genuine pustules exist upon the chest, i'ace not so much swollen, but remains rough and uneven from the dry hard pocks. Temperature normal. Got up for a short time. 16f?L — Eruption drying up rapidly. 17n sented a good mark each T. T^ ""''' ^^ '"^ ^^' I^'^' diffored so^^ewhat ltre;rdin.;vf""'T '' ''^ ^"'^^^^^ a^d IV, and to a lesser t^ rtV/sf V tle""^ 'i "' ''' small, miliary in apnearanoe lill ?^ ■ ""'"'^"^ ^^'^^^ cribedas.j.,. I^:2::^Z:7!;' T-'-' '-'- of the extravasation was tolor h 1 r ""' «f appearance or about ih. , T toleiablj uniform m each case viz at or about the period of vesiculation. The dav of f 1.! Z on which it took place in the cases is a. fnll. • ! ''■"^'*^'" 4th, 5th, 4th 4th Tl,i, f '""' '" ''''^«'"' 4th, 5th, the dev loin .fl "-"T'^ closely with the sta^e in exclusively ,o those localities, W me wS,'''°'^"'' '.°"«'«'' about those on the arms *° " '™ ""'""ces as 'r: o?r; rrx?' °"'t """"™" "^^^''^'-s «■»- delirious get up a Ta^rr ^'"'" "»"• "•''«™ P"«»ts being have oceurredl torusW. ?■; '°f '"«"»"'''»Ses are found to -chani^al m „ ?t 1*!'?'™^'''"™''- '" ^ -P'e mechanral manner. In the oases «„^* Loc, Cit. p. 370. refer to such a cause may 84 A FORM OP II.«!MORRHAaiC SMALL-POX. be excluded, and the extravasations took place in the vesicular stage. Next to the occurrence of h.xmorrhages the abortive nature of the eruption forms the most interesting feature. No patients under my care with an etjual extent of eruption made such rapid recoveries. In all of them the skin was perfectly clear of of scabs in about two weeks, the extremes being 11 (case VI) and 14 days (case III). It is difficult to assign a cause for this early desiccation. On the legs and lower abdominal region It may have been directly due to the extravasation. A vesicle with a layer of extrarasated blood about and beneath it is cut off, so to speak, from the circulation, and has to draw its nutri- tive supply from a distance. In many instances, also, the hfemorr- hage occurred into the vesicle3,and they quickly dried up to small «i ; 1 ( '<5 i [ P ^ ', [ E ^ 1 1 (t> J ( i-s 9 ? ^ w J »- 1 i- 00 9 • rf^ / ■■•^'tTITO TAT T.nQS^* ft' m o ■§ 5 U << 2 p; < 4 69 '9 g-'S^i aj 3 3 *> o\v of the Presidcut on ; Pro- a nd in tlie I I S.^ J Principal ?§ «-^ .?'"'"" Ota § " -^ -I a It the kon- -5 "S -g 6X) g iH^lievod to o * S .S ^ 'p pl'T-ce we fe a « ;lusively to * ® lad already a 2.S g 5 "rt « - Ji tne visit * "3 g ° mushed hn "S "S S g 5 2t condition ** " « o day or two a> M -^ 4J . the follow- rdered to be "-I m M -^ -w . Liie roiiow- 2 :S o g S iition to the * ft a o ^ vorms in the ^ oj •'-^ g Subject many g ^ o S g-es, I did not 5 c'-S 5''"^ the do- Q "I 2 S ' «'"tozoa iii- ^o 5 ^ S «^ 3 t.-mozoa 111 ^ S B inchial stron 5j « I -S J the standard Oh >^ *j § o f cterinarian :» -^ S § -J y yei-y kindly ^ *^ g g ;| imber, stating cj 'S a. - no such cases -f -q I S ^^'Ol'^JoW tells ■^:2 ~ jj v.w.,L.uiu tens M > bally brought t'ay as to be ition, Maich 29tb. ^m\' s-s%' ^ to i" o- a c c ^ ^ B 5 s- "J G- M S" ^T-> TTVT T^nr;« * 'in : 1 p| 1i i 1 :|'^ i S • i ' ^M' m n o ^ 5 '^ ^ n a o p-j M a M 1 ^ » ? o (C o ^ r3 '^ - • I ^ a 05 CO >1 o o § •* O kS r, S* o g ^^ a - ^ Oy >= a ^T a s-j a *^ (t J3 o £. p -°5, "- » ° • a « = cc ?5 kj a a »- ar cr h2 " p ^ v^ o a- cr 3 o -j o' s a Vj 0- S--i» org p ►- K, h-- P 05 ft HJ p «> en ct- ^. ^ ■iUIIiiHA :^ ij P •s i teg 1 "< « 'M o « • rfi g ** g ^ 03 >i^ • ^ *^ P >> O -S t^ bn ij.a||ii9it!iif||f 'm § ^ o3 - a) 3 a> c^ f~ _ « -"-3 r^ 01 O) - 05»2 5«« M-^' ^n3 H a P. ^ CO ^ 3 ^ ^ fen ai 2 ^^5 3 fl a ^ Cs, -3 « ^ ^ -^ "^ ?„ fe -2 S -a g fe "T^ -22 ft w)-?^ nd 2 o a S3 s 2 ,e -^ 535 -a _,-'ftD^(;jicS^03lD 5 =0 g -73 fl ^ *^ ^ jh •■^» a oi -5 ., ^ ^ § . .0 Oj ?> So® c S "^ -f ^ 3 «? 5 o 5 , o3S.CHte^a)--HO"^-t?5Ht>ob^1^ Ss.as|2-cff§oS§.t^s.§g ^ s " 2:3-16 I g i g|)iJ 1=^ § « S "s s-^ § ^ 'i I, d »§ ^ s -S ::^ ^ w);2 ,/, -a ,0 S S) 2 s'StgS^^^^afts^ - :3 " >H 5i)S^'Bl-3S-^S®f1 ft '3 ^ ^■^ 8 03 TS J3 rt . » '^'^ "* fl i=^ fl ^ 5 § g S 2 §* « ^ a .S-o - w Ci CO .rt (/) > -1-3 o 1 -^^ cn I S3 I OS ^11 ^ «s a p) _g S C .^ •-" CC b£ :3 .s 3 •" «i ^-' eL '^ ^ '^ «♦-< PhM CO «4-l s B « 0) B 1-9 CB O *^ L. «5 S3- '^ as -Q Oh Oi O) 3 ..a «..a a o a si 2-i^ cn S a o O) *s be I ..S S-S 8 OS -3 C>srH CO C3 W d Z 10 S D U 0} 3 15 I -I < z o < Z VERMINOUS BRONCHITIS IN DOGS.* By William Oslkr, M.D., L.R.C.P. Lo»d. ; Fellow of the Royal Microscopical Society, London ; Vice-Presidcut of the Montreal Veterinary ]\[edical Association • Pro- fessor of Physiology in McQUl University, and in the Veterinary College, .Montreal. Eahly in the month of January I was a.ked by Principal McLachran 1- R C V.S., to aid him in the investi'^ation of a chsease winch had broken ont among the pups at the ken- nels of the Montreal Hunt Club, and which was believed to ound IhTr^'T ;•"''"■'• ^^'^ P'-«^«'^Jing to the place we found that the affection was confined almost exclusively to animals unoer eight months old, and that it had alreAulv proved fatal m several instances. At the time of the visit ZJJ^T^' n ^"' P^^^e'iting symptoms of diminished air space in the chest. In order to ascertain the exact condition of the lungs, one of the pups, which had died a day or two previous y, and had meanwhile frozen stiff, was ordered to be sent to the veterinary college for dissection. On the follow- ing day It was found at the autopsy that in addition to the pnuemonia there Avere numerous small parasite worms in the trachea and bronchial tubes. Knowiilg how subject many of the ower animals are to bronchial strongyles, I did not Uunk It very remarkable that they should occur in the do" On referring, however, to Dr. Cobbold's list of entozoa iu^ festing the dog I was surprised not to find a bronchial stron- gjle mentioned, and a further search through the standard works on veterinary medicine and helmi.uhology pro' „. fruitless I then wrote to the editors of the jdJinarTal asking for information on the subject. They very kindlv "tl at "'"so ' f""'' "^''''} '''''. ^" '^' ^^^-h number stati ,^ that so far as their knowledge extends -no such case^ liem that one r,uch instance has been verbally brouo-ht under his notice, though not in such a way a« - < thoroughly convincing." * Read before the Montreal Veterinary Medical Association, March 29tli 1 I ' ( « i V i ml » VERMINOUS BRONCHITIS IN D0G3. T shall proceed now to speak of the sytuptoms and pathology of the disease, then give a description of tlie parasite itself, and make a few general remarks. Symptoms. — Only five of the diseased animals were seen during life, and that rather irregularly, on account of the distance of the kennels from the city. Jlowever, 1 have obtained some important details from the keeper, and a case which was brought to the infirmary and kept for some time was made the subject of cli- nical study. Among the initial symptoms disinclinatiou for food and exercise, together with an unsteadiness of gait, amounting in some of the cases to a subparalytic condition of the hinder extremities, were the most evident. In fully half of the cases convulsions oc- curred. There was rarely diarrhoea or any other symptom referable to gastro-iutestinal disorder. Cough was not a promi- nent symptom, being absent in many of the cases. When pre- sent, it was short and husky, "not," as the keeper said, "the regular distemper cough." In the case brought to the infirmary the cough was well marked, and was dry and short. The pulse and respirations vrere increased, and the temperature elevated. Towards the close all food was refused, and even when fed the soup given was commonly vomited. Death took place in most instances quietly, though sometimes during a convulsion, and the keeper noticed that the pupc which lasted the longest had the most fits. The duration of the disease ranged from three days to a week, or even ten days. The whole epidemic lasted about seven weeks. ' Altogether fifteen couples were attacked, all of which, with the exception of three couples of old dogs, were under eight months old. Of the old dogs three had the disease badly, but only one died. Of the total number affected four and a half couples re- covered, eo that twenty-one animals were lost. The dogs which recovered are now in their usual health, though not in such good condiiion as they were before. "With regard to the hygienic surroundings o£ the animals it may be stated that, at present, the kennels are in an old house which stands by itself on the government property known as Logan's fiirm, at the east end of the city. It is isolated, being at some distance from any other building, and is situated on an elevated ridge overlooking the Quebec suburbs. The disease showed itself during a remarkably cold spell ; indeed, for the first three weeks of the epidemic, the thermometer was almost constantly below zero. It was first observed in two VERMINOUS BRONCHITIS IN DOGS. 3 or three pups of four couples which were kept by themselves in a separate room. 14 ft. by 8 ; the floor being covered with straw wh.ch was changed every week. There was a cupboard in the' room and m th.s the pups slept. This room was on the exposel BK e of the house, anc , according to the keeper, was ahvayn^ery cold The res of the anunals were kept in tolerably roomy quarters though at night, with the doors closed. I do not think he ventda .on would be suificient. During the day they h!d free access to a arge yard. The food consisted of porridge and cooked horseflesh, which were given either separately or foiled ogether. lVygc.t nothing else. The oatmeal was of g od quality, nor did I hnd m portions of the food removed from the feedmg pans anything which aflbrded the slightest clue to the origin ot the disease. casrr'^'tfff"Tl^''-'"""''f '' examinations were made in eight cabes. The following notes were dictated at the time. Case l.-Autopsy eighteen hours after death. Body that of a ;vell-nounshed, half-grown. fox-hound bitch. On op^ei it the horax the lungs only partially collapse; the lower bo er of be bes are firm to the touch and dark in colour. The vesse s n the lower mediastinum look full, and the tissues in that region are blood stained Pericardium natural ; heart appear of non" ^e; right auricle filled with dark grumous clol which ext nd nto the vessels and are here decolourised. Eigh ventricle dfa- tended with dark semi-coagulated blood; the conus arteriosus fil ed with a perfectly decolourised clot, which passe Z he pulmonary artery to the third and fourth divisions. The left auricle contains a small coagulum. The left ventricle contains no blood, but the whole cavity is occupied by a firm niirwhi" thrombus, which is connected through the mitral valve with ho one in the auricle, while a prolongation from it extends ^^to the Z«??y.9.— After normal, on invertinrr tliem a ouinfifv nf r *. ^rown frothy fluid escapes through tl^, la^^'x ^ ^ "^ "^'''^ The anterior and middle lobes and the anterior half of ^he po tenor lobe of the right lung are solidified, bein. of a d-i k lectea parts. Tlie pleural surfaces are smooth, and there is no exudation. On section the lung tissue is of a dark '^00^ the surface ot the section finely granular, aud bathed w i h ' quan ity of reddish-brown serum. On close' inspeZ t en that the air cells are umfonnly filled a solid exudation ; attempts I i. 4 VERMINOUS BRONCHITIS IN DOGS. at inflation of the affected portions with are unsuccessful. Portions excised sink at once when placed in water. In the loft lung the apex of the anterior lobe, the whole of the middle, and the root of one of the posterior lobes, are in the same condition. The portions of the organs not diseased are of a rosy red externally, and on section contain much blood and frothy serum. Between the healthy and diseased parts there is a zone of intense hyperemia. Trachea. — On slitting up the windpipe the mucous membrane is found covered with a dark frothy irucus. The uieiubraue looks pale and natural to within an inch of the bifurcation, but at this point it becomes reddened, and uneven from the projec- tion of irregular little masses of a greyish-yellow colour, which on close inspection are found to be localised swellings of the membrane, contaiuiug small parasitic worms, the white bodies of which can be seen lying u])on and partially imbedded in these elevations. They are most abundant just at the bifurc?.tiou, at the lower part of which several have emerged, forming an eleva- tion three or four lines in height. About the orifices of the second divisions tiiese little masses are also seen, and the whole mucous membrane of this region is deeply congested, and some- what swollen. Very few of the worms are found lying free on the mucous membrane ; almost all of them are attached to the masses or buried in them. The smaller tubes, especially those leading to the diseased portions of the lungs, are iilled with a dirty brown fluid, and on squeezing any portion of the organ quantities of it can be expelled. The bronchial glands are swollen and enlarf^ed. The spleen appears healthy. The left hidneij contains a large amount of blood ; otherwise looks natural. Nothing unusual in the right one. The stomach contains a few ounces of dark brown fluid; mucous membrane is pale. Large veins full. The duodenum contains a bile-stained mucus, and on pressin" the gall-bladder, bile flows from the papilla biliaria. Jejunum and ileum contain a dirty black material adhering to the mucous membrane. One tasnia elliptica and one uscaris marginata are found in the jejunum. Large bowel healthy. Z»Ve>- firm, dark red in colour, lobules indistinct, hepatic veins full, gall-bladder contains a tmail amount of bile. There is a clot 'u the portal vein. VKRMINOUS nnONCHITIS IN DOGS. 5 Brain.-^-othiug abnormal about the membranes. Substance of Rood consistence and apparently healthy In the following cases I have condensed the original account. Case 2.-A five months' old dog pup, which had been ill a week- E.vten8>ve pneumonic consolidation of the lungs, involvin/tl e ower part o the anterior lobe, and scattered patche in tl e .Sdd lobe on he left s.de and half the posteror lobe on the right On sectiorj the sohdifled parts presented the appearance aire dy de rite 7 ^"""'"'^ ""°' *^"' '''' -^»'-^«d portionraret a state of engorgement. On slitting up the trachea ind wl chtal tubes much frothy blood-ting"ed serum 2 ^d bu no" trace of any parasites can be found either in the tubes or paren chyma ol t e ungs. m ova or young parasites eat be found m^the blood of the cavities of the heart or of the pulmonary Abaominal viscera appear healthy, though, owin<. to the oh Btruc^^ton >n the lesser circulation, tli blood!Vessels ^rlllt A fev^- ascartdes in the intestine, and one small taenia ellipdif Case 3.— Dog pup, six montlis old. In the left htng there are scattered patches of pneumonia in he anterior lobe, one or two are in the middle lobe, anTS a dozen, the size of marbles, closely sot together in the upper part ila'nt::^ b;l'''"f^'°'^^^""" *"^ anterior lobeTs'oi: m an area 3 by 1 extending along the lower free border and through the whole tliickness. Small patches occur here and there over the other lobes. In this instance the inflamed p^^^^^^^^^^^ smaller and not so extensive as in the other cases. On si tin, up the trachea the mucous membrane looks healthy to wit n 2" of the biurcation. when it becomes swollen, dark red ilcoLr and thickly scattered over with the elevated granular massed noticed in the first case, attached to and in w^ich n^merou small wlnte worms can be seen. A stream of water of consider able orce does not wash them away, but shows that each mtle" elevation consists of a nest of the parasites. They extend to tl ubes of the second order, and are specially ab^und^t a^ e off f^om :r • T' '""r' *'" ^^'^^'^^ '''^' fi-t tubes given off from the mam bronchi. The small tubes are filled up w1 h a frothy serum. Two of the worms are found far in the m'u u Stomach and intesfnes appear healthy, except the lower portion of the ileum, which is congested In this region ten specimens of dochmius trigonocephalus occur, and lurthur up in the bowel eight ascarides. '^'^P''^^"' § 6 VERMINOUS BRONCUITIS IN DOGS. Case 4.-A six moutlvs' old dog pup brought to the infirmary and died tbo next day. ^ In the left lung the anterior and middle lobes and the lower Iroe bonier of the posterior lobe are solidified. In the right lung the lower three fourths of the anterior and m.ddle lobes, and the lower fourth of the posterior lobe, are in the same condition. Pleural surfaces involved. The posterior half ot the wnidpipe contains upon the mucous membrane of its lower wail about a dozen small red patches, which extend in the axis of the tube; some appearing like linear streaks duo to the injection of a few vessels. In all of them the presence of parasites can be determined, though in some of the smaller only one i.- found They become more numerous about the bifurcation z^fi in the mam bronchi occuping chiefly the lower wall. The masses are 190 ated and the mucous membrance between them intens-^ly in- jec ed. None are found in the second divisions of the tubes Abdominal organs contain a good deal of blood. Mucous membrane ot stomach and intestines look healthy. The larce bowel contains a quantity of consistent f«ces. Six ascarides in the duodenum; six specimens of dochmius trigonocepbalus in the jejunum, and ten specimens of trice ephalus afEnia in the caecum. Blood of heart and veins examined ; nothing abnormal found. Case 5.-Seven months' old bitch pup. Considerable em..cia- tion. Scattered areas of pneumonia throughout both iunes • not quite so extensive as in Case 4, but presenting similar characters From an inch in front of the bifurcation of the trachea to the bronchi of the second order, the whole mucous membrane is transformed mto an irregular greyish-yellow granular structure upon which the bodes of numerous white worms can be plainly seen. Two sizes may be distinguished, one longer and of a more opaque white which subsequent examiration showed to be the tema e, the other shorter, thinner, and paler. In this case even about the orifices of the third division of the bronchi, a few'nests of the parasite can be seen. In the mucus from the smaller tubes a few cf the adult worms occur, and on spreading it out ou glass slips, and examining with a low power, a few ova and free embryos are seen. Blood of heart and veins contain no parasites Nothing abnormal in the stomach or intestines, a lar-e sneci men ul taenia elliptica in the latter, also a hy; ascarides. ° Case 6.-A thin, badly nourished dog pup, six months old. VERMINOUS BUONCUITIS IN DOGS. 7 Lung« present numerous patches of consolidation, involving on the r.ght mde the lower half of the anterior lobe and a 12 piece the postenor lobe. On the left side the 1 -ee horded the antenor and .n.ddle lobes for almost two inches rot « m„rg,n, and a broad str.p along the upper part of the posterio^ • 'fr'^'r r.'^ ^T'^' ^'''^'^'^' "^'^'^""^ membrnno of the tubes Casp 7.-Dog pup, seven months old. The autopsy, which was made a the same time as the previous case, reveals a snnilar cond.f on of he lungs, and an entire absence of any para i es either in the tubes or in the parenchyma of the lun^s. Khi' ::^:i:::^St^-r- ^'— '^^i^- and ..^ bee'nill a ~tk'"^' ^'''''''''' ''' P^^'' '^''' -"^'>« «^^- Had Lungs contain pneumonic areas of considerable extent • in the ngh invo ving the entire apex with the dependent borde^ and a sma 1 portion of the posterior lobe near the diaphragm. u the eft lung almost the whole of the middle lobe, and the root of the posterior, are specially afiected. On opening the windpipe the discrete elevations above described upon the mucous membrane about the bifurcation are verv distinct and ho worms can be seen in them. The appearance is verv like that met with in Case 4, and the description need not be rZ fn te blood.^'""''' ''^ *'" '"'''''°''- """"'^"S ^^^°^-^J ^•"•^-d asfollotr''' '""^ ''''"^' ''^"'"''"^ "^ ''^ "''"'^ ^'^y ^« defined J/'yf"' tr: ^'•7''^«-«/^'^-A slender nematode helminth bodylihform, the female measuring about one fourth of an inch n length the male smaller, measuring one sixth to one eighth of an inch ; head corneal, mouth simple, unprovided with papilla. ; tail 01 female obtuse, anal and generative orifices terminal, opening bv a c oaca ; ovarian tube containing one row of eggs, which in the mature species, have developed into dondcr-coiW en-br';" Lh of the male somewhat pointed ; penis consists of a double spioLlum of a yellowish-brown colour; mode of reproduction viviparous Only occasionally, as stated above, were the worms found lying n.: Hi ® VERMINOUS miONCIIITIS IN D008. free upon the bronchial membra.u,. ; na a rule tl.oy lay imbedded in a loeahaedyrauular swflliug of tho mucosa, from wliichportioiis Fio. 1. — Head of'uinle v orm. Fio. 2.— Tail of female worm, showing the youug embryog. of them protruded. They could readily be pulled out with a pair of fine torceps but a stream of water did not wanli them away In several ot the cases examined (more especially Ca.e 4) the whole mucousmembrane of the affected part appeared rou-Mi and .rre,.ular as >t ulcerated and innumerable parasites lay upon and m It Ihe nmture females could easily be distinguished, iot only by their larger size, but by the opaque whiteness of their bodies he majority of the female worms examined were immature, and did not contain dcve oped ova. The males were not nearly so numerous as the females. Forms intermediate between the adult worms and the young embryos (some of which, as already men- tioned, existed free m the mucus) were not met with. The occurrence in the bronchial tubes of the lower animals of nematoid worms bolonging to the genus strongylus is by no means uncommon. Owing to the irritation caused by their development in the mucous membrane an inflammation of the tubes is produced hence the affection is known by the names of parasitic or vermi-' nous bronchitis, popularly called « husk " or " hoose " It is not altogether unknown in man, but very few instances are on record Infesting the domestic animals there are three well-recognised species of strongylus : the S. filaria of the sheep and goafs • S paradoxus of the pig, and H. micrurus of the calf, more rarei; of the horse and ass. In calves and lambs parasitic bronchitis often constitutes a serious and fatal epidemic, so much so that in the latter It goes by the name of the lamb disease. So far as I know no epidemic ot the kind has been noticed in Canada. The species 1 have here described differs in several particulars from either of the above mentioned, and is most probably new to science VEKMINOUS IIRONCHITIS IN DOOS. ^ The origin nl the opi.lerni.. nu.st. I am afraid, like that of «o m.,n.v other, hseasen, remain ..bHc-ure. We have absolutely nothi„.r to aul ..8 ,n formIn^' an opinion on the subject. There had been no c .nge n, the loc-ality nor in the f.od. The straw upon whi.h l.e co.^s Hlop wan ot the or.linary kind, and the usual attention had been pa.d to ehanjr.nff it and also t.. the general .anitarv eon- d.t.on of the place. The disease broke out, too, during a .p.-ll of very severe weather, when the food left in the pans froze qiieklv. Ihe course of the epiden.io was Hhort, lasting between six and seven weeks a suiunent time, however, to destroy almost all the [)upH in the kennels. The mode of invasion in parasitic disease of the bronchial tubes has been, and st.U is. a nuttter of much dispute, some observers majntamm. that " the ova and youn^r panvs.t. s taken up u.th the iood, ,n the first place gain access fron. Iho alimentarv canal to the circulation;" others hold the view that thev pas's directly from the mouth to the trachea, or that the ova an- inh lied by the breath, 'f he former view is the one n.ost generally enter- au.ed, and ,t is urgc.l in its favour tl,at the presence of the worms has been determined in the cavities of the heart and in the blood vessels, as well as in the intestines. .\ow, in the epidenuc umlvr consideration I think this view does not meet the cas,.. SupposinLr the young embryos to have been in.^ested and to have '.uned access to the branches of the porlal vein, they wouhl tlaMi be earned to th.e right side of the heart, and from thence to the lungs, by the pulmonary artery, the capillaries of which ramifv HI the lung substance alone, a situation in which the parasites di'd not occur. o get to the bronchial mucous ineu,brane they must be returned by the pulmonary veins t.) the left side of the heart enter the aorta, and pass out by the sn.all bronchial arteries' which supply the tubes-an exceedingly r.n.nd-about and some- what improbable route. It is to be remembered that youi... 8trongy.es have been found capable, like many other nema! to.d worms, of reviving on the application of moisture after a dessication of a month or more, and even after immersion in spirits of wine, and solutions of corrosive sublimate and alum (Williams), so that their chance of survival under adverse circum- stances is unusually good. It seems quite as reasonable to suppose that the dried embryos were inhaled with the bn atli and lighting in the mucous membrane, found suitable conditions for developmeut. The position of the para.iles aVout the bifurcation of the trachea, at the angles of division of the main bronchi and most abundantly in the lower wail of the tubes, just the localities If 1 10 VERMINOUS BRONCHITIS IN DOGS. ti where small particles would be most likely to lodge, favours an infection through the air rather than by the blood. The uet-atiye evidences in the heart and blood-vessels do not go for much either way, as the examiuatiou in all the cases was made after the invasion of the parasites, and consequently at a time when they could scarcely be found in the circulation. It is a somewhat remarkable fact that verminous bronchitis prevailed to a much greater extent, and is more fatal in youn,' ,,7., Iftonfmil PHTNTEI. .\T TiiK .: (;.\;.Kr.f...... ri;i\Tr\(; noisi 1H7 H kl Profs U!i| i;.f i Jj {Reprinli P] J CASE OF MEURISi OF THE HEPATIC ARTERY mta MULTIPLE ABSCESSES OF THE LIVER. m GEORGE ROSS, A.M., M.D., Prokessor OF Clinical Medicine Mrfim rH,„r.„„ » «.ui<.iAi.,, dICUILL LNIVERSITY, ATTENDING PuYSICIAlT TO TUB Montreal General Hospital. AND WILLIAM OSLER, M.D., L.R.C.P., Lonb. PkokeSSOH o, INSTITUTK.S OF MkdICNE, McG.LL UnIV.R8ITY. (Read before the Medico-Chirurgical Society of Montreal.) iReprinkd from Canada Medical and S URGicAL Journal, July, 1S77.) PRINTED AT THE "GAZKTTE" PRINTING Hor.Si: 1877. * ' *i' l.„ »^.te 1 W .!HMHi-.1i— > (* bJHI^Hj ■ - k >■ D ^^^^^^^B i l II^B M ! ff .i^^* f »»pi i " ■.,! 1 n ^ il ! i ./' ./• ANEURISM OF THE HEPATIC ARTERY. (a) Hepatio artery, (ft) rie-ht hranch mainly involved, (c) lefl hranoii, (d) uas troduodenulis, {ej oystio arteries, ( / ) oooluded branotie* of right truuli. I ANEURISM OF HEPATIC ARTEI^Y; MULTIPLE ABSCESSES OF THE LIVER. BY GEORGE ROSS, A.M., M.D. Phckssc. ck C.,.,c.. M...C.K, MCG.X U.v.ns.v, Ar^o.^o Puvb.cu. TO THB MoNTIIEiL Gb.VEIIAL HospITAL. — AND — WILLIAM OSLER, M.D., L.R.C.P., PROFJISSOR 0, INSTITUTBS OF MediCI.VE, McGlLL U.N IVKRSITT, (Read before the Medico-Chirurgical Society of Montreal.) Aneurism of the hepatic artery bein^ "J' severe pain and a of a d,.,gg,ng and weight in the region of the liver The operflca ve,us on the right side of S,e chest are verV large a..d prom„,e„t. Ordered linseed ..oultices over the liver ' .6(4 —Tenderness less. Hepatic dniness iner.„M in area n^easurmg 8 mches vertically at the line of the „ipp.e No' located fulness or redness of the skin or fluctuation to'be found 6 ANEURISM OP HEPATIC ARTERY, ^f ^ ;):! anywhere. The enlargement of the organ is very general and uniform. Pulse 128, very small and feeble. Temperature contmueshigh with evening perspirations. Is remarkably cheer- ful, saying he feels well but weak, altliough he suffers a good. deal of pain. Ordered acid nitro-raur. dil. Tr. calumb., a a 3ss ter die. 20^//.— Pain and tenderness low down on the right side. Excessive pain is caused by the slightest change of posture. Lies constantly on the right side. Pulse 180. His diet throughout, has been of a most nourishing kind. Milk abundantly, beef-tea, eggs, wine, &c. Dec. Src?.— This morning there occcurred a temporary col- lapse, marked by a rapid fall of the thermometer to a remarka- bly low level, 94.8''. F., accompanied by g--eat prostration and a cold sweat. In the evening the temperature rose to 102.4.*= F,, and during the night great pain was felt in the left iliac region! "whicli was tender. Ordered an opiate, and a small blister to this region. 0^//.— Is rapidly sinking. The signs of effusion in the right pleura, hitherto stationary, have in the last few days, rapidly extended, and there is now dulness over the lower two-thirds of that side, with absence of breathing, and an amphoric note beneath the right clavicle. 7^/i.— Died at G.OO a.m. Autopsy, 31 hours after Death. Rigor mortis present. Skin of a dirty-brown colour. In the abdomen about 22 oz. of yellow turbid fluid. In the right pleural cavity about 20 oz. of similar fluid. Eight /wn/collapsed. The pleura covered with a thin layer of greenish-yellow lymph. On section, the lung is dark, airless and sodden. Left Lung. On the visceral layer of the pleura, especially behind, are numerous small ecchymoses. On section, organ contains much blood, is firm, and only slightly crepitant. Heart normal. Kidneys rather pale, cortex swollen, and malpighian tufts injected. *SWeen. weiryht 44.'i (rrma n4r,^^ adh^rr^t ^- the stomach. Organ soft. On section dark and con<^ested. in o' ill ANEURISM OF nEPATIC ARTERY. ^ m^r' T'"\ ^' ''''' of "Iteration in the large intestine, madder and prostate, normal. Liver, 48791 grammes, (lOf lbs). The peritoneum around t m many places sliowing signs of inflammation. The left lobe vdZ!)^ T r,' *^''"^ '"''^'''^ ^^ ^ ^^^'^k layer of firm JO llowish-oooured lymph. The right lobe also cemenfed to parts in Its ne.ghbonrhood by )- .nph of a similar character. A small ZZZ '^";^""7^^ ' '^' ly of he hver. This as .n the lungs, is two-fold ; the portal yef min- hiT/to ; ' '/'' '""""" ^- '''' Sland, the hepatic arter^ chiefly to Its nutr.t.on. The ultimate branches of the portal vem ram.ty at the periphery of the lobules, forming the Int - lobular yessels, from which numerous capillaries pass into the -tenor, and finally converge to the centres of the lobules Vi* h'%] !!i /• ( * i ij ■ li 12 ANEURISM OF HEPATIC ARTERY. in / the ultimate radicals of the hepatic veins. The hepatic artery furnishes blood to the bile ducts, portal and hepatic veins, and the connective tissue of Glisson's sheath. Its capilk.ies empty their blood by small venules into the interlobular veins. Hence, remembering this distribution of the hepatic artery, it is easy to understand how that in cases of thrombosis of the portal vein, even where the obstruction is complete, the functions of the organ may be maintained, and both bile and glycogen secreted ; for the capillary plexus of the lobules continues to receive through the interlobular veins the blood which has been emptied into the latter from the venules of the hepatic artery. The nutritive blood serves as a substitute, acts' vicariously, for the functional. It has been maintained, and the statement passes current in the text-books, that the converse of this is true, viz : that the portal blood can replace the hepatic, the functional act for the nutritive. This view is based on experiments made upon the lower animals. Schiff states that in the cat the func- tions of the liver are performed just as well after ligature of the hepatic artery as before ; and Betz found that in the dog, after tying the trunk of the hepatic and all the collateral branches, no important alteration took place either in the structure of the liver or in its secretion. Cohnheim and Litten have shown, however, in a very impor- tant paper on " Disturbances in the Circulation of the Liver," (Virchow's Archiv, May, 187G), that in experiments on dogs arterial blood still reaches the liver even after ligation of the hepatic, the corouaria ventriculi, and the gastro-duodenalis, owing to the very extensive anastomoses and connectiono of these vessels. In the guinea pig, on the other hand, the supply of arterial blood can be completely shut off, either from the whole organ or from individual lobes. In the former case the operation is always fatal within 24 hours, and even in this time important changes are found to have to have taken place in the organ. These are all the more marked if, instead of ligating all the arteries, only the one going to the extrem'^ right lobe be tied. The result is an entire necrosis of the portion of the liver sup- plied by the ligatured artery, and in every instance the animal died within two days. ANEURISM OF AEPATIC ARTERY. 13 Cohnheim states that pathological proof of the correctness of tins v,ew ,s as yet wanting, but we are inclined to believe that 1 ;;: 't.. 'T'^ ^ "'p^''^^'^' ^^^ ^^-^ ^^--^ t^e sup. unx .on of the organ best explained on the view, that the shut. ng off the supply of blood, either by the gradual occlusion of the aneurism by clots,or by the quicker process of emboli convey- ed away from the interior of the sac, produced numerous areas of necrosis, wh.ch subsequently became, by inflammation and a seqnestonng suppuration, converted into abscesses. It is impos- sible to determine, in the abs3nce of any positive evidence whether the process resuhed from emboli or simply by the gra- dual obhterafon of an important blood channel ; and in any c°ase there are certam difficulties which will occur to the minds of many in the view which we have suggested. J^here are at least two cases on record of total obliteration of the artery, wjthou consecutive_suppuration,one of which was from aneurism. ^tlli, this, if occurring gradually, and not involving the pyloric artery, need not necessarily, as the above-mentioned experiments prove, deprive the liver of arterial blood. There is no reason to suppose that the obliteration in the case before us did not occur slowly, for the fibrinous lamina, especially at the anterior end, were firm and tough. Again, on an embolic theory it mi^^ht he urged that in this instance the emboli, consisting of fibrinous shreds from an aneurismal sac, should have produced simply mechanical effects, infractions, and not, as in the case of emboH proceedmg from_ necrotic or suppurating foci, abscesses Mechauica emboli do, however, sometimes produce suppuration and in he liver might do so by causing death of the s'truc rl' applied by the obstructed arteries, viz: the portal vessels, bile ducts and connective tissue of Glisson. In the present case supposmg the process to depend on emboli, there would be' arterial blood enough sent through collateral branches to furnish materia for an active suppuration about the necrotic centres Altogether, we think the embolic theory meets the case bettei^ than any other. We must remember, too, that the disease wm not rapi ,y fi,,^, , ^ eame on slowly, lasted five weeks or . Pro/es^or of the Instiiutnof Me,fuin,. DAWSON BROTHE 1877 --—l i - ! — - '^BLliariERS. I , r M I ff, v^*. MEDJ DA'^ 11 INTRODUCTOKY LECTURE ON THE OPENING OF THE FORTY-FIFTH SESSION (IK TIIK' MEDICAL FACULTY MoGILL ONIFERSITF OCTOBER 1st, 1877. BY WILLIAM OSLER, M.D. Profe^^or o/tne Institutes of ^Tedicine. V ? .[I S8ontt|eal : DAWSON BROTHERS, PUBLISHERS. 1877. E*I f PRINTED AT THE OFFICE OF THE "OAZETTE," MONTREAL. Genti introduc opinions beginnin, doubt of offering j and encoi which cot eager live be influen Lecturer i do. Studev on behaJf 80 most sin every one the society a distance, will sjmpal jour weakr you this, familiar, wl To such, wo rejoice to s invigorated of you who m iNT/u)DU(rjy )^r i.ecture. GeNTLBMK.V of the K vrULTV Tl.n A ^ r 1 .. . introductory lecture In, t i, vI.'T , f ' "' ''"'"'"'"S *« opinions ™L d ffcr .^ .(^ ° "'''"'' ""'' ''"«'" bc-i„nin,r ,l,~ ; . ? necessity or advisability „f do^ 't i n:^^ ""' r^ »" °*'™-. *-» -n b'e no wnitn come home to one with the tlmno-lif ^r *u .a«er lives Just enfrin, „,o„ .1,: S Mf oT r",!,!" Lecturer may say, and most certainly by what „e as a Faculty StiIDEVTS of SlEDtCI.VE,— My fi.'af dutv tl,„„ . 1 ■ , on beh^f of the Medical J^-cult^ a he rty « o:,; a ! ,T ri tv noTJ teachers when I say that you come now into tlie society not of mere I'rolessors wlw will lecture at vou from a .st.a„ce, but of men wl,„ are anxious for your , ,C 2 -11 sympathize with your difflculties, and also be r w yo t you tin,. I see among you many with whose faces we are all such, words of welcome arc superfluous ; I will onlv sav „e rejoice to see you back, wo trust with rrfresh d b die' aid J-ou who .or the firs, tune occupy seats in this class-room the J -» wwriiiiBWiimnrrniinMn , ,1 occasion is a memorable one, to which I trust you will lookback in after years with exceeding pleasure as the starting point of a career of usefulness and honour. For you we have a special sympathy. Look upon us as elder brothers to whom you can come confidently and fearlessly for advice in any trouble or difficulty. On such an occasion as the present it is natural that you should expect to hear from me something about the profession of your choice, its position, the pros[)ects it holds out to you, and the relation that you as students bear to it. Probably there are few among you Avho could give a very logical explanation of the causes which induced you to adopt this iu preference to other callings ; with one it has been the intliience of a friend ; with another, perhaps, hereditary predisposition ; with a third a sud- den inspiration ; with another tliat innate enthusiasm for the science which is akin to the natural gift that makes of one man an artist, of another a musician, an inborn natural fitness for that special work and no other, wliioh the man's surroundings, whether fostering or adverse, can neither give nor take away. From these last arise our greatest men ; for others it matters little in what way the impulse has come, so long as the feeling now thoroughly possesses you, penetrating every fibre of your being, that this above all others is the profession you can most heartily embrace. If, however, any tnan of you here enters upon it with the idea that it will do as well as another, that other will most ^robably be better for you. Lukewarm- ness, bad enough at any time, is simply fatal at the beginning of a life-long care r, when it usurps the place of that enthu- siasm that should bend the man's whole nature to serve him willingly in the' work that he has chosen. In addressing a few words to you on the position which the medical profession at present holds, I must admit that diff'erent men hold very opposite views on this point." Some will teh you that the profession is underrated, unhonoured, under- paid, its members social drudges — the very last profession they ■would recommend a young man to take up. Listen not to these croakers ; there are such in every calling, and the secret of their themselves da lie -c |, ' , '" '"^ '» "''"■"-i" they ,ve,-o „, vor^u-o Z "' "'"'•''' ""■= ">»" "''«» tion .OS,,, „ , ;"' T;"-,'"''™"'' '"""'»'''" '»»"™- l>ec„,„o a . n, f , r 1 "" '"■""=°': "f ""■<'-- <1»- ".^oed rathe,- (.11 yo ,° ^^; ,' ■ ■ ""T''"'™ ""» " >>"»'«■=«■ I «™U which, whiif c. : ^ rr;' 'r?™' »''°~-" °" »"«-- ^ ™» you into ,„cl, ,v ° ""'"■" l">'™'-» of «"^ mii'l, h.™"S enlarged tl: '' ' r:,', i t;''*'^',""','"-" '°"^' •'"'' "= hnmvI,..ro ,.„„ , ",|,„. . Z '"'" "'<• !""'«"-■•■•' "»te™ne of all the ^t,Kly ■: aC r I;. »'."■" '""■'' '■"'■ "■'''^•'' ^»"'- <■«"■ -v™™' not help ,;,;";,■■' ""■"'",• '" ''"'■"'« "'-who can- .^r^o,, ;1 r'""" "" "'• ™»' »'■ '■""'- -i-T .u„ii, , y yet ave,,;,,U„ fawV-' ™""""'' ^™ '"""-"^ -^ .ho':::;;;::!? t:;::' :::i''-^''T""V,''" '"™°' "■■°^--"- o.he,. .-.■0,,, :,::,r;i ':?::::;.;"."■" "■•"'t" ■""" "'» •» i.' not raiso,, to c„„,,,,r,,ri':i:;;':\r '"''"'"'■ "° eo.mt,-y , ,, ' ,';^;'.";""""-""'' ™^ "-■■ lives f„,. theh. .he la,al : 11, | J , V it" ""' '" '""°"« "'» ^-^S™ «f !»"> : while the v™. It , ' ».ales.„a„,ship are „„l for -'^ i'^ e.,„U.ale..t i„ .JZ^.^l^ IZ:^:' 8oJ(l!(>r and t!io cf.f- • , ""ik. jjut wliile the ..-n.,,:L:t=;?L'rXaS:^;XS !! !l i.ll r 1 hearts ; he will have no enemies, martial or political ; and his labours if directed by a wise and prudent skill, will be for the welfare and benefit of all. Such honours as are open to him lie chiefly within his own profession and the small circle of the scientific world. Among these his name may be as a house- hold word, his opinions may be quoted as conclusive, his writings become standard works ; and these honours are very real and very satisfactory. I need only quote such names as Harvey and Hunter, Jenner and Virchow, to show you what I mean. But let the student remember that while influence or party may advance a man in other professions above many suoerior to himself, the hero in medical research must wholly depend upon his own deservings. To take a foremost place in the wary and critical field of science he must excel. And these remarks naturally bring me to a consideration of the state of the profession in tliis country. Though not so ad- vanced in the scientific departments as in the older countries of Europe, yet I think the condition is one for congratulation, for in practical work and in the average of attainments the members of the profession in Canada yield to those of no other country ; and this is what should be desired, for general professional excellence brings about the greatest good to the greatest number. For this we have largely to thank that wise conservative spirit which directed the founders of our medical institutions, and which has ever since rcfnained with the promoters of medical loyrislation in tliis countr /. While across the border the stan- dard of quuliiioations has been gradually retrograding, and not until now upon the chaos which resulted from the Free Trade principle applied to medicine, is the light breaking and with it glimpses of a future full of hope, the pcojile in Canada have enjoyed the benefit of a uniform medical curriculum, modelled after that adopted in Great Britain, to which all students have had to conform— a benefit Avhich many of our citizens fail to appreciate, having had no practical accpiaintance with the opposite condition. Early in the history of this country, before tlie establishment of universities, the medical men found it necessary for llieir own protection to organize, and to tjbtain powers from Government to inspect and verify the decrees sllbf""^'?"'"" ^''""° to practice, Jl alsoX a smtabl course of study to examine" men for their license b!: mf rt ^"' 1 "^'"^^ ''''-'' ^'^- ^^^^ thou?hsHll "' '•''"'' ""'''' ^-^Sistering corporations, of r r ^ r ^' '''''''' '^""° '^ t'^« '"^^'«^^« in the number iZi':: hTt '; "' 'r ^^^^^^^"^ latent distrust in tt United So r . "''''^, ''''''''' '^'"'^ ™'-^''^t, as in the leition L;""' '"'"'"■' ^' •'^"^"^•'"^-"^^' t^-- has been e^islation to take ,n part or altogether from the universities ^^pow. of j^^tin, the lic.se to practice togethe;::;,:^ Ue ree In the Provnces of Quebec and Ontario the changes are m d.fterent stages of development. In the former the h°'s tepon,hasboentaken,and while the preliminary examinaU^n nas been removed from the Ivm.!^ r>p ^i « ■ v>„ ^ . nanus ot tlio universities the uZ -C' ^""■— panics the degree „„ its .-eg feu,geo„, 01 „» P,.o„„eo of Quebee, while „,„,lif„i„„ „„ Co„«t,tu.,on of that body to .ome extent, mflnenees^redie to this I ,.„v,„ce to ,,a« the matriet.l„,i„„ examination ot th^ College, and to spend four subsequent years in the study f med,e,ne, the first session to be attonded iunnediatelv af er tl e mat„eulat,„„ exa.nination. the st,anda,d of ,hieh haf o b somewhat advaneed, Freneh and Literature being now eompu sorysubjeets; 2nd,i„ nominating visitors tosee tlnrt the e iT't do Ihetr worlc fa.thfully, and that the examinations are eondu°et zt^t'T' : V " "■'"''"'"^ "'y """'>°''"-3' «'«-s oped system m e.,n„eet,on with the prolossion in Ontario "corporated as the College of ri,ysieia„s and Surgeons flnt' P»v.nee we Kud there that eelleges and sehools of modi 1 are merely teaehing bodies, the power to grant lice e to ITT ","° "■""' ^°'"'y '" '"» Couneiltf the " u ,. ^nd ob,an,able only by exatnination. So also the preliminary I ■•^ l?r ; ( examination of that body is compulsory upon all medical students of that Province. Opinions differ very much regard- ing the Ontario Medical Council, and it is not to be denied that as a body the members have laid themselves open to criticism, but no one can question that its existence is fraught with much good to the profession, and that it has influenced medical education very beneficially and may do so yet more. In the establishment of annual examinations, they have, I think, conferred a boon upon the students, which the students, I am sorry to say, have been slow to recognize. I would urge upon the Ontai'io men among you to conform in all jiarticulars to the laws of your Province, for you may rest assured of this, that you will have no sympathy from us in any att<»mpts to evade them. Thus the men among you who neglected to present yourselves for the first annual examination last spring, felt aggrieved when the Council determined that your obstinacy should cost you a year. 1 had letters from several of you expecting sympothy, but you came to the wrong quarter. Breakers of the law must abide by the consequei' ■ .. : though I believe in this instance, as it was the first offenc, the Council will permit you to take both tlie 1st and 2nd year's examination next spring. In the other Provinces of the Dominion the old system is still in force, and the profession has not such control over its educational matters as in Quebec and Ontario. It seems a pity that a central examining board could not be established for the whole Dominion, but there are serious difficulties in the way, dilliculties which I do not think will in this generation bo overcome. The best we can hope for will Ve central examining boards for each Province, a uniform curriculum, a uniformly high standard of examination, and general reciprocitv Turning from those matters of medical politics, \ , , '-^j to answer the (luestion Avhich has, I am sure, come to er.r'- , ,g of you more than once in the past few days, "How &...dll I best occupy my time V " To answer this I take to be one of the chief uses of such a lecture as the present. To those of you who now begin the study of medicine this is an all-important to do n.ore, but trv to aecon.,,1 t , f " T '•"'^"'^* least, should be d[ssected 2 " .1 "^'l''^'^ ^"^'^'•'^"^■ti^'^. «' comj-uMtuo anatomy, instead of botanv • .u,l T I,,, , surprised that so few men do .. f ' ''"'^ obtained in a ca.-en.U I ^ th' T'' ''' '''■""''''^^ and the bearinc. of 1 . '" ""'' "'^'^^^ °^" «"""<■»"«. -■: .t ti.i 10 One thing, however, do not attempt— to take both ; yoa have not time for that. Shall you attend lectures in any of the final branch«!3 during your first year? Most emphatically, No! It would be as reasonable to ask men to listen tv. l- 'ures in German when they did not know the language. Some of you, however, h Aving studied a year with a physi'-ian, purpose spending but three years in college work, and then you must !»eeO? take one ox- two of 'i:o final branches in your first session. If you have been .iiiigent: in the preparatory year you may appreciate them, but otherwisu it will b;? so much time wasted. The qi:-.. f ou whether the first year student should see hospital practice in diilisrent, and one upon which there is Ic '^ agreement ; some believing that he should defer this until the stM.'ond session, others tliat he should begin at once. I hold mu\ the latter. An hour spent daily in the out-door department of the hospital in attentively watching the examples of disease brought in will do much, especially if combined with a little instruction, towards educating powers of observation in a student, and giving him a general idea of the names and appearances of many maladies ; while every one of you can learn within the next six months to detect fluctuation in an alscess, and how to open it ; to recognize crepitation in a fractura ; and to master many other little practical details, which you cannot know too soon. My advice to you then on this point is, attend the out-door department of the hospital when you can ; the time, from 11 to 12.30, is very convenient, except when you have dissecting to do in the morning. From these remarks you will see that a full programme is prepared for you, and it is for each one of you to set about the task with energy and determination. Gradually those difficulties will vanish which at first appeared 'nniperable. I remember well, when beginning the study of mi e — it is but ten years ..'lo — with what enthusiasm T tc" my Gray's Anatomy and .'...impted to master the strn ' ' one of the cervical verR'bri.c, and thougli I succeedec" headway, yet the matter seemed so ditficull making a little 11 indeed very dry-and, turning over the leaves of that ponderous volume the subject of anatomy ap-.eared so vast, that my heart sank w.thm me and I felt despondent. You .vill also have mo'nents when the way appears rugged and the out-look dark, but never fear; others have succeeded in the foce of the same difficulties, and with patience and perseverance you will do so work Tr V :'T ; ^"' "^^^ ''' *''" ^'^"^ «"^ '^« «"o"«J 7mo'u u "^ "'' '"^"""^ '' ^" accomplished, the d fficulties t<, be overcome, or the end to be attained, but set earnestly at the little task at your elbow, letting that be sufficen for the day; for surely our plain duty is^'It t Tand '' '' '"' " ^^'^''"''^' '"' '' ^^ '''^'^' ^'«« ^^^-^'y at To the second, third, and fourth year men among you, I need not enter into the details of the work re.ui^ed in your respeot.ve classes I will only mention here th'at both maferil mod,ea and chemistry may now bo passed at the end of the second session, and I would earnestly advise the second year men to take advantage of this. Those who feel competent can present themselves for the practical anatomy examinS so that in his year you will only have chemistrv, materia modica, chines, and, perhaps, one final lecture to take, which W be ,,, h if attended to properly. Second y Z; , IV ' : '" ""^^ '"^""^ ' '''' '^ ^ ^"--^ --take, digest. "" ' ' '" " "'"^ '-^^ *''^ ^'-^-^t -" -11 And now let me add a word of advice on the method of study- ing. Ihe secret of successful working lies in the s stemati^c arrangement of what you have to do, and in the ineS , performance of it. With all of you this is possible, for f ^ di urbing elements exist in the student's life to interrxnt the Illot- e u^ whic each hour of the day should possess. ' .1^1 , each one or lumsclt, a tnne-table, with the hours oi lecture stuuy, and recreation, and follow closely and conscientiously the' piisii a large amount of wr-'- ' •■ and anxiety which will surely haunt you ork, and it saves the mental worr if your tasks are done in I %' t'-Ci i: * -! fr I ' i\ Ill 1. 1 12 an irregular and desultory way. With too many, unfortunately, working habits are not cultivated until the constraining dread of an approaching examination is felt, when the hopeless attempt is made to cram the work of two years into a six months' session, with results only too evident to your examiners. The science and art of medicine is progressive ; therefore colleges and teaching bodies, representing as they do the embo- diment of it, must progress witii it and that on several lines. Not only must the results of practical and scientific labour in the different departments be incorporated in the lectures, so that in every subject the teaching m;iy keep pace with the times, but new and better methods of instruction and examination must be adopted, and many other improvements made which shall be for the benefit of the student. At this more than at any other time within the past fifty years the loading minds in the profession are occupied with the subject of medical education, and there is an almost universal feeling that in many quarters reform is needed. It is probable that the next decade will see radical changes in the modes of tuition, while practical work will be introduced more and more largely into every department. With all beneficial reform the Medical Faculty of McGill University will syrapatliiiie, asking her students to participate the-ein, believing not in stereotyped forms but in steady onward progress, convinced that — " On mn- heels a fresh perfection trends, liorn of iifi, I'^jiteil to exeel us." To some recent changes I Avonld briefly call your attention ; and first to the practical examinations in anatomy. Though it has always been customary for tlie Demonstrator to test the knowledge of the student on the stibject, and wliile the oral part of the primary examination was made more or less practical, yet it was felt that something more might reasonably be expected of you. Therefore, examinations in practical anatomy have been established, modelled after those of the Royal College of Sur- geons, England. Nothing will give you greater confidence when you enter upon practice than an intimate ac(juaintaaoo 13 with anatomy, and that you can obtain to norfection in o„r pa . Praofoal oxammalions will aI,o bo beij by tho cliLa profeasora m medical and surgical anatomy ^ " rt,r . ; " "'° '=°"''''' "•■'"' ■=''«l'lisli«l, tho Faculty fol mo. t of mc, ,cal sccnco so nocossapy to tho wcll-boin.. of soc otv thoro IS no cause for rc^-ct ■„ tl,is action on the part of the The abolition of Theses is a change which, I am sure you will nicrly they m.ght |n„e been an important moans of asccrt", in n, a man s capacy and Judging of his fitness for a dc o Mi! » w done ,„ other and more etfoctive ways, and the" 'lis ad Bachelor of .M ,l,cmo precedes tho Doctorate, tho writi u- „f such an ess,ay for tl,e latter appears reasonable but wDT, at MeG,li, the M D. is granted at once, it is su^crfluou 6„„ regre goes w,,h it. " Dorenee of Theses >■ is no morc-'a da^ regarded by candidates with very mi.ed foolingsran uneasT call forth ; and a natural curiosity to hear the comments upon tto prodocttons of brother students. The day, as a rule was pr duct„o of httle good, for the Theses were arely 5 'nded apleasant henng. Many ajoke has been made, and much laugh erected over tho mistakes of unfortunate c'orpetUot out occasiona 7 a senq tiva a.^;,.,v u i, . ^ * V, • 1 , "^ sensuive spirit has been un ntentiomllw bru,sed, and has left us with feelings of bitterness whiclTould r i . UJJjl I 14 Ion;;; mar that jiltatiant and affectionate remembrance of his university life which wo would fain have each one of you carry with him to the end of his days. At the hospital the attendance is increased to ei;2;hteen months, while very important changes 'i ; - ' • made in the clinical d'^partraent whereby the method of teaching lias been more systematizcil. Instead of having clinical Medicine daily for the firat three months of the session and clinical surgery in the last ui-rangements have been completed under which the two classes vfill bo carried on simultaneously tliroughout the six months' course, the class taking r'inical medicine and clinical surgery ou alternate days, having in each subject one lecture weekly in the theatre and three demonstrations at the bed-side. You will find this plan greatly conducive to your advancement, and I look upon it as a strengthening of 'hat has always been a strong point in this school, a poit.t upon which the .eputation of . ny school must mainly depend, viz : the rffectiveness of its clinical teaching. And further, it is no longer taken for granted that you will compound medicines during the summer months cither at the hospital or with your preceptors, but you are compelled by law to spend at least six raor ths in so doing, and to present a certifi- cate for the same before quali'ving for your degree at the university. And lastly, the amount of material at our command will enable us to extend the pathological teaching of the school. The system we ha > o loUowed heretc^ore was goo-i but incomplete. It is impossible [iroperly to instruct studeiitt- how to perform post- mortems and at the same time to donjotistrate fully to them Lhc lesions met Avith. T purpo-;<~ this winter establishing a weekly demonstrative class, in imi., t, ' wever feebly, o^' the course C07iducted by Virchow in ].• in, vhich the material collected may be made thoroughly instructive to the final men among you. Pathology is the ground-work of clinical medicine, and if you wish to obtain a true insight into disease never neglect an opportunity to see and handle its effects on the various organs and tissues of the body. rn" 15 I trust tl,c ^redical Society, eslablislied durin^th.- mt s„„ mor ,«,o„ „.ill ..oooivo your hear,, .,p„„r,. rXZol .h„ take a,Ka,„a,o of it tl,„ ,,o„eli. will b. i„e,,i,„ bl ^"i^ correctly, .h,le ,1 ,» also a traming in tho difficult scicoc of To a ma„ who ba, made hi, gtart iu life, who havin- chMcn li« path 18 now lollowing it day by d ,v lber„ i. T ear.,tirring in the ./t „. a Lnfber'7/ y t ! l:'Z^f, uV „ , ™°'' 'rf P°""=' »■"'- ™* dill-rent risults, in tho busy arena of the worla. Forhcknow, il ,„ ."Ch an oecaaiou their heart, must be seetlii ! t h hou ^t of the future and of all that it may be to them Wh,, M ) opes swell the breasts before hi™ f ,Vhat e Z^i re!o veV^^ den behind the brave young faces I What .eadfas. air^ e set as tho goal winch shall reward the worker for each ■ passionate bright endeavour " that he makes ! Surely s, h thoughts are to each man among y„„ as a trum^^t! S field „. l,(o. And further, like some soft, familiar moloX nmnmg through the clangour of martial m„ ie, th t louTh „^ home must needs mingle with all others, „ the u£t' fondesc hope is the hope that he may be the prid,- ' ,0 J »ho have Chens led him from his childhood ; his (Lc, re X lisbTr :■" "°"''"" ""'™'*^ °f "'-'■ 'rust „ t. ard'ricTm'r " "'^'^ ">''^'"^"H^o«-- for his welfare To the younger ones in such an assemblage as this, who are pale " S"" ""T- '"° ''° "'" '"°" "'• "'- ' '-'" paramount. No longer subject to the narrow rules of school hn, gentle but no loss real, restraints of home ; bound onlv bv tho would not willingly give, tho youth feds himself for the lirst «.me h,s own master, and the sense of freedom rouses the growi!,!. I:! I _ If : f I . ' it:.: I I tffl 'lii m 1 1 manhoofl witlii'' him and j^ivcs impulse to that self-reliance and independence ut' action that in after years brace the m:m for the deeper r.-sponHihilitie^ of life, when the power to choose is no longer a delightful novelty, but an anxious care. iSo nuich for the inspiriting feeruigs which animate the student at thebi^ginuing of a fresh course ; but I am sure many can hear me out in saying tiiat these are not all. The fear of failure underlies every effort, and this fear must bo 8[iecially present to those who run the competitive race of a university career, in wliich a man naturally desires, not only to reach the standard which shall secure him his degree, but also to take a high place among his fellows. This fear of failure abides with some, paralyzing their energies and growing more burdensome as time wears on and their test day is near. But let the student take courage ; for though in the nature of things only one man can carry oft' the highest honours, I doubt if there be one amonj!; vou who cannot come out well at the end of the session if he will only work as he ought. Remember, moreover, that : " K'cn when the wisliud eiul's (Itnyd, lii't wliilf llif liiisy nuiiiis lire ])1}'(1, ' They hriiig their own reward. ' Looking round upon you all I feel no doubt that the majority are resolved to make good use of their time, to study in earnest, and to take a creditable stand in those examinations which in a few months will test the work of every one of you. How comes it then that so many fall away from such good intentions ? Why is it that some barely pass who should come out with Hying colours ? Why do others fad altogether? Not, as a rule, from want of mental capacity ; not from a lack of the bodily stamina necessr-ry for a course of severe study ; but rather from a failure in steadfast perseverance. Men begin well ; they are diligent in their attendance at lectures, they throw their hearts into their practical work, they read early and late ; but after a time the old temptation comes over them, a temptation as old .as human nature itself, one that as Is every age and every path in life, the temptation which the old Israelites felt when 17 "The aoul of the peoj^le was much discoura-od becauso of the lengtl> ot the way" Men yet th-e.l of continuous study, their hearts grow sick undci- the monotonous daily grind The more buoyant spirits feel their youth and health strong within them they relax their rules, they go into society, they begin to' spend then- evenings in ways more pleasant than in the dry digest,un of books ; the hanl bit of reading is slurred over, the looknig up of the lecture notes is put off. " What matter " thoy think, "it can soon be made up." And so the ma'n becomes an idle man, half-hearted in all that he does, and the grand powers within hi.n lie fallow for want of that earnest per- sistent exercise of them which alone can bring out their latent strength and make the student all that he might be. But it would not be foir to attribute all failures to this cause Ihere are some men who fall short, not so much from want of application as from lack of hopefulness. They do not remember their reading as they wish ; they do not grasp scientific principles as they expected ; difficulties thicken ; they grow somewhat bewildered with the extent and variety of knowledge re.juired, and at last give up in despair that engrossing effort which alone can carry them through. " What is the use," they say, as they shirk the harder points, and lay the blame on the system of instruc- tion which should fall on their want of confidence in themselves These are commonly men of no brilliant talent, yet their brains would serve them faithfully enough if they would only put forth mettle. Let such believe the truth that fair average abilities well used, often carry their owner above the heads of abler men—' the genius rarely makes a successful practitioner ; but the careful hard-working student who feels that he must grind up his subject with ploddin,,' rajnc before he can make It a part of himself, and who acts on chis impression, develops the elements of life-long success during his academic course. To each of you, gentlemen, I would give the same advice. This feeling of disgust and weariness in study, this disheartening sense of want of progress, is natural ; be prepared for it, meet it like a man : the mcro effort will draw out the energy you liold in reserve, and you may find, perchance, as many a student has Ivfl t''! if I n'i , 1 ^^H ' ^ 11 III' lil i 't mliiU 18 found before you, that the duties taken up with distaste become attractive in the doing of them, if only from that sense of vic- tory over the lower self within us which is, I suppose, one of the most exhilarating and comfortable feelings that any man can possess. Never lose sight of the end and object of all your studies ; the cure of disease and the alleviation of suifering. Some of you will soon be placed in the chamber of the sick, by the bed-side of the dying, and the issues of life and death may be in your hands. Think of this now, and while you have time use your talents aright. Your lives will be a constant warfare against a common enemy, implacable, often irresistible, who spares neither age nor sex, and who, too often, as the memories of the past week remind us, turns and bitterly avenges the victories of those who have many a time snatched victims from his grasp. Gentlemen, our meeting to-day is a sad one, for sorrow is in all our hearts. One * who had endeared himself to us all has passed to that shadow land, which sooner or later awaits each one of us. Stricken down in the flower of his manhood, checked almost at the outset of his professional labours, it is inexpressibly sad that this fine life, so hopeful, so full of promise, should have been thus suddenly removed. This uay week his cheerful, honest face was seen in the hospital wards — to-day the m : ..rners follow his body to the grave. I need not recount to you who have appreciated his uniform kindness in the hospital his many good qualities, nor need I speak of the talents to which our university awarded her highest honours ; I will rather dwell upon the deep regret of the profession at the loss of one whom we were proud to number among us, and ask the students to imitate that zeal and faithfulness which marked his short career, and which will long make his memory beloved and honoured among those he served. In conclusion, gentlemen, let me urge upon you all to v.or'i- diligently in the pursuit of that thorough knowledge of the science of medicine, which alone will make the practice of it satisfactory. And above all things do not regard the profession • Dr. C'LiNE, House Surgeon, Montreal General Hospital. 19 as a mere means of earning a livelihood, and so enter upon it simply as a business. It is indeed a pitiable sight to see a medical man neglectful of the higher interests of his profession, and given over wholly to the pursuit of wealth. Remember, you enter upon a glorious heritage ; you will reap where you have not sown, and gather where you have not strawed, and t^e knowledge which it is your privilege to-day to acquire so easily has cost others much. We are all of us debtors to our profession : let us then, being mindful of those that come alter endeavour to add our little fragments to the pile. And now, remembering that we have other duties towards you than teaching the details of your profession, I would on this occasion earnestly Impress upon you the necessity of living upright, honest, and sober lives. The way of the medical student IS beset with many temptations, and too often the track he leaves is marked by as many lapses ; a zig-zag path, " To right or loft, eternal swervin'." Above all things be strictly temperate. J will not say that you are m duty bound to give up the use of stimulants altogether —though my own convictions on this poi:,t are very strong — but this I do say, that the slightest habitual over-indulgence 18 as the small flaw in some dyke that forms the barriertoa mighty flood, which widening that flaw day by day, sooner or later drowns every fair promise and brings inevitable ruin. To the thoughtful among you the speculative aspect of mod- ern science will sooner or later prove attractive. Do not fret entangled too deeply. I would rather give each of you good old Sir Thomas Browne's advice : not to let these matters stretch your pia-matcr. Lastly, you will not only be better, but happier men, if you endeavour to do your duty day by day. not from self interest, not from any outside aim however high, but simply because it is right, content to let the reward come when it will. " Knowe8t thou Yesterda,/ it^, rim >vmI reason ? Worked hou well To.r!a;j, tor worthy thin-. ■•' Then calmly wait T-o-mo.ro^,'* hi.l.Ieu sensoiK ■ And fear not thou, what hap 8oe'er it brings!" n "11 I il i I m mm §': H 'I; f" t^ A. w WI ie/irint« PRIN iv, CASE OF ^u^n^Mtjf^ fenitdoii d 3- ^T\nitittta (IIJIOJ'ATHIC OF ADIIISON.) BV WILLIAM GARDNER, M.D. PuoFEsson (IP Medical Jim :!HIS1'«(DENCB, ■llcOlLI, Univeksitv • WILLIAM OSLER. M.D., L.R.C.P. Lon... P«OFBssoH OP lK«m-t,-rB.s ok Meo.c.nb. McGiLi. Univku.sitv. h-e,>nnM /ro,n Oa.va..^ Medhml and S vuaicAh Journal, March, 1877. lktl_..x t I If, 'f!< ! ! i..iE£;, t i J i 1 I ri WI WIL Ruprinted , PRINT I >< f"''- ™», has diftculty m buttoning his clothes, or in usin. his tools Complains of a throbbing, rushing sensation in his tem°pl Says that he has snftbred from decided diarrhea for rather mro hanamonth, ultlienumberofmotionsincachtwentylb i™ aimoiraal Jhe superhcal cardiac dulness is normal iu extent" changed-tl e first sound perhaps less accentuated than normal pliv;: rr'""''" '''»--•-' "--^-dupTer the'tf'oui:;!' ''"'"' °"' "" --'-«' enlarged , Tlie most careful examination reveals n.M.-horo anv pi-menta ion or bronzing of tl,e skin. There is not the slight t'^Se of enlargement of any of the supc -flcial lymphatic .lanl Tl ! symptom of which ho complained most .as'the shoriut breal^i Inch as already mentioned, came o„,vhen he attZt d J Ik facing a wind, and ,vas so urgent as to compe Z „ rtop for a minute or two till he recovered his breath r* . If' m >'?u IMAGE EVALUATION TEST TARGET (MT-3) 1.0 !:: I.I 1.25 z ilia If 1^ 1.4 11^ |||M 1= i.6 V] <^ /} o ^/. ^ :--> .^ '<-> C//^ //a Photographic Sciences Corporation 23 WEST MAIN STREET WEBSTER, NY. 14580 (716) 872-4503 W^ ^ost mortem stains scarcely perceptible. No enh.rgement of the sunerfl- callymphatic .lands. No cadaveric odour. ' Braiu.—^ot examined. Oryiiaking the prehmina.y incision a lave.- ,.r deep vellow iji ftdly an inch m thickness, is cut throngh over the abd'omen. in M ' !''°''" '^ ' ^•^™"''^'^'''>' ''^^'-^'^''V red colour a the abdominal cavity the position of the viscera )..rmal. amoonrr^.'^''^^ ''"''• '" ^'"^ ^'''^^-^ ' considerable amo nt of fa over the pericardium. The left pleural sac contains twelve ounces of bloody, yellowish-tinged, serum. A fe.y strong adhesions posteriorly. In the right pleural sae ten to twelve ounces of fluid of the same character. Adhesions more numerous at apex and sides. PenW/^^„i._Contains six drachn.. of a vellowish. bloodv serum. No ecchymoses on either leaf. .hf.T:~f^?-' '""''''''"^y «''^bby. Sub-pericardial fat abundant about tlie base and in the anterior ventricular groove. Patch of at rition over upper part of right ventricle in front, and another behind, near the inferior vena cava. On openin.^ the lieart ,n situ an ounce of blood, with one small coagulum m the cavities of the right side, and ten drachms in those H r,, Tv^!'^'" ^^'''''^' ""^^ ''^^^' collapsed when laid on W , :, '°f '""''' "'™''- ^^''^'^'^ ^'*^"t"<^l^' ^'^^^ewhat •mated, he endocardium stained by imbibition. Tricuspid valves a little thickened and gelatinous at the edges ; orifice of normal size. Pulmonary semi-lunar valves healthy, one se-^- inent fenestrated. Cavity of left ventricle large walls S' normal thickness. Mitral valves .piite healthy, a little stained ; ordice proper size. Aortic semi-lunar valves a little opaque ; shght atheroma at then- bases, and on the aorta opposite their ll;''i f i- W\ i L idm :. J m ! f, I j 8 nils. GARDNKR * OSLER. free borders. Sinuses of Valsalva very distinct. Nothing abnormal in the left auricle. Muscle substance of the organ exceedingly pale, having a yellowish, faded-leaf apj rarance, especially marked in the walls of the left ventricle. Aorta.; both arch and trunk of full size. Beyond the left sub-clavian tlure is a flattened patch of atheroma, aboui the size of a halfnenny. Lunys. — Deeply pigmented; crepitant throughout; lower lobes (icdematous and dark in colour posteriorly. The mucous membrane of the Trachea at the bifurcation, and extending irregularly nearly to the larynx, is represented by a number of bony plates, lying immediately upon the cartilages, which are themselves very dense, and partially ossified. Spleen. — Weight, six ounces ; soft and llabby. Capsule a little opaque. On section, pulp soft, of a light brownish-red colour. Trabecuhc distinct. Malpighian corpuscles not evi- dent. A'ery little blood in Uio organ ; none could be obtained from the splenic vein. Left Kidney. — Length, 5 ". Unusual amount of superficial fat. Capsule loosely attached, and on removal leaves a very anaemic-looking organ. No atrophy of the cortex, which is pale and bloodless. Tyramids, except at the bases, also pale RigJit Kidneij, 4-^ " long, dark red in colour, uniformly con- gested, forming a striking contrast to the other. Capsule easily detached ; stellate veins prominent. On section, both cortex and medulla contain much blood. ' Supra-renal Capsules. — The right is soft in the centre, and somewhat larger than the left, but nothing unusual about either. Bladder. — Distended with pale urin-.;. Mucous membrane healthy looking. Prostate gland of full size. Tonsils and glands at root of tongue not enlarged. Several ecchymoses beneath the mucous membrane of the anterior wall of the pharynx. Oesophagus presents nothing unusual ; a few small extravasations are noti'-ed near the cardia. Mucous membrane of J-.hiach pale, and at the cardiac end thhi ; at the jiylorus it is thicker. Duodenum healthy ; common PUOOHESSIVE PKaNlCIOUS AN.EMIA. }) bile duct is pervious. Jejunum contains a quantity of .lirty yellowy inucus. Mucous membrane is pale. In the ih,m, leyerspatdics arc scarcely perceptible; the solitary dands owardsthe iloo-crccal valve are alone distinct. In iVo large fmvd iho mucous membrane is auix^mic. No ulceration ^cybala) m transverse and descending colon. .1 ^/r;T^"'''^'' '""""' '^ '"^ "S^"^ yellow colour, especially in he left obe. Capsule smooth. On section a small ,,uantity of IjquuUlood is seen in some of the hepatic veins, lu places there is a very slight injection of the intra-lobular veins, which relieves the otherwise uniformly pale surface. GaU-bladder.-~Fn\l of dark tarry bile. Pancreas. — Looks healthy. Abdominal blood-vessels almost entirely empty. No blood m inferior vena cava or aorta. Intima of both he'althy-looking. ilwranc Duct pervious throughout. Mesenteric and retro- peritoneal lumfUtio glands small, the former unusually so requiring considerable searching to obtain any. The amount ot blood in the body appeared remarkably diminished, and it ^3^ only by pressing along the limbs that sufficient could be obtained from the veins to fill a small homoeopathic phial • It 1 ?f '^'™"™' ^''' "PP^^ ^'^^f «f '•i^J't «l^"l.i, the inner third of left clavicle, half a rib, and one of the last dorsal vertebrae were removed for the examination of the marrow. Blood ^^^s collected from the heart, and junction of left jugular vein with the sub-clavian. ' '' A striking feature in the autopsy is the extreme arnvMuia of the organs, their almost entire bloodlessness, and consequent pallor, the right kidney excepted niSTOLOOrCAL EXAMIXATIOX. The blood taken from heart and veins shows the same gene- ral characters noticed during life. Prolonged examination of different specimens made for this special object resulted in the detection of two nucleated red blood corpuscles. Seart—The fibres are in a condition of extreme fatty defe- neration, the striai being obscured by the number of densely n 1 1 -I ( '. - 15 I 10 1)«S. OARUNKR .t Osr.KU. crowded droplets and lino molecular fat ; only hero and there a fibre occurs in which the striic arc faintly seen. In teased preparations numerous short hits occur, to^rothor witii oil-drops and granules of fatty matter. In places there appears to he a good deal of intorlibrillar connective tissue with fat cells. Muscles of the Trunk.— 'nia fibres of the thoracic muscles— which were observed to be of such a natural appearance- present no trace of fatty degeneration. Spleen.— 'n\Q ordinary corpuscles of the pulp, together with elongated, sometimes branched, cells of the retiforni tissue are the chief elements seen in teased specimens. The red corpus- cles have lost their colouring matter. A few cells containing red blood corpuscles arc seen, but no nucleated red cells. 7i:i'i/uy.— Teased preparations show the epithelium of the tubules, both in the cortex and pyramids, covered with fatty matter in the form of minute drops and fine granules ; nowhere, not even in the large collecting tubes, are the cells distinct. The Malpighian corpuscles also contain many granules and small oil-drops, and the same exist abundantly in the field. Liver.— Qe\h are stuffed with oil-drops ; none noticed without them, while in many the protoplasm and nucleus are entirely obscured. Free fat exists infiltrated between the cells, and in the field. In a few, bile pigment is seen. Mesenteric Glands.— Teased portions present a large number of perfectly normal-looking lymph corpuscles, among which the connective tissue elements occur in the usual proportion. Many of the small vessels and capillaries have their walls uniformly studded with fat grains, and may be traced as dark branching lines. In others, the deposition is not so extensive. Nothing abnormal observed in the axillary lymphatic glands. Medulla of Bones.— The marrow of all the bones examined— sternum, rib, clavicle, vertebra, fibula— is of a dark violet-red colour, thick, about the consistence and colour of the spleen pulp in fever. In the clavicle it is more diffluent, of a lighter red colour, and to the naked eye looks a little fatty— an appear- ance not noticeable in the other bones, not even in the shaft of the fibula. PROaUKSSrVE PERNtCIOUS AN.EMIA. 11 On microscopical examination, tlio following clement^ were found : — _ (1) Colourless corpuscles— marrow cells— of various size, with si-anular protoplasm, and bold vesicular iniclei. The g"oater nuniher of these are larger than white blood corpuscles, and usually have a single nucleus, sometimes two. Others are smaller, more approaching the blood corpuscles in form, while in all the specimens examined, small round cells, like ordinary lymph ." ,rpuscles, are also found. The above represent the common colourless elements found in marrow, and they form the majority of the corpuscles in the field. In eight of the larger cells the extremes of measurements were vVi" bv -,'./' and ,,V„" by ,-A,". ^'"'' (2) Coloured blood corpuscles, of which two varieties are seen; (^0 ordinary biconcave disks, somewhat irregular in shape, and often, as noticed in the blood during life, provided with long processes. They are abundant, forming the large proportion of coloured elements. In the fibula, sternum, and rib the colouring matter is retained, while in the vertebra and clavicle it has disappeared from most of the corpuscles, and they are recognizable only as outlines, (b) Small round red cor- puscles, non-nucleated, from one-quarter to one-half the size of ordinary corpuscles, and similar in appearance to the small forms seen in the blood. They occur most numerously in the- marrow of the fibula, where they form fully one-fourth of the coloured corpuscles. In the sternum and ribs they are not so abundant, though occurring in each field. As described in the blood itself, they do not appear to be biconcave disks, but spheres. The colouration is quite as intense as in form a, and a few were observed to be crenated. (3) Nucleated red corpuscles, the '' transitional " forms of Neumann, which are numerous in the sternun and rib, less so in the fibula, while in the clavicle and vertebra r!,ey occur scantily, or, owing to the general decolourization of the red corpuscles in these bones, are seen with difficulty. As shown by the measurements given below, they arc as a rule larger than ordinaiy blood corpuscles, but present, like them, a perfectly homoeiitchi8 Archiv. f. Klin. Medii in, April, 187(1 t Virchow's Archiv. IJd. G5. lift. 4. Dec. 1875. § I5ullotin (Icncral tie Therapcutique, 30 Julliet, 18TG II Boston Medical and Surgical .Journal, Mav, 1870 •' Bulletin General do Therapeuti(,uo, Doc."] 5, 187G. •* Brit. MedicalJounial, Dec. 30, J876. ft Berliner Klin. Wochcnfichrift, No 33, 1 870 « Ziemsscn'8 Handln.ch der speciellen Bath.' and Therrp. L'd. xiii Art Bro. Bernic. Annj^m . 1S7-, ' ''• §§ Cenlrnlblatt f. d. Med. AV is.sen. No. 42, 1874. rsil 16 DRS. GARDNER i OSLKR. after mounting. It is interesting to remark witli reference to the brge corpuscles, that Ilaycm* states that during a long course of iron— just such as this man had been subjected to— the red disks undergo an increase in volume. Until we possess more definite knowledge than we do at pre- sent of the variation in size of the red corpuscles in constitutional and febrile diseases, it would be hasty, from the limited iniml)er of observations, to conclude that the presence of the small coloured corpuscles is pathognomonic of, or even affords a positive diag- nostic sign in, progressive pernicious anrcmia. It remains for subsequent observors to note accurately the size of tho rod corpuscles in this disease, and it will not bo long before wo are in a position to arrive at a satisfactory conclusion on this inter- esting point. In a disease like pernicious an:\3mia, which after death is is not characterized by any important lesion in the viscera or glands, it was natural that attention should bo directed to the bone marrow, i structure now ranked among the blood-forming organs, and which in leukaemia, and pseudo-leukajmia (anivmi'a lymphatica, or Ilodgkin's disease) has been found remarkably altered, so much so that myelogenous forms of both have been described. AVith t! e two aifections just named the one in ques. tion is closely allied, and in its clinical features almost identical. From tho splenic and lymijhatic forms of both, it is distinguished by the absence of enlargement of the spleen and lymphatic glands, and additionally from leukicmia by the failure of any increase in the wiiite blootl corpuscles. In those rare cases oV leuksemia, where the disease is confined to the bone marrow— myelogenous form— the only distinguishing feature is the excess- ive number of colourless corpuscles in the blood, with, perhaps, tenderness over tho affected bones (xMosler). Immermannf quotes a case in illustration of this. In the still rarer cases of myelogenous pseudo-leukajmia, where the affection is uncomplica- ted with disease of tho spleen or lymphatic glands, a differential diagnosis would be impossible, (compare tho remarkable cases • Bulletin Oencml do Tlu'inpeutique, Dec. 15th 187(;. t Loc. Cit. p. C5I. ■ > PROGRESSIVE PERNICIOUS ANEMIA. Jf given by Wood*). It is not to be wondered at that some writers (Immcrmann and Jaccoudf) should hint at the identity of the two diseases, or that Pepper, encouraged by the appearance ot the marrow m one of his cases, should state that progressive pernicious anaemia was " merely the simple medullary form of pseudo-leukaemia." The evidence of an implication of the marrow in this disease rests upon the following reports: the first case in which it was examined was one of Pepper's, in which the marrow of the radius and sternum was - made up almost entirely of small granular cells." Passing over a case observec' Fede,i: and recordea as one of pernicious anaemia, but which ought to be regarded as a well-marked myelogenous pseudo-leuk^Bmia, the next observation is by Scheby-Buch,§ in one of whose cases the marrow of the radius was pale red in colour, and contained numerous cells like white blood corpuscles, and very few red corpuscles or fat cells. In Lepine's|| case nothing unusual was found. BurgerU states that there was no affection of the marrow m his case. By far the most extended account of the changes m the marrow in this disease is that given by Cohnheim in a letter to Virchow.** The following is a summary of the appearances described : Marrow of all the bonea intensely red ; tat almost entirely absent. Microscopically there were (1) ordinary marrow cells of various sizes, some small and lymphoid m character, others large and with vesicular nuHei : (^ ) coloured elements in almost equal number, of these the common, biconcave, red blood corpuscles formed a decided minority, while the number of red non-nucleated corpuscles of various dhnen- sions was very evident. The smallest of these had the diameter of normal red blood corpuscles, the largest were more thati • Am. jouru. of Medical Sciences, del 1871 t Nouv Diet, d^ Med. et de Chirurg. Leucocythemie. t Quoted in Centralblatt, f. die, Med, Wissen,, Oct. I6th 1ST5 § Ijoc. tit. ' ' II Loc. cit. ^' Loc. cit. No. 34, 187G. "• Virchow. Archiv. Bd. Ixviii, Hft., 2. Oct. 20, 1 876. ,,>' ■ 18 DRS. GARDNER & OSLER. double the slzo of colourless blood corpuscles, and between thera forms intermediate in size. (3.) Nucleated red cor- puscles in great abundance, and of various sizes, the majority equalling in size the smaller of the true marrow cells. The blood examined after death was also found to contain a few of the nucleated red corpuscles. In Quincke's article no details are given, and this part of the question is disposed of with the remark ; " The marrow of the bone showed no abnormality." In Bradbury's case, the red marrow from the right tibia looked natural, and was made up almost entirely of granular spheroidal cells, like white blood corpuscles. In that from the sternum the cells were much larger, and red globules more abundant. Coloured corpuscles were not numerous. These are the only facts for and against the view that perni- cious anaamia is the medullary form of pseudo-leukiximia. The general statement of Quincke, and the more definite ones of Lopine and Burger, are not very satisfactory, as no details are given ; still, they must be accepted as negative evidence. It may be held with Bradl.uiy* that the changes in the marrow of the sternum and radius in Pepper's case were scarcely sufficient to indicate serious disease of that structure, as only the normal elements were found, though in the radius in slightly increased numbers, and the same may be said of Scheby-Buch's case. In Cohnheim's case and our own the constitution of the medulla was altered, and, in addition to ordinary marrow cells, it contained lymphoid corpuscles, embryonal forms,t and red blood corpuscles of various sizes. The detection, too, in both, of the embryonal forms in the blood, though in quite insignificant numbers, places them apart from the others ; and on these grounds they alone arc strictly comparable with myelogenous leuk-^mia. Indeed, the qu estion at once arises whether we have not to do here with • Loc Cit. f III a recent note ia the Archiv, f. Mikroscop. Anatomi., Bd. xii. p. 796, Neumann expresses a wish that the term " tran.sitional," as applied to the nucleated red cor;)uscles, should be dropped, as involving an hypotheaU about their origin, advanced rather too confidently bv him. He would Mihstitiite the terra " embryonal " or •' developmental" form. an unco one of sympton be mad( anasmia might b( The a Quincke, cases is i must eitl complicai the diseai gory of m regarded depending of the CO) and the on Neuraai of Addiso Wood, ii a number dead of va case, founc probably a In 14 e> long bones only one wi its constitut bility of th( AItogeth( in chronic hyperplasia dary change Cohnlieim • Loc. Cit. p t Quoted in t Loc. Cit. I PROORESSIVE PERNICIOUS AyjESW,. jg an uncomplicated case of iiiecluIlarvn^onrL. In 1 • •• The absence of these chnnwa j„ *u Quincke, Lepine, and Bu.: =" /^l "^"7 " "^^ ^"^^ ^^ cases is independent of anfaff f . '°''° '" '°^'^^'" must either re^a d il?^; . .1 ""' ''^'^^'^'^^'^ ' ^"'^ ^^^ complication/ha^tru STol^^^ - an accidental the Lease, r refer all c s in . ,• TV ' ''"'' '' ^"'^''''' ^^ .or,of.,eWno:r;;^irtn^^^^^^^^^^ regarded as an accidental comnhcat 1 T l? T"^ ^' case, found any abundance of the loucocvtos •" L,^ ii. ° probably a case of leukaemia ^ ' '"'^ ^^'' ^"' A togethe the few facts we have arc opposed to the view that n chron,c diseases, accompanied with anaemia and w. tl' X^ t:!c ''' "^"^^^ '' ''' ^^"°^ ^-- -- - -cS; __Cohnhei;j writing to Virchow, on bis case, says, " You will • Loc. Cit. p. 293 !-54 1 I ! ,• 20 DRS. GARDNER i. OSLER. certainly agree with me in taking for granted that the above described condition of the marrow stands in intimate connection with the fatal disease of the patient. That in this affection (progressive pernicious anoemia) we have to deal with a prO' found disturbance in the constitution of the blood all observers are at one ; and, on the other hand, it can at present be no longer doubtful that an important disease of the marrow must have a serious influence on the composition of the blood." With this statement we concur, and are inclined to regard the aifection of the marrow in our case as the fons et origo mali. Our best thanks are due to Dr. Howard, of McGill University, who in his lectures has long taught the existence of Addison's idiopathic anaemia, and who kindly allowed us to have access to the manuscript of his paper on the subject. PE T^A i'RINTKI) 'K\d. CASK OF PROGRESSIVE PERNICIOUS i^NyEMIA. CLIXilCAL REPORT, BY JOHN HELL, A.M., M.l). PATHOLOGICAL REPORT, WITH REMARKS, BY WILLIAIVI OSLEE, M.l)., Professor ol' the Institutes of Medicine. ^fcGill Univeisitv. ^ontraei t PitlNTKI) BY LOYELL P xvumING and PUBLkSHING C 1877. O. '■ ? n ! * in ;'fe; I ' mit PE PA FlilNTED CASE OP PROGRESSIVE PERNICIOUS ANyEMIA. CIJ^CIOAL REPOHT, Br JOHN BELL, A.M., M.D. PATHOLOGICAL REPORT, WITH REMARKS, BY WILLIAM OSLER, M.D., Professor of the Institutes of Medicine, McGill Univor.ii^. fnonttatlt PRINTED BY LOVELL PRINTING AND PUBLkSHING C 1877. CO. I>^) .< h )i I i M; H" ffi i{» CASE OF l>liU(Ha<:8SlVE I'EliNlClOUS ANyEJMJA. CLIXIOAL REPORT. iiv JOHN liELL, A.M., M.I)., IWTIIULOGIUAL REPORT, WITH REMARKS. BV WILLIAM OSLER, M.D. I'rofesor or the lustitutos of Jlcdiciue. MoGill University. J. B., aged 47, a native of Loicostcr, England, a rubber weaver l.y trade, and a re.sident in tlii.s country since 1857. came under my care in 1875, .sutlbrin- from wcalvncss and Iosh of annctito which Bymptoms, with appropriate treatment and dieting, disan- poared In May, 187G, thoy recurred, and persLsted more or le«« ll.roughout the year. In February of present year his condition became .sucli a.s to require constant medical attention. His history IS as follows : lie is a man slightly under the medium height, but well built, complexion fair, intelligence good, family history good; one brother sulFcrs from dyspepsia, another is epileptic, lie IS married and has six children, all strong and healthy. For ti.e first ten years of residence in this country he farmed, follow- ing at the same time the occupation of a shoemaker. Subsequently ho came to Montreal, and for eight months was a conductor on the street Eailway, during which period he enjoyed excellent health. For the rest of his lifo ho served as a fcit cutter for overshoes in the Canada Ilubbor factory. His general health had always been good. A bout three years ago the purchase of a piece of property some distance out of town, and the anxiety consequent upon making the necessary payments, caused considerable mental worry, and he sutlered at the time from general debility. About tho same time two of Ids children had a mild form of typhoid Ic'ver. The chief symptoms ho complains of are excessive weakness and indisposition to exertion, together with loss of appetite. Tho skin is blanched ; mucous membranes pale, sclerotics pearly, and lie sutlers from palpitation and shortness of breath on exertion. On phy.sical examination the organs are ai)parently healthy; liearl sounds natural ; liver and spleen not enlarged ; no enlarge- ment of external '.ymphatics. No increase in t' ilourless blood ".f? ! 1 , 1 1^ 1 ; ^1i ! J 4 CANADA MHKIt'AL ASSOCIATION. (•(»i'|)ii,s(li..s, l)ut eliiingoH IoiukI in \\u' ml corpuaclos, wliicli will l»o noticed later on. Onloml {)ill of red'iccd iron, n,Ts. jj., and iilio.sj.liorns i M ri trr. M:iiv!i Mill. JIii:;i been dopiuswd in .spirits, and nicditiUihi^ suicide. Fools cliilly, luid lias attacks ol' occasional voniitiii;;-, a niunnur is uudil.lo at tlio base. IlearL't; beat I'ceblo. I'ulse, Toi. Tcm])oratiiro, 91) 5°. 17th. Vomited bilo on ^'cttinij; up. Lc^-s somewhat swollen ; fiice putty; complains of irreat weakness and shortness ofbreath, rin-^'ing in cans, and other siy-ns uf anuMuia. Stopped the pills and ordered cit. of iron and str;,:hnia. Temperature, 99-7. Pulse, 92. 22nd. Very little clian-e. Howols inclinoJ to be constij)ated. Urine natural looking, no albumen ; slight trace of sugar. Com- pl:un.s of indistinctness of vision. .Slcejis well. 27lh. lias been in bed .since 2 Ith. Hands and feel not .so murh sw.illen. Slight hacking cough. Feel.s too faint to sit up to have the bed made. Pulse and temperature about the -same. 31st. Has had for two days vomiting and slight purgin-', which are now checked. Urine natural. CompIainsOf numbness of left arm and hand. Vi.^ion impaired, sees peculiar coloured disks. Dr. Buller examined the eyes to-day and reports as ibllows : Choroid unusually heavily pigmented, hut a])parent]y aw^ry. where normal. Optic nerves pale, but not the pallor of atrophy, as there is no consjjicuous absence of the smaller ve.s.sels which are always observable in the healtliy optic papilla. On the surface ol the right nerve the upper of the two small arteries which may generally bo seen running transversely outwards towards the region of tho macula lutea, present a peculiar appearance, the portion traversing the face of tho nerve is much enlarged, .some- what fusiform, of a dark colour, like a retinal vein, but has not .sharply defined walls. Just beyond tho edge of the nerve this vessel isforashoi't distance almost nornial in appearance, but further outwards it is obscured by a thin, superficial, streaky-look in- extravasation of blood. Tho macula itself is occupied l)y an irre- gular dark red patch about half as largo as the optic papilla, ])i'o- bably an extravasation of blood. There aro a numijor of minute blood stains in the region of nerve and macula, nearly all of them thin and streaky, and generally close to .some retinal vessel of moderate size. Some a])p.'ar to bo in intimate relatioi. with tho retinal veins, others with the arteries; they aro all of the same dark throughou none towa paler and Tho pa spcctaclo : thinks visi Tho loi a I, so showe described i was not ni mitting a r A])ril 41 ness in clioi gets up. Ni Fooling transfusion to tho chan was accord kindly sup Iransmittinj was impossi ba.silic of tl withdrawn ] egg- boater being maint; then made ir ratiis in trod patient oxhi wa.s apparon color of tlie moval of tho tho iiajmon-li ligatures to I these boon pi ono or two oi ton minutes. an hour after began to rise accompanyin turo was 102^ DO I'F.RNICrOUS AN.l-MIA. '5 Hurno dark vc„oi.,scoluur. There is a sli.Ma l.a.ine.s of,!,e retina l.ron,,l,out ho ro,ion occnpiod by ex.n.vasati.u,, hut n,,. I - H .0 towards the equator ofthe oycs. The arteries arell ..ide, i • pnicM and .mailer than thoy should he in a stale of health The patient speaks of scoin,^^ a dark spot ahout the si/.eofa spoeaele lens be/ore tho oyo when he looks a. any obi- thinkw vision is not imjiaired. Tho left eye u-as oxan.ined by the di.vet melhod only, and .1- showed nurnerons small relinal lKemo,-rh..es similar to those "l-enbed u. the ri^ht eye. The region of the n^aeuh,, how ^, w=^ not minutely examined, the debility of the patie t not p ! "Httin- a more prolon^^'ed investigation ' April 4th.-l>u!se 112. temju.n.turelOO.r. Complains of tb-ht- noss .n chest, and pains in the bead. Feels siek at st.'maeh w 'n le gets up. Numbness in both hands. Feolin. that he could not ^o on much lon;;-er, be asked lo have Mnsfusion performed, bavin, been previously u-ell instructed as to tho chances of success, immediate and ren.ote. The opera im was accordingly performed on the Gtb at l.lt) p.m., I) B <-ily.^..ppIyin. tho necessary amount of bkid. I "J . , t-nsmittin.. the blood into one ofthe veins of the ibo badcoi t lo right arm was selecte.1. Ten om.ces of blood weio withdrawn from Dr. Buller, defibrinated by whipping with a v e ogg-beater and passing through linen (lawn) \h;tcnpera . on.g maintained by n.eans of hot water. A v shaped inci io . then made m tho vein, and the no..le of Avelings t -ansfusion a, IT J^. .nt^duoc^, and .ix ounces of blood pumped in^m::^ ^ patient exhibiting any uneasiness. The efTcet of the new blood -js api^ront ,n increased f^.llness of the superficial veins, a p " color of ho lips, and increased moisture of the «kin. At eri^ moval ofthe noz.Io from tho vein it was found impossible to check ho haemorrhage by a compress, so that it was necessary to app y gatures to both ends of the vein. It would have been Li Jul those been pLaced .n position before tho vein was o,,ened ,- as it was mK> or two ounces of blood were lost. The operation kited abo .; ton minutes. Tulse at the time was 102, temperature 99.1° Half an hour after he complained of feeling chilly, and the temperature boguntonse; at the end of the hour rigors were well mai^ked accompanying every eighth or tenth expiration, and tho tempera- ture was 102°, the pulse 120, respirations 34. At tho end of second i • i ' ■! i , s. t ' i i i hi !i m i: § CANADA MCOICAL ASSOCIATION. i» f-r homr Mfc^rl'.'ors liful liimiiiihlioil .MJincwliittt. I'lilso i;>2, intciniillont iiml looljlf i<>!«»>|>cni(iiro 10'}.1°. About Uuo*) liourH utul a Imlfaflor tlio oi)omlion iho tomiiciutiiro Wiis 104.1°, tlio hiu;liost it reach oil. Pnlso and roMpirations alioiit llio same, llo tals|iii'ations2S. Ueslopt toloral)ly well Unou^li tlie nij;lit, pasncd 5 viii of noi-nial urine, and towards morninj^ iiad a large lieallhy looking liquid stool, getting out of l»od for the |)nrpose. He ways ho is stronger, and his mind is clearer than iieforo the operation. April 7lh. — Tiie teniperaluro contitiiied to fall, and al R o'clocic in the evening was 01)°. Urine was passed three limes diii-ing the daj', and he had one stool in the morning. The pulse is (irmer, fuller, ranging from 102 to 112, and does not intermit. Takes nourislunent well, only vttmilcd once. Api'il 8lh. — Slept at intervals through the night, and took stimulants and nourishment well. Passe inches in height; com- ploxion fai ij-iir light, whiskers red. The skin presents a yellowish g. Freckles abumlnnt on forearms. Panni- culu3 udiposui^ thin. Brain. — Skull unusu;dly thick- ; marrcnv of diploe red. About PEKNICIOUS AN.KMIA. V'll 2 oz. ol" i^ovum cscMpori on removal ol' tlic (lur;i t i>ai Vessels »f tho piii iiiiitor empty. Paceliioiiluii ,4,n!iiiulafiniis niimoroiis. J{r:iin Hul)staiico palo, of good coIl^«i^(elu•^^ .\.)tliiiit,' nl)iioniial in the veiitrieloti or ganglia ut the base. Tiie leniarUaMo pallor of Uio tissues* ;h ti.o most nolipoable fo.itiiro. W'oighl, ."J Ihs. 3 ok. Thorax uiul Abdomen. — The voluntary mii.scloM exposed in the prolimin-iry incision are of a rich dark rod color. Jntcstinos aiul omontniii pal(> :'.nd hioodiess; ])osilion *f abdominal viscera norn'al. In t!ie thorax the riglit ])leiira (u)ntain>. a i)inl ol'roddisii scrum, the left half n pint, in which a few llociili of lymph are scon. There are pigmentary (?) deposits npon ptii-ietal layer over (liajjhragm and bodies of the vertebra'. J'erici(r) Small rod corpuscles— micro- cytes,— cri-oneously described by Eichorst us ])athognomonic of this allection. They wore numerous, StolO occurring in the field of No. !) im.and oc. 3. The diameter ranged from 1-5000" to 1-9000." They equalled, or even exceeded, in colouration the ordi- nary forms ; some were crenated, and they frequently presented a pit or cujvliko depression on one side. In the re])cated examin- ations of the blood, extending over three months, these forms increa.sed but little numerically. Schultzc's granular masses were not noticed. No appreciable difference could be detected in tlie histological ap].earnnco of tlio blood an hour after the transfusion. The /wart pn^senteil signs of moderately advanced fatty degen- eration, the stria3 hi many fibres being obscured by molecular fat and droplets of oil. Spleen.— Tho normal elements, cells of the spleen pulp, and spindle-shaped corpuscles of the trabeciila, together witli numerous blood corpuscles, were the only structures noticeable in teased preparations. Kidneys.— h\ I'Oth cortical a d pyramidal pinlions the cells of the tubules appear voiy granular, somewhat swollen, and a large number of oil droplets are seen in and about the tubules. Xu'er.— The cells contain oil drojw in excess, and in many the nuclei arc obscured. I'hero is also some fatty infiltration. Tho.r,!arr<:>r ofalNlic bones examined, sternum, ribs, vertobrte radius, fibula, was of a violet-red colour, of good consistence, and, 1 Uurliiier Klinisclii' Wochonpchril't, Xo, I'J, ;87V. PKKNICIOUS AN.KMIA. vvitl. the exception of tliat of tlio fi were found tlio oni inui numorous bula, y Iari';o, coarsely small lymphoid c(>r[Hi ■•ontuined no fiit. There ^■faiuilar, marrow ccll«, ole.s of «cle.s, ;uid rod blood cor both s.es ; and, in addition, vo.y n.ny nucleated J^^^,'! pnscle., corresponding with those described by various Z^^^ ocurr.n. ,n .he n.arrow in cases of leuka.n.ia and by Coh h . n' -f myself- as constituents of this tissue in c^n-tai c ^.s of ponnc.ous an.nna. They were most abundan u U o .narrow of the sternum, fewest in that of the verteb I Tl were considerably larger than the ordinary red ^Z,^ and ol about the same intensity of col.)uration. The nr C t"' . only one nucleus, but cells wlHMwo, three, and, bur wC^^^^^^ -'"-o"; The position of ,ho nucleus was usually ^c^^c" oHen, MHlecd, protruding halfway ,rom the corpus.de l^.e "h I were colourless. ' ' ne nuclei The disease which Addiso)> was the first to reco^^n^.e and de .scribe as Idiopathic Anremia has within 'he n-M flv,. f an unusual decree of interest, owino- ta i ur^'n''' '7!^'^ ^^. in IS7, by Biermer, of Zurich, oK.e;^:^?:^.;:^;:^-; onn of an.nua w fch he regarded us a new disease, uut ^vIHch ]>e,yave,a«mark,n.-thechief characters of theaifeciotl njune '-Progressive Pernicious Ana.nia." L.hert had ^^^^ l^"" abou ],e sa,no tune a. Addison, under the tern. '' Ess U a An i' mm. descn ed sin.ilar cases. Though, no doubt, 1 ! l^l, Add,son wro o, instances of tins disease ha.l been A-on^timf « .me observed, st.ll to hin. is due the credit of havin- l'Z\t in-st accurate clinical picture of the affection in his own inn.: -ay. Judge iron, the following quotation, which "^^ .otimometwithave.y;:^;.J.:;;tn;^;r.^^^^^ without any discoverable cause whateveiwcases "whi h "" iKul been no previous loss of bl.>od, no chloro:; :« . ''i; -nal. sph^nic, nnasmatic, glandular, strumou; or ' " ^ disease. According y, in speaking of this f;,rm in clinicd k^ u ^ , porhaps with little propriety, applied to it the tern. ' op^ ^^ to .listmguish it from cases in which tho-e ex-i^f.vl ' "''1'''^' '«• evidence of son.o of the usual cause. ^t^.^^u^V^ ^'^ ^;c_state. The disease presented in evci,- i:::::::^:^^:::; 1 Virchow's Arcbiv. Bd. Ixviii. 3 ContiaH^latl Wr Uic Jlcd. Wisseuscliarton, No.^ 15 and 2^. is;". ■i ijii ! M. ''! 10 CANADA MEDICAL ASSOCIATION. general cliaractorH. pursued a similar course, ami, with scarcely a single exco](tion, avus Ibllowcd after a variable period by the name fatal result. li occtirK in both sexes generally, but not exclusively, beyond the middle period of life, and, so far as I at present know, chiefly in persons of a largo and bulky frame and with a strongly marked tendoncy to 'l;o formation of fat. It makes its approach in so slow and insidious a manner that the })atient can hardly fix a date to his eariiosi feeling of that languor which is to become so extreme. The countenance gets ])ale, llio Avhites of the eyes pearly, the general fiamo flabby rnthor than wasted, the jiulse, perhaps large, but rcn.arkably soft and compressible there is increasing indisposition to exertion, with an uncomfortable feeling of Ihinttioss or breathlessness on attempting it; the heart is readily made to jialpitatc; the whole surliice of the body presents a blanched, smootJi, and waxy appearance ; the lips, gums and tongue seem bloodless ; the fiabbinees of the solids increases ; the appetite fails ; extj'omc languor and fair.tncsH supervene, breatli- IcKsness and pa'piuition being produced by the most trifling exer- tion or emotion; .'■ome slight a^doma is probably perceived about the ankles; l!;o debility becomes extreme. The patient can no longer rise ii'Oin iii-^ bed, the mind occasionally wanders, ho falls into a half torpid state, and at length expires." With this clas^i- oal picture the case hero reported corresponds in every particular, the characteristic feature being Iho profound aniemia, shown by the pallor of the skin and mucous moml)ranos, and the various functional sym])toms of this condition, hiemic murmurs, etc. ; no emaciation; progressive increase of all those symptoms in spile of medicaments wdnch are etTcctivc in the ordinary anaemias, and, lastly, the abseiic(^, iiost-mortem, of any changes to account f(;r the alfection, bloo'Hessness and fatly degeneration of the organs being the or)ly recognizable alterations. Our knowledge of the etiology of the disease cannot be said to have advanced juaterially since Addison wrote. The xory general fatty degeneration of the internal organs, by far the most constant and marked lesion, is to be regarded as a socondaf\' change. The coarse and histological changes in the spleen and lym])hatic glands, where, if anywhere, wo should naturally ex- pect to find alterations giving some clue to the failure in blood- making function, are not constant, sometimes they have been found slightly eidargod, at others atropluod. Lideed, so far as these organs are concerned, the luiraorous and careful observations of the pa them wh nect der. disea.se. and to tl certain si or pseud( this, viz., excess ; i varieties : enlargenn lymph gh tht "csea] acqnaintei in which tissue is n at any rat blood corj of atroi^hj cases of 1 more vasci corpuscles, whole tissi gous to thi be, as in a in leukaem definite sj ])arts of th tions are n- ofpseudo-l( similarity suggested 1 declared dii medullary As I ha referred ful 1 Berliner h Cliirurg. Lcucoi Hd. xiii. Art. I'l 5 Canada Medio PERNICIOUS AN^LMIA. 11 of the past five yeara have failed to discover any definite lesion in them which would account for the symptoms, or in any way con- nect derangement of their function with the production of the disease. In one direction, however, there has been some pro-n-ess and to this wo shall briefly alhulc. Clinically the cases present certain similarities to those of leuka>mia and IIodi.-kin's disease, or pseudo-leukaMiiia. Now these latter diseases d^itter chiefly in this, viz., th;it in leuka'mia the colourless blood corpuscles are in excess; in pseudo-leukaemia they are not. Both present three varieties: 1st the splenic, in which the chief lesion is the crreat enlargement of the spleen; 2nd, the lymphatic, in which the lymph glands throughout Iho body are mainly affected ; and 3,-d thf: "osearches of Neumann, Mosler, and others have made us acquainted with a variety Icnown as the myelogenous or medullary m winch the marrow of the bones is the seat of disease This tissue IS now generally regarded as sharing, in the young animal at any rate, with the spleen and lymph glands in the formation of blood corpuscles. In the long bones of the adult it is in a state of atrophy, and its ])lace, in great part, supplied by fat. In many cases of leukajmia and pseudo-leuka3mia, it increases, becomes more vascular, its cellular elements multiply, nucleated red blood corpuscles, such as occur in the embryo, are formed, and the whole tissue passes into a condition of hyperplasia, strictly analo- gous to that affecting the spleen and lymphatic glands. This may be, as in a case recently reported by aiosler,* the primary lesion in leukaemia, and the development of the marrow may produce definite symptoms, such as swelling and tenderness of certain parts of the bones ; so that the myelogenous forms of these affec tions are now well recognized. Clinically the myelogenous form of pseudo-leukaemia, though rarely uncomplicated, presents such a similarity to pernicious anaemia that Jaccoud,'' and Immerman'^ ■suggested the identity of the two affections, while Prof Pepper* declared distinctly that pernicious amxjmia was " merely the simnl'o medullary form of psoudo-louksemia." As I have quite recently, in commenting upon another case,'" referred fully to the facts for and against this view, I need not "Jaiiai- m'/'t 'T'- ^"'"'"'"- *'A:;;Ho:r jt.,^;of M ai: 'S;r ^2^'r 5 Canada Medical and Surgical Journal, March, 1377, '''-"^"ct.s, uct., I8.u. 1 i ; i \ ^ j sr! I ! , i 12 CANADA MEDICAL ASSOCIATION. recapitulate them here. In the present state of our knowledge it may, I think, be reasonably affirmed that curtain cases of idiopathic anaemia may bo placed in the category of myelogen ous affections, and among them the one hero reported. To many it may appear far-felched to .seek in the altered condition of the bono marrow an explanation of the extreme antcmia of this disease, but the reports of numerous cases leave no room for doubt that a serious alteration in its structure, and a return in adult life to its embryonic state, may profoundly influence the compo- sition of the. blood, producing anaemia and death. It must be borne in mind tliat the red marrow in the short bones of an adult probably equals in bulk the constituents of the spleen, and struc- turally is very similar to that organ and to the lymphatic glands. In the long bones it is largely replaced by tat, but traces of it still remain. Now, granting that the marrow is a tissue which shares in the blood-making functions, it is quite as reasonable to suppose that, if hyperplasia of the elements of the spleen ca;i lead to serious disturbance in the composition of the blood, pro- ducing the splenic form of leukjemia or pseudo-leukajmia, accord- ing as the colourless corpuscles of the blood are increased or not, so a general increase of the constituents of the marrow may induce similar conditions. For it is to be romcmborcd that, in a general hyperplasia of the marrow, the actual amount of lymphoid tissue in the osseous system equals or perhaps exceeds that of an enlarged spleen. Why a simple hyperplasia of this tissue should interfere with the elaboration of the blood, altering in the one case the mutual proportion of the corpuscles, and in the other simply reducing the total number, we do not know, but we are just as ignorant why an enlarged spleen and lymphatic glands should produce in the one case leukaimia and in the oiher not. Be Von Dr. Ein Gelegenhei suchen un schafFenhei Deri Symptome fusion gen Anamie u; Blat war ( Korperche und unreg lichen Mici feld von I oft eine D Suchens ni ahnliche El (Berl. klin Das J Wirbel, Fi nahme des gewohnlich kleinen lyt kleine, jed Korperchei 1877, 258) Brustbein, grosser ah Farbung. 3, selbst 4 excentriscli in diesem .Jt kt Sei rr Beschaffenheit des Blntes und Enochenmarkes bei H ''^ pernicioser AnSmie. Von Dr. Osler, Professor an der McGill Universitat in Montreal (OaDada]l^-~""* Ein zweiter Fall von perniciSser Anamie hat mir von Neuera Gelegenheit gegeben das Blut und Knochenmark genau zu unter- suchen und die Angaben von Cohnheim und von mir iiber die Be- schaffenheit des letzteren zu bestatigen. Der Patient, ein 54jahriger Englander, zeigte die ausgesprochenen Symptome jener Kranklieit und starb 2 Tage, nachdem eine Trans- fusion gemacht worden war. Die Leichenschau ergab nur allgemeine Anamie und starke Fettentartung. Das bei Lebzeiten untersuchte Blut war dunn und waasrig und zeigte keine Vermehrung der weissen Korperchen. Die gewohnlichen rothen Korperchen waren blass, platt und unregelmassig gestaltet. Die bei dieser Krankheit so gew6hn- iicben Microcyten waren sehr zahlreich, oft 10—12 in einem Gesichts- feld von Hartnack 9 imm. und 3. Sie waren rund, zeigten aber oft eine Delle. Kernhaltige rothe Korperchen wurden trotz langeren Suchens nicht gefunden, ebenso wenig grosse farblose, den Markzellen ahnliche Elemente, wie sie Litten als ira Blute vorkommend beschreibt (Berl. klin. Woi-henschr. 1877. No. 20). Das Mark allt'i- darauf untersuchtcn Knochen (Brustbein, Rippen, Wirbel, Fibula, Radius) war dunkel violetroth und enthielt mit Aus- nahme desjenigen der Fibula kein Fett. Es fanden sich in ihm die gewohnliclieu Markzellen, sowohl die gro.ssen grobkornigen, wie die kleinen lymphoiden, ferner rothe Blutkorperchen, darunter sehr viele kleine, jedoch nicht zahlreicher als im Blute, endlich kernhaltige rothe Korperchen, in jeder Hinsicht den fruher von mir beschriebenen (Cbl. 1877, 258) gleichcud. Sie fanden sich sehr zahlreich nainentlich im Brustbein, am wenigsten in dem Wirbelmark, waren betrachtlich grosser als die gewohnlichen rothen Zellen und von gleich starker Farbung. Die meisten hatttn einen Kern, doch waren solche mit 2, 3, selbst 4 Kernen nicht ungewohnlich. Die Kerne lagen in der Regel excentrisch, oft freilich halbweg^ aus der Zelle herausgetreten. Auch in diesem Falle erschienen sie ungefarbt. — aep.-Abdr, h. d. Centralbl. f. d. raed. Wigsensch. 1877, No. 28. Drnfk Ton H, 8. Harmua In Barltu. i Ueber Von Dr. Oslc Der oben gens Haut- und Blut zeigti gross, abe oval, andei und Fortsa man siu re feld (Hart ElCHHOHST bis 6 oder wareii (mit 0,01181 Mr: Suchen voi und schien* kornchen }'( Die L der Nieren nial und W( im Mesente Rippen, Cla ist dick, el Es enthalt: mit kornigt Dio meister wohnlicb ni runde, den korperchen massig gest: beobachtct, b) Kleine ri als die gewo zahlreicb in machen. 3) forrnen) sind genancten K rothen K6rp KVll Ueber die Beschaflfenheit des Blntes and Knochenniarkes in der progressiyen perniciosen Anftmie. Von Dr. Osler und Dr.Gardner, Profe.oren .„ McGill Unfvr.i.y i.. Montreal (C.n.d.). Der Fall betraf einen 52jahr. Englander mit alien Zeichen der oben genannten nnd weit vorgeschrittenen Krankheit. ausgenommeD Haut- und Netzhautblutungen. Das wfihren.I des Ub ns un '3 cht* Blut ze.gte P^olgen.les: Die meisten .otl.en Korporchen eZlTel gross, aber ohne de. gewohnlichen kreisfdrmigen Contur; vieirld oval andere von verschiedener Gostalt mit unregehua.sigen A. 8m«rrn undForrsatzen Sie sind bla«s und platt und vielo zoi/on au , wen" man .^ rollen as«t, nicht die biconcave Form. In. fedem G aiX MOKST (Cbl 1876, 465) beschriebenen Kfirporchon, zuweiien b.s 6 Oder 8. In 40 aufs Gerathewohl nnternommenen Mes Igen 0,01181 Mm Kernhalfge rothe Kdrperchen wurden auch bei langem Suchen verm.sst. D.e weissen Kdrperch.n zoigton koine AbnoS und sch.enen auch nicht vermehrt zu sein. M. Schultze's ZerX kornchen fehlen ganzlich. ^eriaiis Die Leichensehau ergab betrachtliche Verfottung des Herzens der N.eren und dor Le er, die Milz war oher et,vas kleiner, ala nor' n.al und wog nur 170 Grm., die Lymphdrusen nirgends vergrJert .m Mesenteru.™ .ogar sehr klein. Das Knochonma^k (von St rnu™ R.ppen ClavKula, Fi ula, Wirbel) hat eine dunkle vioIeVrothe FaTe' F .t'h n/n '^^•;, ^^-«''^'«- des Mil.n.renchyms im Fiebe ' Ks en halt: 1) tarblose Kdrperchen (Markzcllen) verschiedener Gestdi m.t korn.gem Protoplasma und deutlichem bl^schoufdrmigeu. Ke^ Do cneisten s, d grosser, als die weissen Blutzellen und haben le^ wohnhch nur o.neu Kern. Aussordem finden sich zahlreiche klefne runde, den Lymphkdrperchen gleichende Elomento. 2) Rothe Blut- korperchen .« zwei Arten: a) gewdhnliche biconcave, .twas unreie 1- mass.g gestaltetc Scheiben und haufig, wie auch wiih end des L bens eobachtct. mu langon Forts.tzen. Diese bilden den grdsseren TheU b Kleine runde, n.chtkernhaltige Kdrperchen, e.wa H-^ so gros ah d.e gewoln^hcl^n. ahnlich den im Hhu. geseheuon. Sie «in/S zahlre.ch .n der Pib.la, wo sie gut % der gefttrbten Elemente aue machen 3) Kernhalt go rothe Kdrperchen (Neumann's Uebergang - formen) s.nd zahlreich im Sternum und der Rippe, i„ den anderen gena„,ten Knochen sind sie sehr sparsam oder wegen dor BlLse der rothen Kdrperchen hier schwioriger zu aehen. Listens and Z i 3i,.r, (Hi nn ? ', ? grosser, als die gewohnlicheu rotben Korpcrchen, zeigen aber, wie diese ein gaiiz glcichmSssio- ^efai btes Stroma mit einem fein-^ramUirten Kern. Sie stellen runde, nicht biconcave Schoibon dar, oft mit un- regeltiiassigen Umrias^n, oder mit einem spitzen Auslauter. Ibre Far- bung ist meiHt eben so starlt, wie die der L»evvoliiilicben rotben, zu- weilen stHrkcr, oder schwacher. Die Kerne sind riind oder elliptifich und nehmen %— H ilea Zellitorpers ein, sie sind solid, gt^kornt inid erscboinen in dcin Zellen gefiirbt. Ein Kcrnkorperchen konnte nicht wahrgenomnien werdon. Die Lage des Keins in <1on Zellen war ver- scbiedeii, bald nacU dom Tode erscbien er central gelagert. In den am folgendi'D Tago untersucbten Probeu da^()^;en lagen vieli; Kerne peripberiscb und andere waren aus den Zellen ausyetreten und er- Bchienen nun ganz ungefarbt. In 3 oder 4 Proben wurden Kerne von Dumbbell- Form gesehen. Zellen mit 2 Kernen waren nicht selten und auch solobe mit 3 oder 4 Kernen wurden beobaclitel. In 15 Measungen ergaben II einen Durcbmesser dieser Zellen von iiber 4),01250 Mm. Im Folgenden geben wir die Messungen von '.i Zellen mit ibrem Kern: 1) 0,01409:0,01136; Kern: 0,00954:0,00863 Mm. 2) 0,01 136 : 0,01045 ; Ker n : 0,00454 : 0,00500 Mm. 3) 0,0 1 227 : 0,0 1 272 ; Kern: 0,00682:0,00772. Es erbellt hieraus die Unregelmassigkoit der Form dieser Korperchen und die annahernde elliptiscbe (Jeatalt der Kerne. 4) Bliitkorperhaltige Zellen, sebr reieblich im Wirbelmark wo 3 — 4 in einem Gesichtst'eld erscheinen und 5 — 6 rotho Kiirpercheii mit deutlich erbaltener Farbe und Gestalt entbalten. Im Sternum und Rippe sind sie viel sparlicber, in der Fibula und (Jlavici;' gar nicht zu sehen. 3) Von Myeloplaxen wurden 1 — 2 im Sterui - und Rippenmark gefunden. 6) Fettzellen im Clavioularmark .ii gerin- ger Zabl, im Sternum-, Wirbel- und Rippenmark gar nicht zu tin- den. 7 ! CHAKCOx'sche octaedrische Krystalle waren iiberall im Mark 12—30 Stundfin nacli dem Tode zu findeu. Der besebriebene H'fund gleieht ziemlicli dem von Cohnhkim*) beacliriebenen. Auch Pkppek**) mid Schkby-Buch***) erwahnen Hyperplasia des Marks bei pernicioser Aniimie, so dass es walir- Bcheinlich ist, dass gewisse ''alle dieser Krankheit zur myelogenen Form von Pseudoleukaniie zu recbnen sind. .' u *) ViRCHOw's Arch. LXVIII. 2. **) Amer. Joura. of med. sc. 1875. Octbr ***) DeutBclies Arch f. klin. Med. 1876. April. Sep.-Abdr. a. d. Ceutralbl. f. d. med. Wissenscb. 1877. No. 15. Drnek ran H, S Uermanii In Berlin MX 0VER8TEATN OF THE HEART AS ILLUSTRATBD BY A CASE OF HYPERTROPHY, DILATATION AND FATTY DEGEN- ERATION OF THE HEART, CONSEQUENT UPON PROLONGED MUSCULAR EXERTTON. — HY- ' •■•■< WILLIAM C)Sr.ER, M.ix, JSOFBSSOH OF THB LvSTITUTES OF MbdICINE, MoOiLL U.VIVEnsiTV, MONTREAL. -:o:- (From the Canada Medical and Surffkal Journal, March, 1878. v;v;wjtV»tal . FEINTED AT THE "GAZETTE" PRINTING HOIIgE 1878. ! I I I , i i I ill ■m i (] HVP I'liOTE.SS OVEUSTRAIN OF THE HEART, AS II.M-STIIATEI) nv A CASE OF HVPERTROPIIV, DILATATION AND FATTY DKGKX- KRATION OICiMK HKART, CONSEQUENT UPON PROLONGED MUSCULAR EXERT] OX. -in- — wii.i.iAAF ()sr;i:i{, ?^r.ix, I'liOKKSSOl! OF TUB I.NSriTrTES „|.' Mkdi.'INI-,, .McHlI.L I'.M VKliSITV, M,..NrllKAI, (Fiom (he Canada Medical ami StirjIcalJouiiiaf, Man-/,, 1878.) ! I H I i' flonirral: PRINTED AT THE "GAZETTr:" PUINTING HOUSE 1878. ' 1 liji P 1 1 I 1 (From Canada Medical and Surgical /oiirnal, March, 1878 J CASE OF HYPERTROPHV, DILATATION AND FATTY DEUEN. EUATION OF THE HEART, CONSEQUENT UPON PROLONGED MUSCULAR EXERTION. Do fatal and uncomplicated cases of hypertrophy and dilata- tion of the heart ever occur as consequences of severe and prolonged muscular exertion ? The following case is offered as a contribution to this question, upon which there is as yet a considerable diversity of opinion among Pathologists. On Nov. 7th, 187G, I performed an autopsy on a large, power- fully-built, muscular man, who had died with all the symptoms of chronic valvular disease, and in whom great dilatation and hypertrophy of the heart were found, but without presenting any of the conditions commonly recognized as productive of these states, — no valvular affection, no arterial degeneration, no erapliysema or other chronic pulmonary disorder, no renal disease ; there was, in foct, an entire absence of the lesions usually met with in cases of this kind. I am indebted to my colleague Dr. Ross for permission to use i r i m V\ K % I I !i! :m i: ? the following clinical notes, taken by Dr. James Bell, at that time the ward clerk : J. W., ict. 39, an Englishman, was admitted into the Montreal General Hospital, Nov. 2nd, 187(5. He is a large, powerfully- built man, with tremendous chest girth, lie had been a soldier for 18 years, serving in the different British stations, and latterly has followed the occupation of a blacksmith. Has never had syphilis, or rheumatic fever, lias always been a healthy man, though intemperate. In July last he suffered from shortness of breath and slight h;cmoptysis, for which, in August, ho entered the hospital, and was under treatment nearly two months for '' some heart affection," being discharged very much improved. He then worked for three weeks as a day labourer and suffered mucli from exposure to cold and wet. On October 20th he had a chill, which was followed by swelling of the legs and abdomen, with slight dyspnoea. He gave up work on the 24th, and was treated as an out-door patient for a few days befa'c enterin" Hospital on November 2iid. When admitted, in addition to the above-mentioned symptoms he complained of great pain over the region of the heart. The logs were oedcmatons, and the conjunctivic and face of a sub-icteroid hue. On physical exam- ination, the cardiac dulness was found to extend a? high as the niipcr border of the third rib, and to the right iKUler of the stern-.nn. A systolic nmrniur was heard at the loft cr.ge of the sternum in the third interspace. Apex beat could hot be dis- tinctly felt. The pulse at the wrist was barely percei)tible. There was dulness o^■er the lower lobe of the left lung, liougli snoring rales were heard over the froi.t of the chest and coarse bubbling r:\les behind. Liver dulness extended from the r)th intersrice to the costal margin. The urine contained nearly 25 p. c, of all u uen. The day after admission he expectorated nearly three /.ints of florid blood and vomited very frequently. In spite of treat- ment (dry cupping, ergot, digitalis, etc.,) his condition became worse. On November 5th the pulse was (^uite imperceptible at the wrist, the cyanosis became extreme, and the patient died early on the morning of the 5th, with all the symptoms of chronic valvular disease. 5 Fost-mortem, 30 hours after deatii. Face, neck, and skin of thorax intensely livid. Tissues beneath the skin of anterior ,,art of trunk and about the root of the neck emphysematous. Scro- tum much swollen. Legs ocdematous. i?.a/«.-Sinnses of dura mater and veins of the pia mater >»11. Arteries at the base not diseased. Xothin? abnormal in the brani substance. Eeart^^, G 10 grms. (2U oz.) Right chambers distended w.th dark clots an.l fluid blood ; the ven^x. cay^ are also dilate.I and full mucl, blood escaping from them in the removal of the organ, l.ght auricle is very large, size of a small oran^-e: .valsol ab„ut the usual thickness, llight ventricle dilated, antenor wall measures 1" in thickness : column^x, carne.x^ are no hypertroph.ed. Tricuspid orifice oT" in circumference : valves healthy Puhnonary valves normal ; circumference of onhce o Left ventricle contains some fluid blood, and a small partial y decolourized clot in the mitral orifice. The chaml>er i. inuch dilated, measuring 41" from apex to aortic rin^-, and buboes considerably towards the right ventricle. Kudocanlium thkdi and opaque, especially over the septum. Masculi papillaros iibroid at apices ; walls over middle cf anterior part 4" in thick ness; posterior M-all J"; ventricular septum, a quarter of an mch below aortic valve, A". Mitral valves slightly thickened at the edges, otherwise healthy. Orifice measures 4^" in circum- erence. Aortic valves competent, segments thin and natural- looking ; orifice at the ring measures 2,^' in circumference. Aorta looks-relatively-smaller than natural. It is not athero- matous either in the arch or in its course. Muscular substance 0. whole heart, and especially the left ventricle, looks pale, and on e.xamination is found to be in a condition of advanced fatty degeneration ; much fotty infiltration also exists between the individual fibres. Arteries of the body present no signs of degeneration. Lungs, gxcvi of serum in left pleura, the Iuul^ on this side ,s collapsed and only slightly crepitant above. Two very large spots of apoplexy in the anterior part of upper lobe, and N. '..11 li 1 i I 1, about them the Inn;,' tissue is hepatizod. Another, also larj^e, occupies tlic anterior bonier of the lower lobe. Right lung is crepitant, but contains much blood and scrum. At the lower and front part of anterior lobe is a small, consolidated area. Spleen, 250 grms.,firm. A/dne//.s, not enlarged. Capsules detach easily ; surfaces smooth. On section pyramids and Malpighian tufts of the cortex are injected. Stomach and intestines present nothing unusual ; tlie largo and small veins are very full. Liver, a little enlarged, of good consistence; venules of hepatic vein gorged — nutmeg organ. The degree of hypertrophy and dilatation will be seen at a glance in the following table : Heart of J. W. lliglit ventricle, ant, wall. Left " " " post. wall. length 4.;")" ^Iitral orifice, circumference 4.2;V' Aortic '•'■ Tricuspid "• Pulmonary orifice ^Vcii:ht of Heart 8'" 87" .A" 2.Y,y (Peacock.) Normal Huiirt. 1.8o .53" 3.38 3. .58 3.17 4.50 M (BiZOT.) Noimiil Heart. 0.43" 2.61 4.21) 2.74 4.81 2.79 9.75 oz. 5.87" - 3.3" - 21.5 oz. The dilatation of the left ventricle is very marked, while the hypertrophy of the ualls is moderate. Judged by Peacock's standard, the mitral orifice is somewhat dilated while the aortic ring is even smaller than natural, though by Pizot's standard it is just normal. It certainly appeared very much out of propor- tion to th- huge left ventricle. The tricuspid orifice is very largo, and the right chamberconsiderably dilated, while the opening°of the pulmonary artery is about normal. The hypertrophy and dilatation in themselves i)rescnted nothing remarkable, and the other lesions were those of every- day occurrence in organic heart disease— hydro-tliorax, ccdoma and h;tmorrhagic infarction nf the lungs, venous congestion of ^4.4i4. the hver, spleen and kidneys ; the fatal result depending on the condition of the lungs. But what could account for the hyper- trophy and dilatation ? This was the difficulty, and so impressed was I at the time with the unusual character of the lesion that a most searching examination of the different organs was made and careful measurements of the heart were taken, but no satisfactory cause could bo found for the cardiac affection, so that the notes were laid aside and the case labelled ' idiopathic' A few months after, in Nos. 17 and 18 of the Berliner Klin- uche Wochemchrift, 1877, there appeared a paper by Dr. Zunker, one of Professor Leyden's Assistants at the Charite, Berlin, on a case of " Dilatation and Fatty Degeneration of the Heart, in consequence of over exertion," which, in its clinical features and anatomical characters is almost the exact counter- part of the one under consideration, except that the dilatation was a little more marked and the hypertrophy not so great. This gave a possible clue to the interpretation of the case, and I immediately made enquiries about the past life of the man, but was not very successful, as his wife had left the city, and from her alone could definite information have been obtained. It was, however, ascertained, that after leaving the army he had worked as a blacksmith, and subsequently as a corporation labourer. He was, as I have said, powerfully built and very muscular, an acquaintance describing him as a " perfect picture of a man." From the facts I have gathered, and the similarity of the case to several which have been recorded, I am inclined to regard the condition of the heart as intimately associated with and dependent upon the over use of a highly developed mus- cular system, . Before dealing with the question of how the abnormal state was brought about, it may be well to make a few preliminary remarks on the influence of prolonged and severe muscular effort on the circulatory system. In the works of one or two of the older writers upon the heart very definite statements are met with bearing on this question : Thus — W\ s Corvisart.* among other causes of lioart disease, mentions imisculai- exertion, and records a fatal case of hypertrophy without valvular disease following violent exertion. Ilopef states that " occupations requiring constantly renewed muscular efforts," produce in time dilatation of the heart. T.athanil was, I believe, the first to recognize fully the impor- tance of over exertion in the causation of heart affections, and under the term "shock of the heart," describes cases of rup- ture of valves, and of hypertrophy, following suu.icn and severe muscular efforts. The attention of army surgeons was early called to the prevalence of heart disease among soldiers, and in the great majority of these without any history of acute rheumatism." ^ McLean^ brought the subject prominently before the authori- ties and the profession, believing the evils to result largely from the constricting iuHuenco of the regulation pack and" other accoutrements upon tlie chest. Peacock. II about the same time, in his lectures on valvular diseases, showed how liable the valves were to injury from riolent muscular efforts. During the American civil war the injurious effect of militarv life upon the heart was abundantly proved, and the rich clinical material then afforded enabled several observers^ materially to advance our knowledge in this direction. In 1870 an important monograph by jMyers" appeared, • Tioati.sr oil tlu' Discasis an.l Organic Lo.sions of the Heart, translatccE liyHobli, Loiiiloii, 1813. pp. 28, 03. t A Truati.se on Uisea.ses of the Uant 2n(l edition, London, isr.j. t Lectures on Diseases of tiio Heart, London, 1S43. §Lectin-oat Koyal Unitoil Service Institution, lS(i3. — I'.rit, Medieal Journal, 18GT. nv,.uiwn II Valvular Di.'^ea.ses of tliu Heart, London, 1865. ^Dii Co.sta: (^hservations upon Heart Disease in Soldiers. Jtedie.-il Memoirs ol the ( nited States' Sanitary (Jommission, 18U7. Tayh.r: lleinnrks on Heart Disea.se.-Transactions of American Medicil Association, vol. 18, 18()7. Da Costa : Onlrritable Heart.-'' Arn. .Journal Med. Sciences," .Fan. 1871 . midwel : On Over-w..rk and Strain of the Heart.— ' Uoston Medical ami Surgical Journal," 1872. •• Diseases of the Heait tmumix .Soldiers, London, 1870. < I and since that date important articles have been written hy Albutt,* Seitz,t Thurn4 Frrinkel,§ and Levy,|| illustrating^ in. various ways the effects of over-work and strain on the he'art The recent works on the hcartlf deal cither not at all or very cursorily with the subject. The above constitutes the chief literature of the subject and from an analysis of the papers the following conclusions may be drawn with regard to the effect of overwork on the heart. _ 1. Sudden and violent exertion may cause rupture or lacera- tion of the valves— a very serious lesion, which often proves fatal within a short time. •2. The augmented resistance to the flow of blood during severe and prolonged muscular exertion increases the work of tire heart, which, in response to the demand made upon it, enlar.res. The blood pressure in the aorta, abnormally high even during the diastole, is much increased during the systole of the powerful left; ventricle, and the coats of the vessel yield, commonly at the arch becoming pouched and atheromatous. Incompetency follows' either from stretching of the aortic orifice or giving Avay of the valves.— (Albutt.) -•]^In the functional disorder of the heart described by Da Costa, Myers, and others, as common in young soldiers and termed by the former, ' irritable heart,' there is hypertrophy of the muscular walls of the organ, caused by over-work at drill and the constricting effects of the military accoutrements. This may in time be followed by valvular disease. ^^It appears from a number of recorded cases that overwork vJl."?;™^ '"" '''"'" ''''''' "'^'^^t-^t.Oeorg.-. Hospital Reports, f J mS'S^-V'Srr^'"""""" '" Hor.ens.-Deutsches Archiv. § Virehow's Airhiv. Bd. C7. „„L?" S*"""" ^"'■'l" °" '^^ I'asystole sans lesions valvulaires These- iuaii g.nalo, Nancy, 1875. Resume in Archives Generales. Janvier. 1870 •fZiemssenn Encyclopedia of 1-ractical Medicine J.ajfoiir—Diseiises of the Heart, 187r) Ilayden— Diseases of the Heart and Aorta, 187,-,. Kcynold 8 System of Medicine, vol 4 1ST 7 ' |i;" \l. J' -ill 'I I It ' U '! '. If ll e- ,4? II t tJ 10 -of the muscles may induce a primary dilatation and hyper- trophy of the heart, which, without valve affection or arterial degeneration may prove fatal, with all the symptoms of chronic ■ cardiac disease. It is this last condition to which I wish specially to direct atten- tion, as I believe the case reported aftbrds an illustration of it. Very few of the writers mentioned above, though dealing specially with the effects of over exertion on the heart, appear to be aware of the possibility of a fatal result as an immediate sequence of primary hypertrophy and dilatation. Peacock* records three cases in which after death no affection of the valves or orifices was found, but simply hypertrophy and dilatation, and explains these conditions by supposing " that from the enlargement of the left ventricle which existed in all the cases the mitral valves had not been properly adjusted during the systole." He offers no explanation as to the cause of the enlargement of the heart, but passes on immediately after to the state of the organ in the Cornish miners, which he refers directly to the severe muscular effort necessary in their work and in climbing long ladders up and down the shafts. Seitzf gives a remarkable series of cases observed in Biermer's Clinic in Zurich, almost all of which presented the following symptoms : " Palpitations, and ill-defined sensations in the cardiac region as if the heart were about to stop, shortness of breath, anxiety, feeling of faintness, cyanosis, anasarca, enlargement of the liver, irregularity and intermittent action of the pulse, dila- tation of the heart, apex beat feeble and dislocated downwards and outwards, increase in cardiac dulness. Heart sounds sometimes normal, but not unfrequently murmurs at the apex." Post-mortem, the anatomical chang-^ • were confined to " Hyper- trophy of the walls and dilatation of the chambers, valves un- affected ; degeneration of a few muscle fibres rarelv fatty." He regards over work as the most important factor in the pro- duction of these cases. In the case reported by Dr. Zunker from Leyden's Clinic, the * I.oc. cit. t Loc. cit. p. Gl. 11 connection between the over-exertion and the heart disease ia very well brought out. The patient, a journeyman mason, had enjoyed good health up to six weeks before his admission. During this time he had been engaged in the unusually severe work of carrying heavy stones up long ladders, llo etood this very well for three weeks, when he began to suftVr IVom want of breath and a slight cough. Soon palpitations came on, the short- ness of breath increased, the legs began to swell, and lie was forced to take to his bed. lie got rapidly worse and was sent to the Charite cyanotic and almost moribund, llydrotliorax of the right side was detected, the chest was tapped, and 128 cc. of clear fluid were drawn off with great relief ; but the attacks of dyspncca recurred, and he died four days after admission with all the symptoms of chronic heart disease. At the autopsy the heart was found enormously dilated, the walls in a condition of fatty degeneration ; no valvular disease, no chronic renal or pulmon- ary affection. In the case of J. W., the evidence of prolonged muscular effort is presumptive rather than direct. The occupations which the man had followed guaranteed a tolerably active •exercise of his voluntary muscles, and it has been from among soldiers and smiths that a very large proportion of tliesc lieart cases have been described. Moreover, the high development of his muscular system afforded the best possible proof of its constant use. There must have been some agency at work to produce the dilatation and hypertrophy, and considering the above facts, and iv the absence of all the recognized causes, I i'eel more inclined to regard it as due to overwork than to look upon it as spontaneous or idiopathic. But how, it may be asked, is all this brought about 'i Severe muscular exertion affects the circulation in two ways : first, by interfering with respiration and the free passage of blooii through the lungs ; the right heart gets over-loaded, the systemic veins iull, and thus an obstacle is offered tu the outflow of blood from the arteries ; in consequence of which the left ventricle becomes dilated and must hypertrophy to overcome tlio increased resist- ance to the an d flow. According to Peacock, the lar W'''^ ^li "•e j I!' -^ 12 hearts of tlie Cornish miners are produced in this way. In the June number of Von Ziemssen's Archiv, there is an interesting article on " Das Tubinger Ilerz.," by Dr. IMiinzinger, descriptive of a form of heart disease simiKar in some respects to the one under consideration. It is met witli among the vine dressers who undergo very severe work in carrying manure in baskets on thoir backs long distances up the mountains. The exertion ro- (luired is very great, and the respiration is considerably interfer- ed with by the constricting pressure of shoulder straps. Sooner or later they suffer from dilatation and hypertrophy ; but as this has always been found associated, post-mortem, with emphysema, it is difficult to say in these cases how much is due to this condition and how much to the muscular effort itself. Secondly, the effect of over exertion may act in a much more direct manner. The experiments of Traube upon dogs have shown that during extensive muscular contraction the blood pressure in the arteries is greatly increased, and the same may reasonably be inferred of men. The more laborious the work, and the more violent the contraction of the muscles, so much the greater difficulty has t'e blood in flowing through the systemic arteries. The arterial pressure is increased and the blood tends to accumulate in the aorta and the left ventricle. If the nutrition be maintained no ill effect will follow from this, for the left ventricle hypertrophies and the balance is restored. That this state does exist is a well attested fact, and Albutt speaking of this early condition of hypertrophy says " that he has found in a few autopsies of such men killed by accident or acute disease, that the ventricles, the left especially, are, like their bicipites, large and red," the heart weighing as much as IG oz. The lower animals furnish good examples of liypertrophy following severe exercise. Houghton* states that the heart of the celebrated greyhound, ' Master Magrath,' weighed 0.57 oz., just three-told in excess of the normal proportion of heart- weight to body-weight, and no other cause could be assigned for the great enlargement than the prolonged muscular effort in coursing. * " IJritish Med Journal," 1872.. la The hyperti-opliy is rai-oly simple, being accompanied as a rule with dilatation, and to this latter the train of ill ell'octs in these cases is chiefly due. In the case before us at some time or other mitral insufficiency was established, either from a dilatation of the orifice, so that the curtains could not meet to close it, or, what is more probable, as Bristowo pointed out, from a degeneration in the muscular papilUic and tendinous: cords, resulting in a mal-adjustment of the valves. The apices of the papillary muscles were fibroid, in })laces calcareous, and the cords somewhat shortened so that they might readily be supposed in the dilated chamber to '• tether tlie valves too closely and prevent the ap[)osition of the segments." Wo may reasonably infer that this man had had an hyi)ertrnphied heart for years, the balance of jjower being pre- served so long as the nutrition of the organ was kept up. With the onset of fatty degeneration came the disturbing element ; the walls, no longer able to resist the blood pressure, gradually yielded, the dilatation overcoming the hypertrophy. With tin's would follow all the ill cilocts of loss of compensation as in ordin- iry cases, and just such as have l)ecn reported in this one ; congestion and anlema of the lungs, dilatation of right chambers, general venous stasis.— all the symptoms in fact of a break- down in that marvellous piece of machinery, the heart. ■^H ; • 'im Hjf ^ i ,M ^^^^1^ ' - '' m^K ^H^E| .| j£4'^H Ki m ^B||hh ^HHi/'f '*™iii^H. HB| ' , ^^K: ^^IH ^^^^B HB ' '-' W/t Hi! iWB B|| ^ ^^^K \ £^l ^^^B l^^l Kl" V if f*^ ^ t I 1 li ' i ; m ilii I' I I<1 t t It )S 5 1 tS ry C4 ?! xxn MONTREAL GENERAL HOSPITAL. PATHOLOGICAL REPORT Foil TUB YkAR KN1)IN(J Mav IST, 1877, BT WILLIAM OSTJ^; M. D. Or Mcflii.L Ln IVKRaiTV. ' Pathology is the basis o! .i.'l true instruction in practical medicine."— Wil *i.-s! J §h 1 I. . - f (if !i i VOLUME I. MONTREAL : DAWSOX BROTHEES, PUBLISHERS, 1878. I,- imLi IlJ -ii I ^0 Mu ^mhr JAMES BOVELL, M. D. MBBITOS PROFESSOR OF PATHOLOGY IS THK TKINITY MEDICAL SCHOOI.. TORONTO' THFS FIRST VATHOLOQICAL REPORT FR03I A CANADIAN HOSPITAL IS ORATEFULLV A.\U AFFECTIONATELY INSCRIBII). I ! ;i 1 1 , I' .: kt en foi iiit r by ins Be; nol J the ^ giv atfe mel as a ]>at] T the onh thei tiga 13.M TREFACE. Records of exactly one hundred autopsies have been entered in the post-mortem book of the General Hos-ital for the year ending. May 1st. 1877. A few of special mterest occurring n private practice have been included I he post-r . ms are performed under my supervision by the stuc Jtending the Hospital, and the system of inspection followed is that of Virchow, at the Charite Berlin, fully given in his " Sections '^echnik." The notes are taken on the spot from dictation. In the foUowini.- Report brief summaries are oi\ on of the cases of practical and scientilic interest. When possible, a synopsis of the clinical features is also given. The cases are grouped under the various om-ans atfected, as this i., thought to be a more convenient method than dealing with the individual diseases • and as a rule, the organs are dealt with in the order of their pathological importance. To the Medical Staff of the Hospital, by whose order the autopsies are conducted, I am deeply indebted not only for permission to publish this report, but also for their kind courtesy in all matters relating to these inves- tigations. ! ti'u I .,[5 r 1 1 t'l.' i ! ; 'h\ f , la.M St. ('ATHElilNE SritEET, Dec. loth. 1877. i I I CONTENTS. OSSEOUS SYSTEM. Fracture of 1 st and 2n(l Kibs, near heads ""^a Acute Necrosis of Tibia— Pywinia 12 Acute Necrosis of Femur— Py.Tmia lU Cancer of 2n(l and ;!rd Vertebra', and corresponding ribs on right side. . . 14 CIRCULAIOllY SYSTEM. Heart :— Idiopathic (so-called) Hypertrophy and Dilatation in Kenestratioti of Valves of Aortic and Pulmonary Arteries 20 Arteries : — Atheroma 20 Aneurism of tirst part of 'i'horacie .\orta 20 Sacculated Aneurism of asc. ndiug portion of Arch of Aorta 21 Sacculated Aneurism of Aorta at termiiiaiion of the Arch 22 Aneurism of Hepatic Artery— Suppurative Hepatitis 22 Aneurisms on branches of Pulmonary Arteries on walls of Phthisical < avitius 3Q Aneurism of right middle Cerebral Artery ;^o RESPIIIATORV SYSTEM. Tracfiea : — Ossification of Mu( ous Membrane 32 J/ungs : — Pneumonia of right upper Loiie. Simple Menin^'itis 3;! Hepatization r— Diphtheritic ('olitis 34 J'neumonia about a Phthisical Cavity in right Lung 34 (.'hronic Phthisis — Pneumonia of only sound portion of Lungs 3-) Simple J'neumonia of left Lung ; right-sided Pleurisy 35 Pneumonia of right Lung, uniform involvement of Pleura 35 Remarks on the cases of Pneumonia 3(j Gangrene about Phthisical Cavities in left Lung 37 Fibroid Phthisis 38 ( 'lironic Phthisis ; perforation ; pneumothorax 3*iiil i CONTENTS. nn<;u^:_ '-ASTRO-INTESTINAL SYSTEM. Epithelioma '■*"* l^harynz :— Miliary Tuberculosis , (Ksophagus : — I'ost-niortfiji perforation.. *'•* — , t , 4^ Stomach : — t.'anccr of Cardiac Orifice Medullary ( 'iinccr— perforation ........ . . . , . . . . . \ .' .' ', " ' ' .' [ ' .' _' _' " " ' ^[ f!m(ill Inieitints .— Incarceration of JK-um nicer of Duodenum a- ■J'yplioid ul(ciati(.n— pcTf()rati(,n V- a 4i; Typlioid [•'.■vcr, sliyl.t ulceration .".!..'..'....!."!!!. . .,.,' i\ one suiiill nice.' ^^ C.rcum: — Hound ulcer— pcrfuratiun ^„ Appendix Vermifonnis : <'oncretions in Obliteration of Orifice, tubcdilatcd ......[[...'... r,o IVrforation ' ,, , .'' ' J eritoneum : — Acute Inrtiimmntion ^ , Tubercular reritonltis. . . '1\ T- ■'- lAver : — Hypertrophic ( irrho.si.s .; ;.,, Syphiloma ... hi) I'nmaiy Cancer Secondary Cancer ( -'ancer of neck of (iall Bladder " ' ' ^;^ ^ Suppiiration of Portal Vein ^j,. Spleen : — Enlarged ^ In Typhoid Fever » ■ Amyloid degeneration .. , Miliary Tubercles ^ , Infarctions .,, 1 1 ^^^^^ Kibroid thiekcuing on Capsule 7 1 Supernumerary Organ 7 , CONTENTS, (> GKN'ITO-LRINAUY SYSTKM, Kidney : — Innainniatioii ' ' ' J 2 Morbus liriRlitii ^ TiiberculouM Disease IVrinepliritic AliKcesR " " ►..' Madder : — Ulreration eoiiseqiieiit iipmi Stone ,r, '•> iterus : — Epithelioma (>r Ceivix — pvoniclra Ovary : — Dermoid Cvst . * CEI;E1!I!(»-s| ISA I, SYSTEM. Tubereulosin : (Jenoral 'J'uberculosis— Spii.fil .Mriiini;vs aHrctcd ;.,. Cases of TiiliiTciiliir M. uiii^itis _ '" j^'^ (iEXEJlAI, DISIIASMS. Two Cases of I'ertiiiious Aiiamia o. • It o-x . I 1 ; 1'^ ; ii \/ i !!. Jli H||i' 1 'uBH 1 wH ^^■j 1^' |H ^Hl jS ^Hn 'S ^^H' mal ^B ^^^^B i i hhH ^^^B 1 ' I^K^Ih ^Ht ' - • t^b' ^^^^K'^ ■■,'( iifl m II IHHH 1 I PATHOLOGICAL REPORT. MONTREAL GENERAL IlOSl^ITAL. Osseous SYSiEyL—Fradures. Case lxxi. — Fracture of 1st and 2nd ribs near vertebrce, from direct violence ; deep abscess of the neck ; obliteration of subclavian artery ; Empi/ema. J. L., cet. 20, was struck on the sttrniim by the shaft of a fire engine ; almost immediately after a tumour formed in the supra-clavicular region, the arm on that side became paralysed, and on admission was pulseless. Tumour inflamed, was opened, and discharged a milky lluid and blood, subsequently pus. Empyema super- vened, and death. Abscess found to be deep in the neck, immediately above the left pleura, and about as large as a good- sized orange. On putting the fingers into the sac the ends of the fractured ribs can be felt in the posterior wall. The fracture of the 1st rib is straight, just external to the tuberosity ; the inner end is imbedded in the wall of the ^iac, the outer lies one and a half inches from it. The 2nd rib is fractured obliquely, just external to the angle, and is also comminuted. The inner end projects into the sac as a rough, sharp process, and lies at a higher level than the outer end which is external to it. Between the two is a small separated portion enclosed in the sac wall. The lining membrane of the cavity is stained, and in places covered with Hakes of fibrin. Immediately below the anterior part of the lloor of the sac, the apex of the left I « n 12 I'ATHOLDOK^AL R^:PORT. lung is firmly attiuhod, and is soparutod from the abscch? by coiidonsod tissuo, } of an inch in thickness. At the posterior part of the floor onlv a thin membrani^ ^^eparatos it from the pleural cavity. An orilice, in communication with an external one at th.' root of the neck, exists at the upper part of the anterior wall. Th ■ subclavian artery runs alonsj the inner and upper part of the sac, being- lifted somewhat out of its course. It i.-i completely o])literated by a thrombus, which begins an inch from the aorta and extends to the first portion of the axillary. The subclavian vein is also obliterated, though to a less extent. A])ove the artery, at the top oi the sac, is the brachial plexus, the cords of which ai)pefs,r stretched and ihittened. Between two and three pints of pus in the left pleural cavity. Lung compressed. Acute Necrosis — Pyccmia. Case t.xxxiii. — Necrosis of tibia. Ilcerative endocar- ditis. Pijiemic pneumonia. A. B., let. 12, male. No definite history of an injury ; jiains of a rheumatic character about the joints, only slightly more marked at the left ankle ; symptoms o't pytemia : death within a week. Acute periosteal abscess found in the lower end of left' tibia, with necrosis of the bone, which is denuded and roughened, especially in front. The cancellated part does not appear much aflected. Pericardium is beginning to inflame. In the anterior wall of the conus of the right ventricle is a purulent depot the siz(» of a bean, and not far from it a superficial loss of substance, half the size of a three-penny-bit. Trace* of atheroma in the sinuses of Valsalva. Scattered throughout both lun>;s .are small, firm, slightly- elevated spots, ranging in size from a pea to a niarble. They are most abundant in the upper lobes. On section MONTREAL GENERAL HOSPITAL. 13 Home ar.' dark in colour, their lirmiu'ss alone distinguish- ing them from the, lung tissue ; others have a greyish red appearance, while others again have softened in the centre, forming small abscesses. A small supernumerary spleen is present. Case xc VI. — iVecrosii- of femur. Pt/cemic pneumonia. Abscesses in superficial muscles. Pustular eruption on skin. J. C, .rt. 30,— The clinical features of the case are well Mamraarized by Mr. Vinebarg,* as follows : The disease, attacked a strong and apparently healthy man ; no history <^f injury : the symptoms at the outset simulated those of rheumatism ; the pytrmia set in rapidly, ran its course without rigors or marked lluctuations and remission of temperature, while the presence of a pustular eruption and erysipelatous patches on the skin, with the tuberous elevation beneath the skin— not unlike farcy buds— and the general symptoms, presented a clinical picture very like that of glanders. Left Femur. — Muscles of anterior region of lower third of thigh infiltrated with i)us, the posterior ones not so much so, and here and there are distinct abscesses. The }ieriosteum of the lower end of the femur is raised, and contains beneath it much pus, the bone is bare and Toughened in Iront, behind, and on the inner side; on the outer side the periosteum is still adherent. It is covered with a dirty greyish exudation. Scrapings iruin the bone and roughened surface examined with the microscoi)e show an enormous number of large myelo- i'laques. The marrow where the bone is sawn looks healtlxy; that of the end of the bone itself was not examined, SA;t».— Numerous flattened pustules with reddened bases exist over the skin of trunk and upper extremities. Mu scles.— In those of the arms and legs many small ♦ In a paiier read before the McGill Medical Society, May 8, 1877. : :• '! i ■ .-f I •!• I i 'S^ .fl iB^ ui fpr y r 14 n-m m l'ATlInp: inl. mphenom vein occliuh.d by u thrombus Blood dark nnd lluid. Durin- lile thon- Ava.s a lar-.. numbor of Schultzo's .Tanuhu- masses, and the net-wo;^!.- ot iibrin libnis which separated out on the slid.' und.-r the microscope Avas unusually dense and coars,. Commencing Pericardilis over rioht auricle. Lungs. — Numerous Hrm, slishtlv-elcvated. noduh's ran-mg m size from a pea to a mari>]c, in all the loben' but most abundant in the lower. On section, most .,1 Ihem present a wiiib- oTanular surla.e. interspeis,.d here und there with hunuorrha-es : some of the Jar-cr ones in the lower lobes hav,> softened at the centre into al,scessev Ihe margins ol' these pneumonic areas are cono-ested sometimes ]uemorrh:irteb^a^ 2nd and 3rd. Bodies not en^ ,v -d, but soft and poroiTs. On stripping olf the anteri... lio-ament a soft, greyish-white juice oozes out. The transverse and articular processes also involved. Two soft cancerous growths sprmg fromthe junction of the lamina? and bodv of the 2nd, and encroach upon the calibre of the canal'- at the centre of the back part of the body of the 3rd is another tuberous outgrowth. The cord does not appear much compressed by these masses, and the membranes are unafiected. Ribs, 2nd (right side). For two inch<^s beyond the anole the bone is enlarged, double the size of the'3rd • the arti- cular surfaces are bare. The compact tissue has disap- MoXTREAI, (JK.NKKAL HOSPITAL. la pcarod, and the cancerous i-rovvth has elovated and inlil- (rated tho porio^st.'unl. On section lar-e cancelhn are Hoen, Idled with a roddish-white juice. At tho middh; of thi.s rib IS an irrc-uhir .swi-llino-. one inch in length.whi.h presents tho same apt)earanee as the head. nrd Rib (rioht). Not nearly mj ni i^h enlar-ed, the articular surlaces not all'.Mted. Conipae* tissue gone but periosteum is Tree. ' miiib (left). AnelonoatedswtM;„n..,;,out the middle one and a hall' inches in h-ngth, m.-st mark,>d internallv' On section external part soft and cuts readily ; the central part is hard and dense. mPub (leit). A still larger swelling- of same character, two inches in length ; not hard in tho centre, but not so porous as the heads of tho aftected ribs. Liver not enlarged ; contains a dozen or more white masses, situated superlicially, ranging in size from a wal- nut to a small pea; surfa<-es of most on a level with liver -tho larger are elevated and with depressed centres On •section many htcmorrhagic centres are seen in them. Brain. A rounded cancerous mass— 1.V' by 1^"— ociu- pies th.' superior parietal convolutions o"f the rio-ht side extending into the longitudinal lissure for a short distance' On section it is greyish-yellow in . olour, except at the centre and margins, where there is more blood. Small masses also m the right corpus striatum and left thalamus opticus, and on the pia mater .f the lower convolution of the left occipital lobe, and on the pia mater of the rio-ht crus cerebri. All of these, on examination, are cancerous in character. Lungs. Left is emphysematous, several very lam-e blebs existing near the root. Throughout both lobes a"re num- erous, firm, fibroid tubercles, ranging in size from a pin's Head to a pea. Lower lobe is solidified, in a state of red hepatization, the air cells being iilled up with fibrinous plugs. t > 16 PATHOL(H}K'AL REPORT. The right lung contains hardly any air. At the lateral part of the upper lobe i.s a large dense caseous mass, the size ol' an orange, with a sharp, round contour towards th(! Jung, and much puckered on the pleural surface. It is very firm, nnd on section beautifully marbled. At the lower and back part of this lobe the lung presents a very peculiar appearance over an area equal in size to an orange ; it is irregular, soft, and spongy ; no definite; cavity exists, but the tissue at the upper part is soaked with pus, while below there is pus mixed with blood. It looks }iot unlike the fibrin of blood clot soaked with pus but on examination proves to be a rapidly breaking down lung tissue, infiltrated with cellular elements. The pleura over it is very thick and fibrous. Nearly the whole; of the lower lobe is in a condition of grey induration, being firm, airless, and scattered through it are a few caseous masses. CiRcuL.vToRY System.— Heakt. (Jf livt' cases of heart disease, one only presented fea- tures of unusual clinical and pathological interest. It is ■-an instance of hypertrophy Avith dilatation and advanced fatty degeneration, consequent, I believe, upon prolonged jnuscular exertion. I am indebted to Dr. Koss, under whose care he was, for permission to use the clinical notes taken by Dr. James Bell, at that time the ward clerk. Case xiA\. — IIy/>ertiophi/ and dHatation of the heart. No valvular or arterial disease. No chronic kidney affection. Hydrothorax. Pti^.nonary apoplexy. General venous stasis. J. W., iPt. ;51», coachman ; admitted November 2ud, 1876, with dysp Ti.L'a, hiemoptysis and vomiting. He is a large, powerfully built man. with strongly developed muscles, and in good ndition. His family history is •good. Was t. soldier for l.Rf years, serving in India and -other British stations. Never had syphilis or rheumatic '■Mm^. MONTREAL (IHiVEKAL HOSPITAL. 17 fever. Has always been a healthy man, though intem- {)orate. In July last he fsulfered from shortness of breath and slight hjwmo})tysis, for which, in Angu.-< he entered the hospital, and was under treatment Jiearly two mor'ths for "some heart affection," being discharged very much improved. ]!(> then worked for three weeks as a day labourer, and sulFered much from exposure to cold and wet. On Octob.^r 20, he had a chill, which was followed by .swelling of tht; legs and abdomen, with sligl dysp- ntpa. He gave up work on the; 24th, and was treated as an out-door patient for a few days before entering Hos- pital on November 2nd. AV'hen lidmitced, in addidon to the above mc^ntioned symptoms, he complained of great pain over the region of the heart. The legs werea3dema- tous, and the conjunctivce and iac(^ of a sub-icteroid hue. On i)hysical examination, the cardiac dulness is found to <'xtend as high as the upper border of the 3rd rib, and to the right border of the sternum. A systolic murmur was heard at the left edge of the stt^rnum in the 3rd inter- space. Apex beat cannoi be distinctly felt. The pulse at the wrist is barely perceptibl(>. There is dulness over the lower lobe of the left lung. Eough snoring rfdes are heard over the front of the chest, and coarse bubbling rrdes behind. Liver dulness extends from the .Oth inter'- space to th." costal margin. Th(( urine contains nearly 25 J), c. of albumen. Th.' day after admission, he expec- torated nearly 3 j.inls of llorid blood, and vomited very Irequently. In spite of treatment (dry cupping, ergot, , -i". Mitral valves slightly thickened at the edges, otherwise healthy. Orifice measures 4.}" in circumference. Aortic valves com})e- tent, segments thin and natural looking; orifice, at the ring, measures 2]" in circumfeience. Aorta looks— relatively— smaller thnr, natural. It is not atheromatous, either in the arch or lu its course. Muscular sul)stance of whole heart, and especially the left vcntricl(^ looks pale, and on examination is found in a condition of advanced fatty degeneration ; a good deal of I'atty infil- tration also exists between the individual fibres. Arteries of the body do not present any signs of degeneration. Lungs. 3xcvi of serum in left jdeura, and the lung on this sidi! is collapsed and only slightly crepitant above, Two very largo spots of apoplexy in the anterior ])artof ' )be, and about tliem the lung tissue is hepatized. •, also large, occupies th(^ anterior border of the >be. Right lung is crepitant, but contains much nppc ! I MONTREAL GENERAL HOSPITAL. 19> blood and serum. At the lower part of anterior lobe in tront IS a small, consolidated area. Spleen, 250 grms., firm. Kidneys, not enlarged. Capsules detach easily ; surfaces smooth On section pyramids and Malpighian tufts of the cortex are injected. Stomach and intestines present nothing unusual ; the large and small veins are very full. Lioer,ji little enlarged, of good consistence; venules 01 hepatic vein gorged— nr^tmeg organ. Brain ^hmsQs of dura mater ancWeins of the pia mater tui. Arteries at the base not diseased. Nothing abnor- mal in the substance. When this case came under observation in the autopsy room, I confess to have been not a little puz.led, and so impressed M^as I at the time with Ihe unusual character 01 the lesion that a most searching examination of the Uitterent organs was made, and accurate measurements of the heart taken. There were none of the common causes present to account for the hypertrophy of the heart-no valvular disease, no arterial deo-eneration, na hron,c renal or pulmonary disease; and Though aware 01 the iact that an idiopathic (so-called) hypertrophy of he heart was described, still, I did not know that a Lai issue might ollow m such a case with all the symptoms of chronic valvular disease ; nor did a consultation of the various works on the heart guarantee such a supposition A lew months after, in Nos. 17 and 18 of ih^ Berliner Kkmsche Woclu^^^chriJI, 1877, an article appeared upon a latal case ol dilatation an,l latty degeneration of the heart consequent upon prolonged inus.ular exertion, whi<^h in" Its symptoms and anatomical characters is almost the exact counterpart of (he one here recorded, except that the dila- tation was a little more marked, and the hypertrophy not so groat, On making enquiries it was ascertained that this patient had always been a very powerful, muscular man, and since his discharge from the army had worked ! i: I '■ ; s i . 1 t^ 'I'll n i! ,' 20 r.VTHOLO(ilCAL REPOKT. Ill I ;'■*■ ; ; M ;<. ( lit i _i ! i. ^s a jlackFmith. Unfortunately, his wife, from whom alone definite information conld have been obtained, left the city soon after his death, so that the details of his past lile are necessarily incomplete. However, in the absence of all the commonly recognized causes of heart disease, it appears reasonable, with the evidence of Albutt, Meyers. DaCosta, 8eitz, Thurn, and others before us, to attribute the lesion in this case to overstrain or prolonged muscular exertion. The case, however, is one of such unusual interest that I propose to deal with it more fully in a separate paper. Fenestration of the valves.— In exactly 20 per cent, of the oases were those peculiar little perforations met with in the aortic valves, while in the pulmonary semi-lunar they occurred in only 7 per cent. They are either congenital or result from atrophy, and probably have no patholo. \.jA significance. Arteries. Atheromu. — In twenty three cases the aorta presented j-igns of this degeneration, usually slight in amount. In five instances the arch was dilated and the atheromatous condition very marked. Aneurism. (vASE XXXVI. — Aneurism of commencement offfiorrcic aorta, unsuspected during life. Death from general Tuberculosis. A. B., tvA. 32, a well-built muscular man. Th(^ aor^ ^ presents at the arch several calcareous i)lates and pate' ee •dark, airless, and sodden. Left Lung. On the viscf'"8, layer of the pleura, esp( ■; lly behind, are numeroi i •; i U ■ecchymoses. On sectic, ^rgan contains much ,' i"od, is firm, and only slightly crepitant. Heart normal. Kidneys rather pah. cortex swollen, and Malpighiaii tults iiijucicd. Spleen, weight 445 grms. (14 oz), adherent to the stom^( w MON'TREAL GENERAL HOSPITAL. 28 Organ soft. Oil soctiou dark and conj^c-led. Intestines normal. No trace of ulceration in Ihd large bowel. Bladder and prostate, normal. Liver, weight 4879A grms. (10.? lbs). The peritoneum around it m many places shows signs of inflammation, ihe left lobe being intimately adh(>rent to the stomach by a thick layer of iirm yellowish-cohnired lymph; the right lobe is also cemented to parts in its lu-igbbourhood by ]ymph of a similar chara(>ier. A small amount is also observed on (he descending colon, but tht^ general peri- toneal surface is not affected, the serous covering of the intestines being clear and glistening. Th(^ liver itself retains its normal shape, the upper surface is smooth and not adherent. Towards the riglit border a yellowish- coloured swelling is evident, which is perceptibly fluc- tuating. Other less distinct yellowish spots are seen scattered over the organ. To the touch the upper and back part of the right lobe is exccu'dingly soft and fluctuating. On the under surface many yellowish-white nodules are apparent, some large, othcn-s quite small, all distinctly fluctuating. A similar one of larg(^ size is apparent on the under surfacie of the left lobe. A trans- verse incision through both lobes reveals the fact that we nave to deal with a diff'use suppurative hepatitis. An' immense quantity of yellowish- white, custard-like pus ilowed out. The right lobe is completely honey-(^ombe(- by a series of small, closely united abscesses, ranging in Hze from a marble to a walnut. I^he septa between these are composed of a dark-red tissu(V Most of these ™all abscesses communicate together; some have merged lo form larger ones. They all possess distinct lining membranes, which are frequently stained with bile. The left lobe is in a similar condition, and in both the abs- cesses extend throughout the thickness of the organ. Thus, the only portions of liver-substance which \re found comparatively free are the jobus quadratus and ' 1! ! I t ,M I 5S 24 PATHOLOdlCAL IIKPOUT. « .■• :. I that portion of the orij^aii lyinq- immediutcsly ubove and a little to the l(>ft of the gall bladder. These parts on section are of a dark colour, lobules distim t, small bilo vessels very evident. The jjall-bladder is small, contains about three dra(;hms of a clear, somewhat viscid secretion On pressing- it and along- its ducts no liuid could be forced out at the jmpilla biliarin. It was with much difficulty that a probe could be passed along the. d it to be inches it passes to the right and giv.'s o'X two branches (,/") which appear occluded, then tiiriis at right angles and pas.ses backwards ibr l.lincluvs towards the poK- tcrior border of the liver, terminating by a conif al cxtrem ity which is continuous with the main bnuich of th(^ artery. The arteries of the body had been injected, and the red mass is found in the trunk of the hepatic before mm ' ' MONTREAL GENERAL HOSPITAL. 2& its bifurcation, in the j^astro-duodenalis, and the left hepatic branches, all of which are full and tense. The hepatic artery appears to enter the aneurism about j of an inch from the obtuse end, the gastro-duodenalis and left hepatic being given off apparently from the dilatation itself, and on slitting up the hepatic artery it appears at iirst sight as if these were its only branches, and that its (•ommunication with the aneurismal sac had become obli- terated. Careful inspection, however, of the lower and ])osterior wall reveals a small canal, the calibre of a hypo- dermic needle, which leads directly into the sac. The aneurism being opened by a longitudinal cut on the upper surface, it is seen that the anterior third, comprising the rounded end, is completely filled with lirm decolor- ized huninai of fibrin, concentrically arranged. The middle third of the sac contains semi-coagulated blood and red injection mass, after emptying which there is Hcen a cavity about the sijie of a small walnut. This is in communication with the hepatic artery by the small canal already rc^ferred to, which passes for rather more than half an inch through the fibrinous lorainie of the anterior end. Two small branches, both containing lujection, pass from the cavity, one, the cystic, ( e ) going to the gall-bladder, th(i other, a somewhat larger branch, passing to the central part of the organ. The sac is lined with sheets of fibrin which at the under part are thin- ner than elsewliere, and at this point the blood has miiltrated tli(f propter coats of the aneurism, which, in con - Kequen<:e, look reddisli black. The terminal portion of the sac lies chiefly in the substance of the riffht lobe, sur- rounded by suppuriifing hepatic tissue, which had to be iiissected away to expose it ; and on section the cavity is (ound almost completely obliterated by fibrinous lamiiKJ^, which in the centre are softer, and not so colourless as at the other end of i he sac. No direct passage could be traced through this frcra the central cavity, and the main ^ H:t k j^J '1 ui i m ii'. l|ffi' IIS ■ f t I Si > \ f ■ \\\ >■! 26 PATJK)LO(UCAJ. KKPOIIT. :!ii branches given ofl i,om the aneurism ar. Ibund empty. and at their commencement plugj^ed with librin, which in several extends as a thin sheet along the infiV . Ihe condition appears to l,e one ol smiple aneurismal dilatation ol the vess.l, the walls being thin, .lightly roughened on ihe interior, hut not markedly atheronuUous me trunk of the hepatic artery itself looks healthy, and there are no .evidences of general vascular degeneration. Among the many interesting ])oints in connection with rnis case, tiie causation of the multiple abscesses takes the iront rank; not only because in this one alone amono- tiie recorded cases was the fatal termination due to a suppurative hepatitis, but also on account of the extreme rarity of an opportunity t. study the ofleUs of ^isease of the hepatic artery upon this organ in man. AaKing ior granted, as from the careful examination we may jus^tly do, that the portal system did not in this in- stance furnish the materies morbi, we have to consider the consequence of total obliteration of the hepatic artery or ot Its main branches, and also the ellect of small emboli.' in the form of particles of fibrin, plug- ng its terminal twigs. It will be necessary lirst to refer brieily to a few ana- tomical and pathological points in connection with the blood supply of the liver, xhis. as in lun .s, is two-iold ; the portal vein ministering solely to the functions of the gland, the hepatic artery chiefly to its i;, ration. The ultimate branches of the portal vein unify at the peri- phery d the lobules, forming the inte: ul vessels, from which numerous capillari.js pass in th. uterior, and hnally converge to the centres of the lobules, as the ulti- mate radicals of the hepatic veins. The hepatic artery furuKshes blood to the bile ducts, portal and hepatic veins. and the connective tissue of Glisson's sheath. Its capil- laries empty their blood by small venules into the inter- lobular veins. IleiKv, remembering this distribution of 1 ^ MONTKKAL (JKNKRAIi JIOSPITAT,. 27 the hopatic artery, i( is oasy to understand that in < ases of thrombosis ol" the portal vein, even where the obstruction is comph'tc, the runctions oI' the oroan may be maintained, and botli bih^ and glycun-en secreted ; lor the capillary plexus of the lobules continues to receive through the interlobular veins the blood which has been emptied into the latter from the venules of the hepatic artery. The nutritive blood serv as a substitute, acts vicariously, lor the functional. It has been maintained, and the statement passes current in the text-books, that the converse of this is true, viz : that the portal blood can replace the hepatic, the functional art for the nutritive. This view is based on experiments made upon the lower anxiuals. S ; :fr states that in the cat the functions of the jiver are performed .just as well after ligature of the hepatic ., tery as before ; and Betz found that in the dog, after t> ing the trunk of the hepatic and all the collateral branches, no lortant alteration took place either in the structure of the dvcr or in its secretion. Cohnheim and Litten have shown, however, in a very important paper on " Disturbances in the Circulntion of the Liver," (Virchow's Archiv. May, 1876), that in expe- nments on dogs arterial blood still reaches the liver even after ligation of the hepatic, the coronaria ventriculi, and the gaslro-duo(!<>nalis, owing to the very extensive anas- tomoses and connections of these vessels. In the guinea pig, on the other hand, the supply of arterial blood can be completely shut off, either from the w hole organ or irom individual lobes. In the former case the operation IS always fatal within 24 hours, and even in this time important changes are found to have taken j-lace in the organ. These are all the more marked if, instead of iigating all the arteries, only the one going to the extreme right lobe be tied. The result is an entire necro- sis of thi' porti.m of the liver supplied })y the ligatured ■' ! 11 ii ■ ! i ( I I ■ I'ATIIOLOCHCAL IIP:P()11T. jirtery, and in every instance th. animal died within I wo (lays. nos^^'nr'lf'" '^'''' *''"^ pathological proof of the correct- toTJ fi ''T '■' "' ^'^ wanting, but I am inclined o b 1 ovo thai by tlm case the deficiency is supplied ; lor 1 think th(. .suppuration of the organ best explained e.thlt"] 'T' '^'"\ '^" '^'''''''- "'*■ ^'^" -^"l^l^li^ «^'»>Joocl, nrt 7 "''''^"^' occlusion of the aneurism by clots or by the quicker process of emboli conveyed away from' iie interior of the sac, produced numerous areas of necrosis, which .subseqiumtly became, by inllammation am a sequestering suppuration, converted into abs,;esses t IS impossible to determine, in the absence of any posi- fve evidence, whether the process resulted from emboli or s'mply ],y the gradual obliteration of an important blood 'ooa. T h,M-c IS no reason to suppose that theobliforatior; '" this case did not occur slowly, for the iibrinous amime, especially at the anterior end, were lirm and ongh. Again, on an embolic theory it might be ur-od t lat m this instance th(, emboli, consisting of iibrmom^ shreds trom an aneurismal sac, should have produced simply mechanical eirects, infarctions, and not, as in thr^ ease of ,.mboli proceeding iVoni necrotic or suppurating toci, abscesses. Mechanical emboli do, how^^ver, some- times produce suppuration, and in the liver might do so by causing death of the structures supplied bv 'heob- ■^'ructed arteries, vi^ ; the portal vessels, bile ducts, and '•onnectivc tissue of Gli.sson. in the present ease sup MONTIIKAJ- (tENEKAl, HOSPITAI. 29 posing the process to dopend on .mholi, lhor<. would b. arU^nal l,lood onongh s.nt throned, collulo.al hran-hos to furnish .natonal lor .n activ. suppuration about th^ nocrotic centres Ahogolher, tl.. embolic theory mee the case better than any oilier Tf ,•« <« i , u.]^^ ihnnu r '"'>*'•"< I- It IS to bo remembered .Iso that (he disease was nol rapidly lalal, but came on lowly, lasted hve week, or more, and it is not unlikelv that cunng this l.me much ol" the fibrin was depo .te place Ihis ,s rendered still more probable by a con- sideration of the condition of the left hepatic bnLl the commencement of which is involved in L aneu sm'^ which now ovvin. ,> ^le filling of the proxim 1 eiid o the sac with hbrin, appears to be almos the direct con mua ion o the main trunk. In fact, for a shor dttant from the bifurcation, the upper wall of the left branch is made up of condensed fibrin, which is grooved bv the ht 'i channel. This explains, too, the o.-curr^roHliJ^^^ t^ n the territories supplied by the left branch. Therimo .^itiro obliteration of the obtuse end of the sac o c ui'ed tilled with a creamy pus. and had walls lined bv def.nill pyogenic membranes. ^ ^lefinite There is no clue to the oricrj,, ,.(• fi. , . . TK . „ ni "ugui oi tlie aneurism itseir Ihe ago ofdie pMi..„t, and Iho absence of irt,.ri„l ration olsowhero. ar,. almost sum, ;,. t to x ™ f """ n.atous dogeneration a» a ean.,o, a, d Ih", -a oi h '°' a,.,H.ar thinnod but not evidently dt :"' 0^ b" asenc.es capable of producing anouri.n,, .tpec ,1 ' o ■ smaller vessels, embolism is tbe most i nnorta u Ld tht un,a.u ab,. |,„s,l,ou of the hepatic arlcry for emboh we are mchned to regard it as the most probable cate! <■ 'I W ! '^■^' WF , 1 m 1 i' f4 ii Hk f 1' • Bl F lk ■ fjV I * 1 ? ''M^- \ ; fr Jtl 30 PATHOLOGICAL KEPORT. It is scarcely possililo, .•oiisidering- the situation of thi.s artery, that strain could have had anything- to do with it^i production. I Case Xh\iu.—Ane/trisma/ dilatation of branches of pul- monary artery on the walls of phthisical cavities. Death from ha:moptysis. J. L., a)t. 44, ill for sonic time with phthisis, died unex- pectedly of hjumorrhage from the lungs. Lungs.~^e\Qn cavities, in size from a walnut to a small orange, found throughout the organs, chielly in the upper lobes. Five of these contain blood with clots. Caseous masses numerous, and here and there small tabekdes. On section of the lower lobes, irregular areas of a darker colour are noticed on the congested surface, which on inspection are seen to l)e small bronchi filled with clots, the lung tissue about th(>m being deeply stained. On slitting up the branches of the pulmonary artery three aneurismal pouches, the size of peas, are met with in vessels run- ning on the walls of cavities. Th(>y appear to be simple (liverticulaof the vessels, the inlinia being continued into them. From the side of th(> cavities they look like little irregular swellings on the wall. The origin of the hae- morrhage was not (liscov.>red, though all the branches of the ]>ulmonary arlery in the right lung and lower lobe of the lelt were slit U]). The vessels of the upper lobe of (he left lung were, ]>y mistake, not examined. No doubt the hannorrhage in this cast; was due tt^ the rupture of one of these snndl aneurisms— the cause of the haemorrhage in most of th.' cases of death from hiemop- tysis in chronic Phthisis. (See Kamnssen. l':(linburgh Medi- cal Journal, 1808, and Powell " Trans. Path. Soc/' xxii.) Case IX,— Aneurism at srrond bifurralion of the rii^hi middle cerebral artery. Rupture ; extravasation of blood inti> MONTREAL (lENKlJAL HOSPITAL. 31 the Sylvian fissure, and laceration of substance of ,h. , sphenoidal lobe. Death in 3G hour. ^ '''''^°'" Mrs. R., a>t. 40. See report of rase by Dr Bell r Med. and Sur^^. Journal, Angnst, 3870 ^~ ^" Pos^ wor/e/», 11 hours after death S ''noH •" '^"'"•^^■^^^-^' 1--Iy nourished woman orft 7 "' "^"'"'^^ "oiiceable about the soft parts the ealvanum. Veins of the pia mater moderl? y ^^ ated blocHl ,va., r,.m<,v.d, most of which whh in and abo,» he Sylvnu, «»»„,.,, Only a ihin lay.,,- „|- b ^od xish at . ol„„ons ,„ the h.t.ral r..gi„„ on „,, ,.i,„ht sido. Tl o drc e of W„l,., and middh. CM-ebral arlory „,.re rpm v f ««bs,.q„ont examination. Tho .nbs^a 1 'pT , appears healthy; the ventriele. , . '^ ','"■ '"•"" nbuf^i-mol ; . u , , '^"I'LV, aiui nothni"- ciuuoimai IS obs(>r\('(] -iLnnf fu i- "'» mmmmM and the b,o.,d had escaped th-on.!. a ! ^ l-I^X ' riie remaininir vossels oP Iho Lv ; /''-'o'^" ounce. »o.he.on.a.™.eha,ut';;z:nnt; .?:r^- Mdomtnal or'r-ans hf^-iMh^r . ... n- .• v^aJIs. A beautiful f.J ^'^''^^> ' '''' -'^i^^^-hoa of the kidney,, ^-. I'^y « ol an inch m dunueier, and with a pale !' ! ilii; i M ■ :l3is ' m t : ''hi ■4.^ \ J J--' S2 rATirOLOOlCAL REPORT. yellow convoluted wall. The central coagulumwas of a dark rod colour. In the same ovary at the other end wa« a small corpus luteum about J the size of the large one, with a decolorized coagulum and mnt. 47. Trachea. — Bi'ginning just below the cricoid cartilage, and extendiiiy- to the bifurcation, tlie mucous mem- brane is represented by irregular o.ssiftc i)laies, which towards llie Iront of the tube and near the main bronclu form a eonlinuous bony membrane. The free surface is denuded and very rough, numerous i)i(s and projections altermiiing with eath other. Towards {\\(\ })ronehi the ossilied membrane is thicker, and lirmly united to tiie subjacent carliiaires. ^3 o -MONTREAL GENERAL HOSPITAL. LvNGs.—PnejdHonia. Ao Sylvia,, «..M , a,o ,^ '■""W.^h-wlnlo ly„,p!,, a„d 'am., .1 , , '° "'"'"' 'Oiidito,,. A thick "o'y sol,. V..„t„clos .ontaiu a modorate amount of iluid, ; ! t i 34 PATHOLOGICAL REPORT. i :l and thtnr walls arc soft. Horc and there on the course of the vess(>l.s are small extravasations, and the same are noticed along- the vessels on tht' ibxxrth ventricle. No trac(^ of miliary (ul)ercles found about the vessels or parts at the ])ase. Case x\ . — A/most nilire hepaiiza/ion of left lung', loith small pneumonic area in right. Extensive diphtheritic Coliti.i M. S., ;et. 22. In hospital six days. Lnnga. — With the exception of the apex, the whole of the left lung is solidiiied, and in a state of red hepatiza- tion. The visceral pleura is inllamed and covered with a layer of lymph, which in the fissure between the lobes is very thick. In the posterior part of the lower lobe ol riy-ht lung- is a patch of hepatization the size of an orange Large Intestine. — The mucous membrane of the caecum is covered over with a thin layer of yellowish, firmly adherent lymph, which can be stripped oil', showing a much injected surface ])eneath. The first foot of the colon presents nothing abnormal, but in the next eighteen inches the mucous membrane is congested and covered with elevated patches of lymph, many of which are isolated, the majority, however, being united and arranged in a linear direction. The patches are elevated, the isolated ones of the same shape and size as rupia crusts ; on section they are seen to extend through the whole thicku'jss of the mui-ous membrane. These patches occur throughout the descending colon and sigmoid ilexure ; in the latter region there is an irregular one, 4" in length. Cask ]^xii.—Dint)etes, phthisical cavity in right lung sur- rounded htj lifjiatized tissue. .1. W., i.et. 20). Clinical history, Can. Med. and Surg. Journal, Auyust, 1877. Lung.'i. — Posti-rior pari of upper lobe of right lung i« occupied by an irregular cavity, elongated in form, hold- MONTBEAI. OKXERAL HOSPITAL. 35 ing ..bout .„, ou„oe The wall, are mad. un of a dirtv brovvM,, pasty material, caseou» in character. Th™ 2 no hbrcd or other changes about the cavity, but i , su ounded by lung- tissue iu the second stage o pneurao ^1 rho whole or the lower lobe of this l„u„'i, so id ,i d "d the lower lobe on Ihe other side is in ,he .,„,„,. .ZiZ Case L.XIIl.-CT,ro»,-,.y„/„',,s. Aim,,, eulir. dn„;,rlio.. 0) Mk /„«,,. ir„m, j,orn„n im;,u-ca In „ ;„,«„„„:;:"' J. F., ffit. 35. In hospital for a long time caught ,ald -d^d,ed of inila„.„.atiou of tho onl, Lund ';:::^::^ Lungs.-mghi Jung., ,vith the exception of anterior half ihe unaffected part is m a condition of red henati^atio. " co^eud AMth a thick Uiyer of recent Ivmph Lel^ luri- almost entirely destroyed by cavities. ' ^ A. G., a>t. 22, ill U days. ^.j..--Thn^e ana a half pints of serous tluid in ri^ht pleural sac. The pleura of lower and middle lobes covered with thick lymph. Both of these lobe .oSld and airless. Anterior two third.s of upper lobe of eW ni condition of red hepatization; the pleura ove tT? rr^di!::"''^-^^-^----^-----^ Case li. — Pneumonia cf n"-/!/ lumr i.v\... • ; 0.1 pieuia covcrinsr it H. L., a^t. m. u^:~^'- ''f^'^^^^y i-'P-H.cd. Fhe visceral lay.r Meu a ex ensu^Iy .niiamed and covered with a den«e ^u ot yellowish-white lymph, in^ places, fullv |" iu p I ! 11 h ill I. 36 PATH' >hO( tlCAL liEl'ORT. thkkiioss. Lcit Iniiq: muc]i (niuoriivd niul (rdematous, Rij?ht lui)o- weigh.' 3 lbs. (i^ ounces; Mi, 1 ]b, 13 oz. /Je/HrtyA:.v.— Throualiout Iho past winter pneumonia prevailoci to an unusual extent, and was very fatal, espe- cially to elderly and debilitated persons. T(>n latai cases occurred in the General Hospital, some of which, as above recorded, pres(>nted very interestint.- pathololing complication, the pneumonic symptoms being masked })y the cerebral phenomena, and rendered liable 10 be over-looked. It is interesting to note that the pneu- monia was of the upper lobe, a situation which, when aliected, aitpears more liable to be accompanied with brain symptoms, delirium, ike. The complication of diphtheritic or croupous colitis in imeumonia is not referred to in any of the text books on Pathology or Practice of Medicine which I have consulted. Dr. Bristowe* was the first, so far as I can learn, to call attention to this condition, which he found in two out of 80 cases of secondary pneumonia, and in four of 16 cases of the primary ono-hnllW,; u,i, . 'cl,' """^""■••l'ill--io. n-clu, eel ™. ...■arly do 1 ,i , ° T'"' ", " '"'"' I"-™- udalio,, ot ,,.,.„,, J" ""'■""' "'I'i'l^'"-. tran.. darKjrene. 10 .h« vcsseb a,.d bronchi « i,T,.n.„ ,, "X ' ' "^'^"''» "Uheim,„ediat,. n,.,,.hbou,.h„od i: co, :^ U, „, ,^ '""' iironohial tub,.s contain an oli;.„.,iv,. ,.,„„«, ^nj,,,. i.i."mbran.. is ve,.y d^ik-coloc,,-,.,!. ' ^ ""' !!!-■:, i I ? \' 1^ ■ ^11 J ! Ml 38 PATHOLOGK AL REPORT. Philtisis. Of twelve cases, threr only are worthy of notice. ('ASE xxxviu— Fibroid contraction and induration of ■entire right liin^, raoiti/ at apex. Displacement of heart ; hypertrophy with dilatation of right chambers. For clinicul history see Can. Med. and i"— the lung presents a marbled appearance, is dense, firm, and with the exception of one small spot do.se to the root, airless; a few small dilated bron< hi are evident below, while immediately beneath the pleura are one or two inconsiderable cavities filled MONTREAL QENERAI. 110SPITAI-. ^9 with a bloody and purulent matter. The anterior border of the organ is in the same condition, and on section (lumerous small cavities (some of which are dilated bronchi) with bloody contents are seen. The organ is not excessively pigmented. The main bronchus and its branches of the 2nd and 3rd degree are somewhat dilated. Bronchial glands lirm, not enlarged, moderately pin- ynented. ^ Left lung adherent at the apex only. On section a large ..rregular cavity with thick dense walls occupies the upper and anterior part of the apex, the lining mem])rane of which is hirmorrhagic. The remainder of the organ is extensively emi)hysematous, especially at the anterior border, but presents no other degenerative signs. Heart. —The cavities of the right side much dilated and full of blood, walls of right ventricle appear somewhat thickened. Tricuspid orifice dilated, admitting four fmgers nearly to the second joint. Segments of th.- valves ;i httle thickened at the edges. Musculi papillares look elongated and the apices are fibroid. Cask hxxxi.— Chronic phthisis.— Perforation of the Inmr —Pneumothorax. Dermoid ci/st of right ovary. .1. S., ret. 21.— On opening the abdomen the liver is '^een to be displaced downwards, the iipper border corre- sponding to the lower margin of the ribs. On penetratino- the right pleural sac a considerable amount of air rushed ont. 18 ounces of a clear, serous fluid in this cavity Umg,.-T\v^. left upper lobe is riddled with cavities • the lower lobe is slightly crepitant, and contains numerous caseous and tubercular nodules. Upper and middle obes o Tight lung almost airless, except at free border • :Ower lobe collapsed. No adhesions except at extreme apex The visceral layer of the pleura of lower lobe is covered with patches of lymph. At the uipe. ad poster- lor part of this lobe, about an inch from t.e root of the i \ j f li I'M liH ^•; I • i i'mp ] I I ' 4 40 PAT I ro LOGICAL REPORT. Ztu 1 ' 'T' ^'^^'"''^ ''^'^^"^ '^'' "l^l'*-^^' ^*''>''' there in .ma oval perlorat.on 2V" hy U"', through ^vhich air b bles en pressure. For a coupj. ol" Hues about th. u^Iio pleura ,s pale ; b.yond this the membrane i. mjected and .over.,! with veeent lymph. The perloration ^Ws not Kul n.to . aeJinite cavity, but into a rapidlv .'^oltenmgportmn ol' lung, inliltrat.-d wUh pus. „d n^ l)arts quite .lilllurut. Cask Lxxxn.-Chronn: rhUnsis. (ana r of Ihe rrrlehur nnd ribs. Reported under Osseous System. PjiEI-K'A. Smn// Jihroid thichmin-s oh visceral la,jn:~ln three in- stances localized iibrous outo-rowths ol' ilu- pleura have been m.ticod. much resemblini.- miliarv tubonhss in si^.. and general appearruco. Th. first case nx which theV occurreok is as l.i.l.w,s : '• Scattered over the surface o^" pleura of both lun-s, chieily of low.r h.bcs. ar.' small white, firm granules, l^eling. to th(^ touch like small shot' and restunblino miliary granulations. S.nne of them however, are Hatter, not granular, and thev mav bo simple hbroid tiiickenings of the pleura." Su.h'thev' proved on examination to be. They occurred in a case of cancer o'" the hver, though not so abundantlv, on the pleura covtT. ing the left lunii-; and a third time on the pleura ..f the upper lobe ..f the left lung in a case of pneumonia. Thevr are lound chieily on the interlobular tissue, .soiuetiines a^s shot-hke elevations on small opacities of th- membrane These are of interest on account of the resemblance they present to miliary tubercles ; so much so that an experienced pathologist seeing them in th." lirst case raised a question as to the nature, whether simple or tuberculous, of the meningitis accompanyiii'^- it Inllammoiion.-OnmQon cases in whidi the membrane was affected, thirteen were simpl,> in character, and MONTREAL (lENERAL HOSPITAL. 47 othci two wore cases of empyonu,. fj' the IblJowin- cases tho effusion was enclosed in pocket., and thouoh,fbv<.onvonience.t].cchestvt^^^^^^^^^ PostmcteuUh. whole of.he fhud coul.l ,u"; 'i;'; Case Lxyu.~l>/nrns, : Folly and Jihroid Heart. Riglu l'/e,„„.-By lapping-, about sm,,i pints old,. ,r c ro„.,„lo„n.cI (l„i,l ,ve,e .vithd.awn. On Lno, n " 1 .a,l !,,.,.„ ,.on,ovod. Tho npp,,,. ,vall ot th,. cavity ! "Xt,.::. •'"■;, "'■ '"■''"""" '■""•>"• Another J,,,: A:'B!n.'t"o""""'"''""""'°'"'"'°'"'' '■"'■" -E-'Wrn. .iorif it'i!"''''7'^'"',"' " "' °' ""'^ '" ""» -^"^"J-- Ant,.. ra L „V °', ';T' '" '™ '""■'^'■'■'' °»" "'" «="= °f ^> l-=- ™.8e nnmodmto J- at tl,e apei. the othor oon-ospondin- n po.,t,on «.ilh tin. thi.d and fourth ribs, just Ll.rna] In. ..amlasv. This latter pockot con.municate I ml round onlic w.th ,ho general .-avity, which oc , - lie. the lower and whole of th, back part of thi.s side any way the content, of the cavity at the ap,.v and- no^ .-iitirely emptying the other one. . ' ^ '"'" ""' IJastro-Inti-s-i-ixal Svsteaf. ToxovE.—EjiMelioma. Case >ii-v.~EpMelwmnofri?hl side of Ton^'ne nUn.l IMAGE EVALUATrON TEST TARGET (MT-3) % // ,' *<^ Cx V 23 WEST MAIN STREET WEBSTER, NY. 14580 (716) 873-4503 % \ d '-L-' r-^u i \ \ ^ O \ 42 PATHOLOGICAL RErORT. The tissues of the neck behind the deep ftiscia, princi- pally on the right side and in front, are uniformly infil- trated wit., pus, which expends also to the anterior mediastinum. There is no definite collection of pus. Lungs.— Le[t healthy looking. Middle and part of the upper lobe of right are firm to the touch, non-crepitant, and the surface section is bathed with a sero-sanguineous fluid. A small purulent focus exists at external part of middle lobe, not an accumulation of pus, but an area 1" by .V", irregularly infiltrated. Case xmi.—Epilhelioma of Tongue. Secondary nodules in liver. A. B.. irt. 72.- -Tongue almost entirely eaten away by the cancer, the base only remaining. The tissues in the neighbourhood are involved and the internal surface of the lower jaw on both sides is much eroded. Epiglottis and larynx not afl^ected. TLe liver contains three masses of secondary rancer. the largest the size of a horse chestnut, situated superficially and presenting the usual characters of these growths. The lungs present caseous masses at the apices. Heart somewhat atrophied. Spleen very small, weighing scarce- ly two ounces. Pharynx.— 3//7/«rj/ Tuberculosis. Cask lxxx.— C//ro«if Phthisis. Miliary tubercles in lungs and pharynx. A. ft., ret. 22. Lungs : upper lobes riddled with commu- nicating cavities, one of which, the size of a small egg, is filled with a clear, somewhat viscid, jelly-like material. Numerous tubercles and caseous nodules in the lower lobes. Pharynx. — Scattered over the posterior and lateral wails are numerous, small, firm, granulations, which on examination prove to be miliary tubercles. They are con- MONTREAL OENEllAL HOSPITAL. 43 Sned to the pharynx. There is no ulceration and the :arynx is nr t involved. With the exception of two suspi- cions spots in the cortex of the right kidney, the other organs are unaffected. In another case of chronic phthisis the same condition of the pharynx was observed, and without ulceration. Thet,e cases are of interest as showin-' the existeiice rf extensive miliary tuberculosis in the pharynx without iLceration, ind without invclvement of the larynx. The <'ondition is by no means common in phthisis. Attention has recently been directed to this subject in an able article by Fr;hikel.=^ CESOPHAGUS. Post-mortem digestion.— In case lxlx, a man dead of Typhus fever, an oval perfoiaticn of the oesophagus at the |H»sterior wall, just a])ove the diaphra-m, was found It extended U" in lenoth by i" in breadth ; the ed-es thin, dark m colour, not at all congested. A small amount of iluid was in the tissues of the posterior mediastinum The vlomach contained semi-digested food, and its mucous membrane was softened. V t V- i <^\-.-. A Stomach.— Cancer. Case x\iy.— Cancer of the cardiac orifice, invowimr the (/■aophagns. Secondary/ masses in other parts of tlie organ. M., H., ret. 52. «^owac/t.— The cardiac orifice is blocked >y irregular cancerous projections from the mucosa, so that the tip of the forefinger is with difficulty introduced. Ihe growth appears as an annular ring, extending for abuut an inch above and below the orifice. Ihe walls are here much thickened, and the distinction between the coats lost ; the surface of the cancer is much ulcerated. i;ora distance of an inch or more the mucous membrane ^cbnf., No.. 4.. an,I 47, 1876. (See Cak. Mko. and SpRo. ,,oi„NAr,, Feb. 1877). 44 rATIIOLOC.ICAL REPOllT. of tho lesser curvatuiv appears healtliA", l>ut I)etweeii this and the pylorus i.s a long-, Hat. cancerous mass, not ulcer- i'ted. A string of jirojectin- nodules extends aloni?" the greater curvature, and on the posterior wall is a thick, flaf mass ]>eginning to ulcerate on the surfac(>. The growth correspcmds in histological "havacters witli medullary cancer. No secondary masses in any other organ. Case l.xu.— Medullary Canrer, involving- lh>^ p,,lorir zon- of the stomach. Perforation, peritonitis. F M., let. 38, had had for some time indelinite gastr; symptoms, accompanied with occasional attacks of vomit- ing. Then^ was no tumour to he fdt externally. He left the ho.spital, to r(>turn a sliort time after in a condition ol collajise. ^Wowrvi.— Intestines of a l)right red colour and covered here and there with ilakes of lympli. The omentum i, pushed up ami lies beneath th(i costa -tilages. Oil separat-ng the transverse colon from the M.mach'a round perforation about the size of a sixpence is seen in the latter, through which the contents escape. Stomach.— On opening the organ a large, irregular, can- cerous mass, about 2V' in width, extends around th.> pyloric zone, but does not iir.olve the orifice. In t!ie centre of this, corresponding to the lower and anterior part of the greater curvature, is a round perforation, th(> margins of ^^■hich arc thin and of a dark colour. The proportion of fibrous elements, yet the general character of the growth corresponds rather with the medullary form of cancer. MONTREAL OENERAr. llOSPITAi.. 45 Small i\TKsnsE.— Incarceration. Cask xcii -/'„„„„„ ,,/ „„„ ,;,, „f ^^^ ;,^„^ ^^ .MP allachal to the sigmoU llexiire. M H.,u.t^50, tak.Mi ill s„dd..nly with yomitini; and symptoms „1 obstruction, ,vhich contimtod 48 houm, when hW diod nuexnoctedly in a ..mdition of coma On opaun,.- abdomen, a small amount of l.loodv Itaid i, lound m „.nton«al cavity. Th. intestines am .slat" coloured, relaxed stnooth, and present no sig-n ,„■ i„„am- ,na ton. On tractng them towards the ca-etL it rs fo„,ul hat the ower two feet of the ileum have pas.sed throu" a loop attached to the sigmoid ilex.,,, anc{ have becot^e strangulated iKang: v..ry dark, in places almost bla k " ■ inc. ros.. „, the part .-as beginning. Careful exami'.^ )on of the ,oBstr,rtm.o. band shows that it is .on.ieeced l^bo h ends ...th th,. stgmoid llexure, and is eompo'od lafty a, d hbrous tissue, m structure lookit.g very like the g^anduhe ep,pl„,ca. near it. At its npper ^art, an fnea he attachment, ,t is broad, but the part farthest from the arge bowel ,s exceedingly thin. The intestine passe, hrough on the side of the ring next the sigmoid ,1^7 ..bontr, irom the ileo-ca-cal valve. The mesentery passes hrough on the right .side, and at and about the IZZt ■»n .s very dark. The diameter of the rino- is about "n ;-h. It ,s remarkable that though the stranaulatedpo on of the boweUvas dark .and congested, yelthe. fwe e :;:,:r "■"""""''"""■ »- »y 'y»pi. up„n the ;"," Nothing- abnormal in other orij-ans. J^lceration— Simple. Case ^('i-~ Round ulcer of duodemm. ^l^ou^l'v^^"'""^ t ^'''':^'^ ^»d pulmonary collaps About n Irom the pylorus, on the posterior L I * ! i I ise. all 46 rATllOLOOICAI. REPORT. ol' the diiodeimm, is a distinct ulcer tho size of a three- lieniiy hit, with slightly raised ediie.s, lying- between two valvulfc conniventes. Nothing else abnormal in the intestines. In two instances— one a case of grey degeneration of the cord, the other a case of cancer of the uterus— there were simple round ulcers in the ileum. Typhoid Ulceration and Perforation. Of seven autopsies in typhoid fever the following are oi interest : — Case II. — Perforation of ti/phoid ulcer during convales- cence, oicing to an indiscretion in diet. A. P., tet. 18, a convalescent for nearly two w^eeks, during whi.h time the temperature had been normal, k day or two before his intended discharge he ate several. mutton chops, and within 24 hours was in a state of col- lapse from perforation. Abdomen. — Coils of small intestine of a rose-red colour ; several pints of a dirty iluid, mixed with la^cal matter, in the peritoneal cavity. A few Jlakcs of lymph on some parts of the ileum, but the congestion is confined to the coils near the abdominal walls. On carefully examining the intestines a small perforation is seen, situated about eight inches abov(^ th(> valve, and through it fttcal matter exudes. On slitting up the ileum the perforation is found at the bottom of a)i ulcer about the size of a copper. It i.s button-hole in shape, 4'" in length, 2'" in breadth, and look^ like a small transverse rent in the muscular coat. There is no inllammation about the ulcer, but it and the others in the bowel appear to have been healing. Case XXVtii. — Per/oration of a deep nicer at end of second week. A. B., trt. 40. had been ill with typhoid fever two weeks ; symptoms of peritonitis 18 hours before death. MONTKEAL OENERAL HOSPITAL. 4f Abdomen.-hitestino. of a vivid red colour, and th. genera peritonomn inflamed. Ou carolully working- down the coi s Irom the duodenum, no lymph or adh-sions aro met with until the ileum is reached ; on tra.ino. it towards the pelvis the coils are found matted too-other and cover- ed with thick greyish-yellow lymph. About a Joot from the valve a perforation is seen, lluid faeces of a vellowi.h colour llowmg- out, so revealino- it. Intes(un'.-On slitting up th" jejunum and ileum t!i. mucous membrane is found pale, and in the lower two eet of the latter there are six or eight round, deep ulcers the largest, about the size of a shillin- presentino- an ir- regular perforation. The mucous membrane ab';)ut the ulcers IS not injected, nor are their edges raised. (Jase xcni.~.T>/phoid Fever. Perforation. Peritonifi.- J. ii., a>t. 2!>. In hospital 9 days, Peritoneum.-Qoil^ of intestine present a vivid red aj)- pearance, being covered here and there with Hakes of lymph, and stained with faecal matter. Nearly two pints of a dirty semi-foculent fluid in the cavitv. A1,out twelve inches from the valve a perforation is seen. Intestine.~kH the louver part of the ileum is approached there are several ulcers, most abundant in the foot of out above the valve. Mo.st of these are small and round, not elongated, and have yellowish-stained sloughs adherino- fo them which, with fow exceptions, are only b.^ginnino- to separate. About a foot from the valve is an ulcer the size of a shilling, which has perforated. Near the vahv are SIX or eight round, punched-out ulcer.s, the bases of which arc formed by the muscular coat« of the intestine 1^0 ulceration in the ca3cum or colon. The following also present foatur.vs of interest, ns show- ing what a slight amount of intestinal disturban.'e may accompany fatal cases : .1 : t' m . ,1, 48 PATIIOLOOICAL KEI'OIJT, Cask xxxiii.— Fo?/r ronnd ulrers in the ileum. Peyer's mtrhes not genemUy involved. Slight hypostatic pneumonia. A B., ;rt. 24, a small, ll>ebly developed man. In hos- jntal 8 days. hdesline^^. - Several intensely black patches, quite sni>erlicuil, on peritoneal surlace. Mucous membrane of j.junum covered with a Ihiky, y<.lIowish matter, very closely adherent, and Avashed off with difficulty. In the ileum, fivr inches from the valve, there is a som(nvhat elliptical ulcer, placed rather transversely to the axis of the ffut, and al)out th.' size of a penny. The base is made uj. or the circular libres, and the ed,o-,.s are neither elevated nor con-ested. Two other smaller ones are situated close to It, and live inches higher up is a fourth, also small, and havinu- a punched-out appearance. The jnitches abov(^ this are not elevated, but have a peculiar maho-any-brown colour, and on close inspection th(^ individual Ibllicles are seen to be a little swollen. The solitary glands are scarcely visil)le. No ulceration in the large bowel. Meaen- 'eric glands moderately swollen. Case xxxiv.— ,sV(o/t^ swelling of Peyefs glands, only one yma/l spot of ulceration. J. Ci. ;et. 40, a stout man, of intemperate habits. In nos])ital live days. Temperature moderate, and general symptoms not bad ; he had no delirium, but was exces- sively timid and nervous, so much so that the House Sur- geon exi>n'sscd the belief that he was frightened to death. Intesfwe.^.—Vvyei'-^ patches slightly swollen, their bases congested and the follicles in each very distinct. Th.^ solitary glands in the neighbourhood of the valve are en- larged. In only one small patch, about a foot from the end oi the ileum, is there any trace of ulceration, and on this it as not at all advanced. No affection of the large intestine. Mesenteric glands a little swollen. Spleen weighs 15 oz., and is very soft. \M MONTREAL OENERAL HOSPITAL. 4a fl-em.-Eight and left segments of aortic semi-lunar v« ve. have merged together, presenting one sinus beWnd wtth an md,st„,.;t separation near tlie attachmenttoZ; ^rta.^ Segment a little thickened, but valve appearslt C^CUM. dafsatdThif "Tk"'*""" ''°""S ">»"• ■'» hospital 4 days and a half, w.lh symptoms at first like obstruetion of the bowels, subsequently those of peritonitis C! weeks before he had an attack of whatwas ^ppos^d t be strangulation, from which he recovered J6«,„.„._Geiieral peritoneal surface much inflamed ares „,e„ , a distended, the walls soft andtumetd The inUammation is much more extensive towar. t tlZZz\'"'''''"'^''"^ "' '"» i.eo-cLc vai;; LMdences of a bygone peritonitis are seen in the form of hght opacmes and piickerings on the serous suZ" both visceral and parietal i-uriacts, .^Z^^f ''''''''' "^^"^^^^"^ ^"-^-^^ other- iherZ^^n", inflammation about it i« most intense, and tile lymph most abundant. On carefully sei^aratino- if . round Datch 91 " ,•„ r , . ^ »<-paiaimg it a paicn, ^j 111 diameter, i,s seen mi ihn. nUA^ ■ 1 Panetes. of a g-reyish-red colon;, anTsoZwrat dep^^^^^^^^ tines abm^t it? ' " "^^tameter, the coats of the intes- nnes about it being, much inflamed. On slittino- „n fl. > gut a sino-le ulcer which H^ , r Y . s,^i«ing up the upper inrl nnH n f perforated, is seen on the upper and outer wall ; its edges are thin, and the mucou. 4 1^ ^< "•> ail in ^S' ! li hi 50 rATlIOLOOICAL IlEroKT. Hi, r i '^ " il III No(hinn:(>lse noticeable membrane about much inllara.'d. in the large intestine. A^mryt-v.-rerloration of tlie cu-cum is rather an un- usual accident, much more so than perforation of its ap- pendix. In this case the trouble probably originated in an attack of the 0/ph/ilis stercora/is of llokitansky, in- duced by the lodgment of hard masses of fa-ces There ivere evidences about the perforation, between the caecum and ihac fascia, of inilammation (perityphlitis) of an older (late than the general peritonitis; and there can be no doubt that It was in the first illness that the perforation happened, its evil effects being limited by a local inflam- mation, which subsequently, owing to some not ascer- tained cause, spread to the general peritoneum. There was a very marked contrast between the area of inflamma- tion immediately about the perforation and that towards the head of the caecum ; the former was darker, more greyish in colour, and the contiguous surfaces were not ^0 easily separated. It is important to note, with refer- ence to the diagnosis, that the symptoms appeared to point to obstruction of the bowels; doubtless, a more thorough inspection would have satisfactorily decided the question. Appendix Vermifor.mis. In three cases there were found in it firm concretions of iaecal matter, oval in form, and about the size of date stones In Case xxviii., mentioned above, its calibre was obliter- ated for the first half inch of its length, patent for an inch beyond the obliteration. In another case of typhoid fever It was also partially closed. It was ulcerated in a case of phthisis, chiefly at the coecal end, which was almost entirely closed by the swelling of the membrane, in consequence of which the tube was dilated with the retained secretions, being nearly the thickness of the thumb. not MONTREAL (lENEIlAI. IIOSI'ITAL. rhe iollowiiio- is ^k,, ,,,,i,, .- , ticra :_ ' -^ instanc.. „f porforati. 51 >n Case i.x.«vin,_.l/«„«s ,-, ,/„ „,e,c«/.„, s»™„™. general pen ton ills. "I'l'tnaix, The «;>y..W,•.^. lies diroctly over the promontory of th. sacrum, ami is about the loiurth -ukI s,Vr or 7 «H«.o,. Ti • , "^'oia anci sizt ot the index h ge,. U .s .„„ch svvollon, and the ^vall» soil. On cave, fully n.m„v„,g ,t (he fluid cont,..Us escape IVom a , oval perlorae,o„ on .he nn.ler «ide, which i. a,lherent o he .s»no» over the sacrum by (hick ly„,ph. On i, .^ ." o the appendix, „„,■ .,,n its „,.ilico bo seen. From th, side „1 the latter the probe enters a small snions "h ch 'rT "/th"" "' """ir™ ''™'^''"> ""' »-ousTnem- -■.mc of he cecnm. Abont IJ" from the e«c«m is a onnd perloral.on, J- i„ ,,,,„eter, the maroins thin and p ])ressure along right costal border and ensiform cartilage. The vomiting became more marked, and he had occasional attacks of diarrhtra. The symptoms pointed, though vaguely, to disease of the stomach, either round ulcer or cancer. The vomiting was with diiliculty controlled, and ])ati.mt became very weak and aniomic, the skin slightly icteric. Towards January he got so feeble that he was unable to movi; from bed, and the voniiting was so persistent as to necessitate feeding i>er rectum. Through January and I-^el)ruary the vomiting diminished, but the patient wasted slowly, and the case was regardedas malignant disease, involving per- haps the peritoneum. In the l)egiiining of May the peri- tonitis became acute and general, and he died on the 25th profoundly exhausted. For some weeks before death hunnorrhages occurred in various parts of the skin. Peritoneum, contains 50 oz. of a turbid, slightly bloody lluid, in which are ilocculi of lymph. ^ Here aiu'l there the .oils of intestines are matted together by easily separable adhesions. The transverse colon and stomach are m this way glued together, the former covers also the anterior border of the liver. The entire peritoneum, ex- cept the portion over the stomach, is of a dark red colour, iniiltratcd. sodden, and readily stripped olf from the sub- jacent tissues. Localized patches of Tymph occur here and there upon it. The wliola membrane presents a great ! >• MONTIiKAI. nKNKlnr. lliisl'ITAl.. ,r,.| h M,rl.,o and r,,,,.-,,.. ,„ „i.„ |Vo,„ „ h.-mp „.,.,! lo a HM |,,.a. As a rulo lh,.y arc i«olat..„-,., aro firm I,,' t„r,' \r' "'^"'-"•■"' -'" -'"-> 'o ,ho d,,>th o .r.a«s..», Ihoy ar,. r.,„,„l („ |,„ „|,„„,, ^,„|^„| ,„, ^^jj^,^,' .haraCor.a iml,. small.Tlhan th.. ,.„L„.|,.»s bloo^ o 2 *Kan,l w„h on,, rarely two, nnolei. In s..cfi„„« iCZl ho.. „n ,h. „,l..„i„„| wall, Iho corpuscles arc s,.™°t n(,hra e lo some extent the ,„„...„,„, „„„„ ^he me e iCTTc glands are l.ntlitil,, enlarged. 7fart .■,.cchym„s,.s on pericardinm, walls llahln- mnscle pale, v.-ry little blood in the chan,l,ers. ' ' ParWari, '" "'■ '"'''" ""■'• '" "S"' -- Visceral and Jymph. A l,,w ounces of ll„id in lelt sa,- anT;"::,';,^ "''• "PI'" '"•>« '-l-itant, lower collapsed firm Wock , '"""■'"'■ '""'ler of npper lobe is u Iped which T"^ '"""'• ^""-™hat triangular ooSlt *!'*'='?" '^ """i" "I" "f a ™all cavity, ioots fhe l„ f " " l!'"'"'' ""'"'• ""<' ""« »' h™ <=>>«=o«» and of » °- r ";"''"' '"^'"""'' '*<>"' 'x-ins solidified and^of a grey,sh colour. No miliary tubercl™ in either S,,leen, weighs H oz., unaltered Liver 2lbs. oj „, ,„,,„i„^ ^,^^ ^,^^^.^j^ the *t?^;7.7"'.'".^'^''^"'™yfi™ '■> texture in ■p^ I ; w * 'i lA: K 1 B: f! ^^K i 54 PATHOLOaiCAL REPORT. S/omach. —^Incous membraiu' of normal thickness, but, soft and r^^adily torn No trac(> of cicatrices or tumour. It contains about a pint of fluid. Smal/ Intestines contain yellowish liquid fiPces ; walls are thick, owing- to an inliltrated, swollen condition of all the i oats. Mucous membrane is dark in colour. Peyer's iilands not enlarg-ed. Lar^e Int^sline contains lari>-e masses of yellowish solid fiTPces. ^rfl/« present ; nothing- abnormal. Medulla o/6o«e.'{.— Thatof the long bones has a uniform greyish-red colour, nowhere having- the yellowish fatty aspect of normal marrow. In the cancellated portions and short bones it has a lighter red colour. On examina tion there were, (1), red-blood corpuscles, presenting con- siderable differences in size, some hardly the «.'„.," in dia- meter, and many curiously irregular in form. (2) Ordinary marrow cells, and lymphoid corpuscles, which together with the blood corpuscles constitute the chief mass of the tissue. (3) Nucleated red-blood corpuscles— the embryo nal or transitional forms of Neumann, of which in each specimen examined four or fi^-e examples were met They are larger than the ordinary coloured forms ami have usually a single nucleus. The colouration of thes(^ corpuscles is nearly, if not quite, as marked as in th(^, ordinary forms. (4) Cells containing red-blood corpuscles, of which a few examples occurred. There are no myeloplaques. Clinically, as well as pathologically, this case present.^ many points of interest. The prolonged gastric irritation, which was Ihe prominent symptom during the lirst fiv(^ months of his illness, receives no suitable explanation in the condition found i)ost-mortein. Are we to suppose the peritoneal trouble to have begun with the onset of the symptoms in September, or wen^ these latter due to some constitutional dyscrasia, upon which the aflection of the MONTREAL GENERAL HOSPITAL. ri'j. e onemu was o-raftod. daliuo- only tliroe woeks ),efor. death, when .sympton.s of acuto inflammation of the mem brane developed . Certain eases of tubonuhn- peritX dLVa'eoT"^ ^'■"""' ''' 'y'^'^'^^^ P-"t-8- -the to sea e of some visous co^-ered by the peritoneum, as the- caused by the ehronie irntation indueed dnring the n,.a.i- ua eruption of the tubercles. The condition: however I'^'^^'^^'i^y the injeef and tumeiaction of the coats- tL^ni/T r'-r^.'^'*^'' ^"^ ^^^^^'^^^^-^ that mattino. of the coils together by hrm adhesions and tubercular matter which IS seen in many cases of chronic tubercular periton- m!; Tf i '' \q^^««ti°'^ ^vhether the recent inflammation TtZZ ^^j:\\''' f n^er-added on a membrane already tudded with tubercles, thoug-h with the exception of the- ve?y oTd'''' """ '^' ^'"'^'^ peritoneum, they did not look The anaemia and wasting, together with the gastric imtation, presented a clinical picture, not unlike certain of those constitutional affections dependent upon some profound alteration in the constitution of the blood, such as pernicious anremia ; and the finding post-v^ortem of a condition of hyperplasia of the bone marrow. I at first regarded as lending support to this view, seeking in it the explanation o the deterioration of the blood ; for there can be no doubt that alteration m. the medulla of the bonea may seriously innuence the composition of this fluid Moreover, the peritoneal affection was not what I had been accustomed to see in tubercular conditions of this mem- brane, for, with the exception of the large masses on the l^arietal layer, the tubercles were, not firm and nodular in character, as is usual with these growths on serous jnembranes, but had rather the appearance of localized iymphoid mfiltrations. Since the occurrence of this case 1 ' If 1. 1 1 1' 1 Mr ! !i! iir<- ii ti M I i ' •5'6 PATHOLOGICA], REPORT. however, two other instances of hyperplasia of the bone- marrow in chronic wasting diseases have come under my notice, so that I am now less ready to refer this one to the category of myelogenous affections, but would regard It rather as a case of tubercular peritonitis, latent in its course, and towards the end accompanied by an acute Hiflammation of the membrane, the consequence probably ol a fresh outbreak of tuberc^les. The absence of the tubercles in the other organs is a condition which not unfrequently obtains in this alfection. \a\-E.U.— Hypertrophic Cirrhosis. Case i. —Cirrhosis of Liver, with enlargement.— Jaundice No Ascites.-Delirinm Tremens {?).-Er,mpetas of the head. .1. H., ;ct. 34, intemperate habits, admitted to the Hos- pital April 30th, 1876, with jaundice, diarrhcca, and deli- rium. He had been seen by Dr. Tvoddick a few days before, when he complained of pain in the region of the hver and great enlargement of the organ was then detected. Nothing definite could be obtained as to the duration of the jaundice, for he was incoherent, and had no friends. Shortly alter admission he was attacked with *'rysipelas of the face and scalp, to which he succumbed rapidly on the 4th of May. At the autopsy the body was found to be well nour- ished and of fair muscular development. Skin moder- ately jaundiced. Several purpuric spots noticed. r!min. — Healthy. Abdomen.-lHo fluid in peritoneal cavity. Liver projects considerably below the margin of the ribs. T/torfl.x -No fluid in pleural cavities. A few extrava- sations on the visceral leaves. jy^^ar^— Slight thickening of the mitral segments and mme atheroma at the bases of the aortic semi-lunar. Other- wise healtliv. mr i!?? MONTREAL GENERAL HOSPITAI>. ,'J7 Lung,, — Crepitant, except lower lobe of left luno- which IS collapsed. "' r.ff'TV^'?^" 19 oz„ (538.46 grammes). Capsule a Jittle thickem^d and puckered. Pulp soft A7.Vy, -Right, 9J oz.; left, 8 oz., of a greenish-yellow hue. Collecting tubules of the pyramids full of urates and bile pigment. Stomach, ~ Qoni^ms ~xi of semi-coao-uk,ted blood. Mucous membrane dark-coloured, swollen in places and congested. Intestines, dark, and contain a small quantity of altered Wood^ J^arge veins not particularly full, but the mucous membrane is reddened. W weighs Gibs. llAoz.,(3053grms),andisuniformlv o^nlarged No adhesions, or iibroid thickenings in car^sulf Surface of organ of a dark olive-green colour, and studded with small granulations, half the size of a pea and larger. lhe.se htle projections have a greenish-yeUow appear- ance, while the intervening tissue is w^hite. On the under surface of the left lobe the largest nodules are seen The organ is very firm, and cuts with resistance, the surface of section presents a deep, greenish-yellow colour, jp^hile the ;obules are separated by strands of white connective tLsTue. The porta vein is large, appearing even dilated. The gall-bladder is elongated, filled with inspissated bile, whch towards the orilice of the cystic duct has col- omnM ,' '^rT"^'"''^ ^""''^'^^ ^'"^^'^^ balls, which ^ ompletely close the orifice. The mucous membrane of the due us communis choledochus is somewhat swollen, but ^hi^ bile ducts do not appear to be dilated Mtcrosropic appearances—Sections under a low power present islets of liver substance surrounded by a connec- tive tissue rich in nuclei, which in most of the speci- ^.bstan"t;1- '"'Tr' '^^"^^ "^ ""°^'^^ *^^ ^i^- ^u7T . . ™'^ ^'^^'''' ^^''^ *w° ekments is rarely •v^ell defined, but there is a gradual blending of the one i ^5 f 1 ; ' ; 1 1 ; 1 h f 1 i ! Mi ' I hi \\i S!l . 68 PATHOLOGICAL IIEPOIIT. With the othor. In certain lobules the invasion isunilbrm and mterceliulav, groups of two or three cells heino- separated by a nucleated growth ; but in most the imasion IS peripheral, and lobules in all stages of destruction may be seen.with the liver cells in the central parts still iu close contact with each other. The connective /issue differs in no respect from tliat seen m ordniary cirrhosis, save that the nuclei are perhaps more abundant in proportion to the fibroid tissue. Only 111 the central parts of wide areas is there an indistinctlv librillated appearance, and here the nuclei are scattered while in the neighbourhood of the lobules themselves th.> tissue IS more embryonic in character, and the nuclei pre- dominate, in some spots being crowded together with littl.> or no intervening material. The method of invasion can be traced m all its stages, the new growth creeping in, as It were, from the periphery between the cells, sometimes separating them in rows, but frequently surroundin- individual cells or groups of two or three. This appear- ance will, of course, vary with the direction of the section ■ It at right angles to the central vein of the lobules the appearance is of fibrous bands passing in from the peri- phery, while if parallel to the central vein.cells, or groups of them, are separated by an intervening tissue, rich in small nuclei. Such is the condition of the external zone o^' most of the lobules. There is no definite limit between the two constituents, such as is commonly seen in the atro- l)hic lorm of the disease, where strands of fibrous tissue eaicircle and constrict lobules, and the boundary between the two IS often, as in specimens before me, clearly defined This was rarely to be found in the case under consider- ation. The fiver ceils do not present any remarkable alterations. In lobules not much involved in the sc-lerosis, they appear- quite natural, but in the affl-cted areas they are stutied with yellow pigment grains or oil drops, frequently a MONTREAL OENEUAL HOSPITAL. 50 rombinatioji of the two. Tho fatty inliltratioii is not extensive and is very unequally distributed, being- marked in some lobules -ind absent in others. In the periphery of the acini, cells in all stages of atrophy may be seen, some appearing llattened, but thi^ majority look simply diminished in size. Where tho central part of a lobule, containing 40 to 50 cells, alone remains, the ^vhole proees.s can be distinctly traced. In the outermost part little groups of yellow granules are seen in the libroid tissue, in the next zone small cells tilled with thes(> granules occur, separated by numerous nuclei, while in the central ])art are 10-15 cells, the outlines of which are still dis- tinct, the nuclei well marked, and the bile pigment not so excessive in amount. In various sections numerous iine specimens of bilirubin crystals occurred, scattered among the cells. Here and there in the extra-lobular tissue bi/iar!/ canali- cult are seen, made up of rows of cuboidal cells, enclosing- a very narrow tube. They do not appear to be specially numerous, certainly not more so than in sections of a well-marked specimen of atrophic cirrhosis obtained a short time since from the body of an old toper. The recognition of a distinct variety of cirrnosis of the liver accompanied with enlargement, has only been made within the past few years, owing in a great part to the labours of certain French Pathologists. When the specie men came under observation it appeared to be such an anomaly that the standard authors were ransacked for information, but in vain ; the only references to an increase m volume of the organ in cirrhosis related to the initial stage of the disease and as a consequence of fatty inliltra- tion. Happily, just at the time, a niimber of the Revue des Science!, Medicales came to hand, with a condensation ol M. Hanoi's Thesis on Hypertrophic Cirrhosis, in which he seeks to establish this as a special variety of the disease, characterized clinically by enlargement of the m PATHOLOGICAL REPORT. organ prolonged jaundice, and the absence of ascites and pathological y by the foot that the affection ori' nates about the bzle duots, and leads to an increase, not°a dt mution, m the size of the organ. Cornil and Ilanvt# descnbe the histo ogical condition, and support this v ew of the ongm of the disease. In a recent number of thT Lntjsk and Foreign Medico- Chirursical. Review^ there i! a.1 excellent m.„.^ of the papers on the subject, and Ihe wnter agres in the main with Hanot The chief histological differences between this and the common form of cirrhosis appear to be that the growth tends more to iin-ade the acini, and that greater numbers oi the so-called biliary canaliculi are found in the extra- Jobular connective tissue. As will be seen in the above aescription, the first of these characters is well marked in our specim.'n, but the second is not so decided. The^ clinical history of the disease in this instance, so lar OS knowii^corresponds with that of the cases recorded oy nanot. The liver exceeds in weight any of the speci- mens mentioned in the authorities relerred to. Syjihiloma. Case Y.—S,/phi/if.ic ulceration of hft frontal bone. Latere node on left tibia. Gummata in Liver. T. M. fct. 24, admitted May 4th, with syphilitic disease of Irontal bones, and died of erysipelas of the head on the Liver weighs nearly f,lbs., and is elongated in the trans- verse direction. Left lobe much llattened, measuring 8" Iroin anterior to posterior border, the right lobe at the gall- bladder measuring only G". Capsule much thickened, especially about the longitudinal ligament. Five pucker- • "Manuel d' Histologic ratlioli.gi.iuc,-^ p y>2 f July, 1877. I '*■ MONTREAL GENEUAL H08PITAL. 61' ed cicatrices are seen on surface of the right lobe, and some small extravasations exist beneath the capsule ' On section of the organ from right to left three gummata are seen in the substance, each about the size of a large wal- nut, two corresponding to cicatrices in right lobe.'' Each presents a firm, white, central area, which cuts with re- sistance, and a capsule of fibrous tissue, which towards the liver substance is not well defined, but blends insen- sibly with It, and at this part is more translucent. Four others presenting similar characters are seen; two the smallest, in the left lobe. Microscopically the central portions show an indistinctly fibrous appearance, at the periphery the fibres are more marked, while the zone in the immediate neighborhood of the liver substance shows- a small-celled growth involving the lobules. The other organs presented nothing abnormal. Cancer. Case ^^Y.—Primnnj Cancer of the Liver. Amte>i. Jaun- dice—Secondary mass in tail of Pancreas, small secondare nodules in Kidneys. A. B., a)t, 65, in hospital for several months. Body much emaciated. Abdomen distended. Skin moderatelv jaundiced. From the peritoneal cavity 250 oz. of bile-stained serum were removed. Intestines slate coloured, and here and there small flakes of lymph are seen upon them. The descending colon passes down to about an inch and a half below the crest of the ilium, thou turns and pa.sses up iipon the kidney nearh to the spleen, at which point it is firmly united to the omental tissue ; turning again it passes obliquely to the lumbar vertebra, descending in front of them and the sacrum to the anus. In the whole of its course it is closely attached. The ileum two inches from the valve is united by a firm band to the psoas muscle Z,tt,er.- Weight 4^ lbs. ; closely adherent to the dia- i -- \ I iM Is I 62 PATHOLOGICAL IlEI'OKT. phra-m bohind and at the ri-ht border, and aLso below to the tissue in the neighbourhood of the right kidney Though soniewliat smaller than natural the shape of the organ is maintained. The upper surface is exceedingly irregular, owing to the presence of numerous cancerous masses, a very large one much depressed in the centre being seen a little to the right of the longitudinal fissure oecupymg an area fully three inches in diameter. Abov(^' the gall bladder there is another puckered spot, and nu- merous nodules exist in the liver substance about it The whole of the surface to the right of the longitudinal fissure IS involved in the disease, and the capsule here is thick- ened, opaque and iibroid. The posterior border is not so much aifected, only here and there presenting isolated nodules. Where the longitudinal ligament is attached to the diaphragm there is an extensive, somewhat flattened, canc(>rous mass. The under surface of the right lobe i.s comparatively free, nodules being seen only at the anterior border. The lobus Spigelii ]>resents a single deep puck- ering. Many elevated tuberous nodules exist in the under surface of the leSt lobe. All of these masses are raised above the surrounding liver substance, and the majority of them present cup-like depressions. A longi- tudinal section from right to left, through both lobes, shows th(^ greater part of the liver substance to be the seat of disease. The large white mass noticed in the right lobe extends fully two inches into the organ, and innum- erable small nodules are arranged about it. Quite three- fourths of the liver substance exposed on the section is occupied by th(^ cancerous growth. The lower and posterior parts do not contain so many nodules. Th(? hepatic tissue is very dark, and stained wath bile ; the cent:-al veins of the lobules are injected, and apparently dilatea ; a good deal of blood escapes from the laro-er veins. ^ The gall-bladder contains a small quantity of dark bile. MONTREAL GENERAL HOSPITAL. 63 A cancerous girdle surrounds the middle of the organ, and the fundus is also affected. Nothing abnormal in the heart and luns;)i. Kidnei/s.— Two small cancerous nodules the size of peas in the cortex of the left organ, and two others some- what smaller in the right. Spleen, small, and looks healthy. P(wrrens.~The tail is firmly united to the tissue in the hilus of the spleen, forming a firm, hard mass, about the size of a walnut, which on examination is found to be cancerous. Slomach.—Ahont 20 small, punched-out ulcers, with htumorrhagic bases are seen on the mucous membrane of the fundus. The intestines are dark in colour, the A^eins full, and the coats sodden. The abdominal lymphatic glands are not enlarged. The left external femoral artery contains a firm thrombus. The general character of the growth and the absence of any considerable mass of cancer elsewhere render it more than i)robable that the disease in the liver was l)rimary. The presence of ope large tumour, around which numerous smaller nodules are aggregated, is almost .stan.-e is deeply bile-stanied ; the lobules are not very distinct. Ther.> are but iV>vv cancerous nodules in the interior. On openino- the distended gall-bladder it is found occupied by a Iar4 coagulum, the upper part of which, owing to the sinking, ot the blood corpuscles, is decolorized. Hardly any serum is jn-esent except that contained in the meshes of the clot Nine or ten gall stones, about the size of marbles and ^^'lth numerous facets are found. At the neck a small .m^ular mass of cancer projects into the cavity, and com- P ete y blocks up the cystic duct. The walls of the bladder are thin, not cancerous, and at the posterior part just where tne transverse colon is attached, there is a i>ortion infiltrated with blood. On close inspection it is seen that ulceration and destruction of the wall has here taken place There can be no doubt that by this process a vessel has been opened, and the haemorrhage caused. The glands m the hilus of the liver are enlarged and cancerous, and compress the hepatic ducts. The portal vein does not appear to be interfered with. Heart and Lun^r,^ quite healthy ; a few ounces of fluid in loft pleura. Slight atheroma in aorta and aortic seo-ment ot mitral. ° Sl>h'en not enlarged, and of a deep brownish-red colour. Ca.se LXXXVIii.— ^x7e;?sn'e abscesses in the mesentery Jollowtng typhoid fever. Suppuration of the portal vein and its branches in the Liver. Empyema. Perforation of the appendix vermiformis\ Peritonitis: Miliary Tubercles in (nngs Amyloid degeneration of spleen, liver, and mucous membrane of small intestines. 5 I ^ J m I'ATIIOLOfMfAK KHI'OKT. :|f' A. K. iPt. ;'.V. llisi,.7 o*' '"» -ittack of typhoid rov(>r three inontlis holoro, from which lio had not cntiroly rocovorod. rciuimiiiiyrt'hriic 1111(1 very weak, limpyrmn supervenod, and linully iin ullack of acute peritonitis There was no jaundice, nor, so far us I can KMirn, did the xyniploms point specially to any trouhle in the liver. Peritoneum, extensively inflamed and contains 80 ounces of turhid lluid. The inilamination is most intense ahout, and has evidently spread from, the appendix vermiformis, the cwcal end of which is obliterated, while tlfc under surface presents an oval jierforation. Pencardiimand ILurl heallhy. Loft pleura contains 54 ounces of i)us. Left /ung' compressed and, with the ex- ception of the apex, airless. Numerous miliary tubercles scattered through it. liight /mw^ crepitant; one or two ea. On passing a probe into this it is found to iiommunicate directly with the enlarged and suppurating portal vein, to be shortly described. Mucous membrane V j^'■T^nnm and ileum reacts on the application of iodine. J" ihiug abnormal in the Iw^e bowel. 'ie mesentei;/ is enlarged, thickened, and the whole MTiv. tare fluctuates like a sac of pus. Towards the root, and at some spots near the bowel, the fluctuation is limited, as if the individual glands were involved. On MoXTIMvVI, (fKNEKAI. irosPlTAL. «I7 Hoctiou or til.' nwrnhr-AXw, pus is lomid to sproad uuil'on.ily hotvvecn the lol.ls. and, alfr (horou-hly washm.r wJiU water, It appears as if riddU-d by communiraliiijrcavitic»« In -oino sjx.ts tho pus is linut.-d within the oapsulivs <.!' Jyrnphalic, ;r|ands. On (.a.-ini.- (li.. nics..nt,.ric veins Iron, the intestinal border numy are found (o leaddirecttly into those suppuratinj.- areas, others are shut off by thrombi At the distal border, vvh(>re th(^ mesentery is ( nt jiway 'dose to the superior niesenlerio artery, there is an irre* j^'uiar openi.i- i,.,„„ ^vhieh pus Hows, while a probe lu it passes in several direetions. Whether or not (his repre- sents the superior mesenteric vein it is diUieuit to SUV ; the situation corresponds wi(h it. Lirer, enlar-ed, iirrn (o the touch, but at the same tin,*' yieldinir and elastic. On section the substance cuts with resistance, looks ...li.stonin-andontheapplirationol iodine the intermediat.' zone or each lo],ule becomes a mahooany- brown colour, the central and interlobular areas remain- mg unalllMted. On the surface" or the or-an, especially on the posterior and riuht Imrders are several small, irrcHihr ^wellinos, which on s(>ction are Ibundto contain pu'^^The abscesses are tolerably numerous- in these re-ions ami range m size rroin a ])in's head to marbh-s. Many are in communirntion with each other, or are separated by nar- row i.ort..ms of liver substance. On closer dissection it is iound that th.>se abscesses stand in direct connection wi7n, and indeed, are only suppuratin- ])ortal veins. This having' been ascertain,-d,a thorouoh inspection orthis vessel was undertak.'ii. Outside the liver the vein is ivpresented by an eluiiivated abscess with thick, irreoular walls, ma.le up anteriorly ol' condensed connective tissue, posteriorly to a large extent by the head or the pancreas, th(. lobules ol which have been laid bare in the suppuration Immediately where the vessels enter the livi'V its calibre is relatively dimiiiished. Tl :ie splenic vein ends . ^ i i i abruptly on the wall of the suppurating vessel, l,ein. 68 PATHOLOGICAL REPORT. m I closed by a thrombus, while the portion behind is mud. dilated. Unfortunately, in removing- the liver, duodenum, stomach and pancreas tog-ether, the mesentery was cut off just below the latter, and no trace; could be found of the su])orior m(>senterio vein and the manner of its com munication with the portal. On pas.sing a director along the branches of the portal vein and slitting them up they are found full of pus, sometimes cream-coloured, at others ting-ed with bile. Tlie branch pa.ssing out to the right lobe of the organ, at about an inch from the hilus, widens into two large sinuses, ()n(; going to the right border, f.hc other towards the ]iosterior. Into thesfi open nunv/rons branches from which largecpiantiliesof yellowish creamy pus can be squeezed. Near the upper surface of the righi. lobe is a cavity of the size of a walnut, in communicatTon with a vein, and from its upper end one or two branches are given off. The posterior border of the organ appears on section riddled with such cavities, which an; found in every instance to be merely dilated branches of the vem In the anterior portion of the organ over the gall bladvler there is less disease thin in other parts. The extreme left border is also unaffected, and the branch going to it doe,s not contai)! pus. The; lining wall of th(; suppurating vessels passes over abruptly into thi* liver f-ubstance, rs Jirm, and of a peculiar yellowish-white colour. There rx no zone of hypencmia about the inflamed vess.jls, the hepatic; tissue beyond the opa(iU(; white margin looks natural. In branches in which the suppuration is not far advanc(>d, the remains of the; intima, like a soft, stringy mass, can be seen, as if the process was confined rath(u-t> the adventitiaand Glissou's sheath. ()n almost any sectioji of the organ peculiar yellowish-white areas occur, very often of an irregular foliaceous appearance. Occasionally groups of them appear isolated, but on making a section through them they an; always found to be in connection With suppurating vessels, the smaller ones bcnng surround ♦- MONTUEA'. OKNKKAL HOSPITAL. 69 id by one or two necrotic liver lobules ol' a irli.steninr 21" at the left of the left mternal iliac and ending on the wall of the rectum is a riarrow shut sac, full of pus, the walls thick, dark in colour, smd lined by a definite pyogenic membrane. There is im communication with the rectum, the walls of which at the i)oint of attachmcMit appear healthy, nor is th,.re any open- ing at tho upper end. i ri: I . 1 ; B \ if 1.. \ '. 1 I i ! fi I I i I I i ! 1 11 i :i 70 PATl 10r.( )( i I( 'AL llEPORT. I'r ii The ritihi vena rt;y^o.s- is renuukiil)ly large aiul distended with blood, nlniosf equalliiinr in size the iut', vena cava The left is also laruc Suppuration of the jmrtal vein— pylephlebitis— is anionic the rare ailections of (h(> liver. Freri.hs (ISGl), colloeted twenty-live eases, of \vhi(h only three or four followed, a,, in this instance, suppuration in the mesentery; the others r<'8ulted from injury, uleerative iiro(>(>sses in intestine and stomaeh, abscess of si)le(>n. c*ce. In the Pathological Society of London two or three cases have been pr.'sented up to the prcs(Mit time. The remarkable combination of lesions met with in thi.s ease, and the absenc(> of a proper clinical history, r.-nder it somewhat dillicult to decide upon the starting point of the process,— the first link in the s(Mies. The typhoid fever may b.; regarded as the primary alfection to whioh the suppuration in the mesentery and chain of r(>tro- pcritoneal glands was secondary ; the pylephlebitis resulting probably from an extension of th(" inflamma- tion in the nieseuteric veins to the vena porta- and its branches. Another source of infection, however, was present, viz: the infhxmmation in the appendix vermifor- mis, which formed the starting-point of the diseases in three or four of the recorded cases; 1)utl see no reason in this instance to regard the ulc(M-ation and perforation of the a]ii)endix as anything more than an accidental occur- rence, arising from o})literation of the orili.e— probably the result of a typhoid ulcer— and retention of secretion The fatal issue wa;^ due to the extension of the inflam- mation in the neighbourhood of the ai)[)endix to the general ix'ritoneum. It is impossible to say, not havin- a clinical record, whether the emi)yema was a setiuela o! the tyi)hoid fever, or of pjrjrmic origin resulting from the pylephlebitis, though it is remarkable to find how rarely i^ytemic abscesses occur in this disease, being noted in only ii out of the -25 cases colleral circulation was (>stablished, thouo-h, unfortu- nately, owing to tho hnigth of tini.. sp,nt over the other conditions, no careful dissection could b,. made. The rio'hl vena azyg-os was greatly distended, and the left was also much largvr than normal. The only distended veins observed m the abdomen were those about the hilus of the spleen, and the viisa brevia of the stomach. Spleen. Size.— The extremes occurred in a case of cirrhosis in which the organ weighed 3U- oz., and in a case of cancer ot the tongue in an old woman, greatly emaciated, in which it weighed only 21 oz. In seven fatal cases of Typhoid ftver the extremes were 7 oz. and 19 oz. ; both in cases of perforation, the former at the end of the 2nd week, the latter after nearly two weeks convalescence. Albuminoid degeneration occurred under the following conditions .-—eaucer of vertebra3 ; syphilitic ulci'ration of trontal bone, with gummata in liver ; tubercular nephritis ; pylephlebitis. In none was the enlargement very great. Miliarij tubercles were met with in threi^ instances, one a case of general tuberculosis, the others chronic phthisis. Fresh infurctiofu were found in a case of aortic valve disease, and in a case of Bright's disease during preg- nancy. In the latter no atfection of the heart could be determined. The capsule in nine cases was thickened and libroid, either in localized spots or over the whole surface. In one instance it was of almost cartilaginous character, and in another the localized thickenings were calcareous. Small supernumerary spleens were met with in three cases. i I >:-4 ' ■ , i »; 72 PATHOLOGICAL REPORT. Gknito-Urinai;y System. Kidneys. Inflammnfion.—\n two oases of death after lithotomy ii, oJd wen these organs were extensively inflamed, though not m a condition of suppurative nephritis ; one of them case xeiv (see below, under Bladder), the alfection was limited to the apices of the pyramids, which were much involved and covered with a grey, diphtheritic-looking membrane. Morbus Brighlii. Of five cases two (xxix and xlvii) occurred m connection with pregnancy, death having taken place in the latter three weeks after delivery in the former at the seventh month. They prcsenteu well- marked examples of the large mottled kidney, the organs weighing in both 10 and 11 oz. each. Case Ix was of special interest, but, unfortunately, the notes got mislaid and were not entered in the post-mortem book It was an instance of chronic Bright's disease, with small contracted kidney, occurring in a girl aged 20, who had a well-ascertained history of an attack of scarlatina SIX or seven years before. The kidneys were reduced to about one-half the normal size, capsules firmly adherent surfaces granular, substance very firm, cortices much' diminished and the arteries very prominent. The heart was considerably hypertrophied, the left ventricle parti- cularly so ; no valve disease. Tuberculous disease.— M.\\[s,xy tubercles were met with m three cases of chronic phthisis, in three of general tuberculosis, and also a<-companying the three following cases ol chroni<^ tulx'rculous nephritis. Case X\\.— Tuberculous disease of ri of the organ. Pelvis' and r^reter healthy. Bladder united to the rectum by recent lymph On ^'penmg it the mucous surface is rough, irregular, and contains numerous caseous masses, many of which have iilcerated. At the posterior wall is a large dark ulcer, in the centre of which are two small oval perforations The oater surface of tlie organ is covered with fine miliary granulations. ' The prostate is o(vupied by two large tuberculous cavi- ties. The tun :' i Case UV—Ofd scrofulom disease of right kidney, which n converted into cysts. Recent affection of the left. J. T., ivt 32. For clinical report by Dr. Ross, see Can. Med. t^ Surg. Journal, Aug. 1877. Right kid'tey, small, presents a lobulated appearance, and to the touch is semi-fluctuating. On section the whole organ is seen to be converted into a number of cysts coii- taimng a serous fluid in which white flocculi float. There are about a dozen of them, averaging th<^ size of a walnut and coramunieating together. The lining membrane of Home ol them is smooth, of others rough from the presence ; i 74 .^./^ ^-^. fi'./r. Am I li /vT PATHOLOGICAL REPOllT. A small ivmnant oi' the cortex'of of tuberculous matter the organ is loft. Left kidney, very largo, more than three times the sizt^ of the right. On section, the pelvis is found dilated, and the walls thick, and covcn-ed with a greyish exudation The calyce.s are also dilated, and their walls in a similar condition. Iho pyramids and cortex are swollen and injected, and throughout both are numerous suppuratini; foci, and small caseous masses, the latter being very abun- dant, and closely aggregated together at the upper end of the organ. On strii)ping off the capsule, the surface i« found studded with large and small tubercles, the smaller ones coming away with the capsule, the larger adhering to the cortex. These masses are firm, usually solid throughout, but occasionally softened in the centnv yi/rtcWc/-.— Mucous membrane roughened and ulcerated, fully three-fourths being destroyed, and in places the ulcer- ation has extended to the muscular walls. The urelers are not aflected. Lungs contain a lew masses of caseous tubercles. Cask lxxlx.— 0/(/ dhen^e of the right kidney, which ii converted into Jive or six cysts, filled with a puttylike materia' Extensive tuberculous disease of the organ. Miliary tuber- cles in lutigs. Albuminoid spleen. A. G-., a middle-aged woman, short, stout and well- nourished. No history. Right kidney, weighs rather loss than 2 oz,, (60 grms), and is converted into live or six cysts lill(>d with material not unlike fluid plastor-of-Paris. A central cyst contain^ a clear gelatinous lluid, while the contents of those of th.- lower end of the organ are more consistent and caseous in character. There is no trace of kidney substance to be seen. The pelvis and ureter on this side are much con- tracted, but still pervious. Left kidney weighs 12J oz., (350 grms.) ; and is much 1 M 1 "/' vkrv-^ '4" '''*'' "rO^TRjy.VL •<■ ^«- enlarged. On section the lowcl- third of the organ is occupied by four large cysts containing caseous matter, which ho more in th(! ])yrainidal portion, s.^parated from t|ic,mp^ule by a layer of cortex ), of an incli in thi.'knoss. Th(^ remainder of the organ i.s comparatively healthy though scattered through it are numerous tubereles^ ranging in size from miliary granulations to peas. The vessels are full, especially in the pyramids. The pelvis and calyces are slightly dilat.nl, but not thiekened, and only a tew tubercles exist on the mucous membrane. The ureter is of full size, and the inner coat presents here and there a caseous patch. Bladder small and contracted ; mucosa rough and exten- sively ul(!erated, the. muscular coat being bare over the greater portion of the surlace. Lung, crepitant throughout. A tinv cavity, the size of a pea. ,n the right apex. A few miliary granulations in both. Spleen ; Malpighian corpuscles enlarged and translucent reacting with Iodine. l^cri-ncphritic Ahscens. C.VSK x\\.~!^uppuraUon about rii-ht kidne,/. PijfcmU abscesses in elboivs. ankles, and anterior mediaslinum Ferilonitis. Pleurisi/. «. L., ict 11, sent to ho ,.ital supposed to be sufferino- Irom rheumatism, but the joint aliections proved to b<^ pyjomic in <;haracter. On removing the intestines a large, lluctuatingswellino- IS observed in the region of the right kidney, behind the peritoneum, and extending downwards in the direction of the psoas muscle. On cutting into it a pint of laudabh- pus escaped. The abscess is situated behind and below the kidney, the lower end of which is directly bathed by the pus. The Tsoas muscle is iniiltrated, and its iibres shreddy and degenerated. The pus has burrowed beneath F I ■ ft j 1 '' t ' \ !l :T'1 76 PATHOLOGICAL KKPOKT, the pelvic i^.'ntoiunim and is in immodialc coiita(;t with the walls of the bladder aiwl va-iua, n.>ither of which are however, perlbrated. There is no diseas.^ of th.^ })on(>s of the ^pme or pelvis. On slitting x^p the common and internal iliac veins, the lattiM- is found ohslructed by a thrombus, which is closely adherent to its walls and ex- tends for a short distance as a rough projection into the common iliac. Rii-ht kidueij is Uattened: on section it is soft and the cortex presents a mottled appearance. Iheivr and bladder normal. On removing the st(>rnnm an a})scess is found in the anterior mediastinim, clos(^ to the bone, and extending for an inch along the cartilages of the 5th and 6th ribs on the left side. Pericardium, is rough, both layers being covered with small papillilbrm processes. No flakes of lymph ; J oz. of turbid Iluid. The left p/eura close to the vertebral column is intensely inflamed, covered with lymph, and the tissues in (he neighbourhood ecchymotic. Lungs crepitant; one pyjvmic blo.k in the anterior border of the h'ft low(>r lobe. Bladuek. The following case is of interest as showing the effect of prolonged irritation of a calculus on the oro-an. Case xciw— Stone in the Bladder. Prostatic timoun nround the urethral orifice. Ulceration on mucous membrane Pyelitis ; ulceration of apices of renal pi/ramids. A. B., wt. 80, had suffered from stone for years. It was crushed in several sittings and a largi> i)roportion brought away, but he sank before the whole coidd be removed" Bladd-r contains iin ounce of turbid fluid, and 3ii of inn.'i- suilac... iVround Ih.. xiivtiiral orillco an' sovoral outgrowths I'ronr th.. ]>rostato ; the larncst is behind .sprino-ni- Irom the base, ol" ibo gland, and proj.vtin- likr un onlari-vdniiddh' lob.v Tho anterior ono is irregular not so pn.iament and is divided by small lissunvs. On thJ right between these two portions is a jx-dunculated tumour, a little larger than a pea, Ireely movable, and whieh iits directly over the oriiice ol" the urethra, bein.- displaced by tho passag*; of tho catheter. " The prosla/e itselfis not much enlarged ; the ducts are dilated and .ontain numerous reddish-brown calculi, the largest about the size ol a buck-.shot. The ureters are motl(«rately dilated, the right more than the left, the mucous membrane is swollen and inllamed Thi^pe/vis of th(! right /ddney is dilated, and the linino- membrane covered with a dirty greyish exudation. The same condition extends into the calyces and the apices of numy of th(> pyramids are eroded. The same thing, though in a less degiv.', exists in the other oro-an llTJijiv n.~Cancer. Cask ^\.\.~Ei>itheUoma of cervix; obs/rucfion of the mnal ; tlilatation of Ihe uterine cavity. Pi/romelrn A. J., u't. 80. Utervs.— On removal of the abdominal viscera, an oval tumour is seen to occupy th(^ i)elvic cavity, extending to the brim, and situated in the position of th(> uterus, betw°een the bladder and rectum. It is soft, iluctuating, and on examination proved to be the greatly distended body of the uterus. On attemi)ting to make out its exact position, the linger was accidentally thrust into the lower part of the tumour, (the walls in this situation being very thin) and a larg(> quantity of pus escaped. On removal of the pelvic viscera it i.s found that a cancerous mass involves the i \i ir i 1 78 rATIloLOClU'AL m:PORT. V ' cervix uteri, and upper part ol' the vtigiim, occupying the whoh; circumieroHGe of thi> Ibniier and the upper third of the latter, not extending to either rectum or bhidder. No trace of tlie canal of the cervix remains, an irregular por- tion, somewhat pedunculated, (corresponds to the position of the OS externum. The disease is confined almost entirely to the cervix, extending only to a slight extent around the lower zone of the body, (causing a thickening of th » wall in this situation. The cavity of the organ is dilalcd into a sac, the size of a cocoa-nut, which contains nearly a pint of i)us. Th(! walls are thin, scarcely 3'" in diameter ; the inner surfaces smooth and of a dark-gn^y colour. The round ligaments and Fallopian tubes are inserted at the junction of the lower and middle thirds of the dilated body. The latter are not enlarged ; one could be traced and opened as I'ar as the wall of the Ui ':as, where it wais lost. There is no dilatation of the inti^rnal orilices. The canc(^r is soft and white in colour in th(> va"-ina and lower part of cervix, firmer above where it gradually merges with the uterine wall. In histological characters it correspends with the so-called ejnthelioma of this region. No secondary masses of cancer. Case lxx\i.— Chronic Phlhists. Ovary. ■Dermoid or Filifero Pneumo-thorax. cyst of right ovary. J. C, let. 21. Right omry is occupied by a mass the size ol' an orange, which to the touch is yielding, as if lilled with putty-like material. On incLsiiig it the capsule is found to be thin and membranous, easily peeled off, exposing a fatty- looking mass, around which are numerous brown and black hairs. At one point a dense whisk passes round the en- tire circumference of the tumour. The hairs are readily MONTREAL (lENKlUL HOSPITAL. 79 detachod and aven.o« ..jg-ht or ten iiKlios in K-nn-th boiii" jmintod at, both ...ids. Th.y juv nearly all .snp.'rfuiar forming a thin layer, immediately within thi' (^apsul.., and on top ol' the fatty sebaceous matter, whieh .onstitutes a layer } " m thickn.^ss, whit.^ in colour, and containino- a few hairs. This rests upon the central body oCthe tumour .which forms a firm mass, about the size of a walnut, closely attached to the broad ligament, at the usual site of the ovary. The surface is rough, irregular and pitted, and Irom It numerous hairs arise and pass out throuo-h the sebaceous matter. The layer has the structure ot" skin and contains numerous hair follicles and sebaceous .^lands' On section of the central mass a small cavity, the size of a marble, is found, full of clear, viscid fluid. Beneath this <,'orre^=poading to the attached l)order of the tumour, the parts are very dense and hard, and on careful dissection an irregular piece of bone was found, shaped somewhat like the flange of a screw, having a handle-like process and an expanded, concave body, which is beset on both surfaces with sharp dentate projections. In colour and hardness it resembles enamel. Cerehro-spinal Syste.m. Tuberculosis. Case x\m.—Small mvihj and caseous viasses in Imi"- General tuberculosis. Meninges of brain vna^ected ; cen- tral softening. Spinal meninges extensively involved. (). B., ivi. 20, sailor. Symptoms chiefly spinal, and attributed to a fall which he had sustained three weeks before his death. Autopsy 36 hours after death. Brain, extremely soft, and with difficulty removed. Sub- arachnoid fluid in excess. Large veins of pia mater moderately full. Convolutions pale and flattened. Arach- ;■ i h 80 PATHOLlXHCAL KKPUKT. noid aiul pia mator are clear and natural lookino, both at base and cortex. The Ibrnier whiirt? it stretch('8''l'roni Ih ' cerebellum to the cord is cloudy, but there is no lymph or inllammatory elluHiou. Middle cerebral arteries and pi;i mater of Sylvian iissures carefully examined for tuberclcH, but none were found, even on nucroseupioal examination. On section of the hi'mispheres the brain sub.stanoe i.s soft. moist, and glistening-; pum^ta va.sculo.sa indistinct. Lateral ventricles much dilat(>d, and contain ^iiss of fluid. Thedila- tation affects especially the posterior Imrns, which extend far back towards the cerebellum. The walls are excessively soft, and, for the mo.st part, converted into a niddish-whit" creamy substance, consistint,'- of de!--en(!rating- brain matter, blood corpuscles, and Gluore's cells. A .identic stream of water washes the layer off, leaving- the parts beneath rough and irreg-ular, and to the touch very friable. Se|:>. turn lucidum soft, and on removal separatc^d from the fornix. Velum interpositum and ( horoid i)lexuses pale , no lymph or tubercles. Walls of third ventricle soft, bu^ intact, commissures uninjured. Corpora striata and tha.i- ami optiei soft and moist ; grey substance reddened. The most careful examination failed to detect any tuber- cles either in the meninges or brain substance. Spinal cortL On removal, the arachnoid stretching frarn the cerebellum is noticed to be opaque and granular r.aid uiwn the table the cord presents at the lower part slight irregularities and bulgings. The dura mater is thick and opaque; the arachnoid lining its inner surface is scattered over with numerous miliary tubercles, like grains of sand, very abundant in i\v\ dorsal and lumbar regions, less so in the cervical. As far as the lower pan of the cervical enlargement the visceral arachnoid is clear and transj^arent, and the pia mater can be distinctly seen through it. From this point to the termination of the cord the arachnoid is opaque, and the sub-arachnoidal space filled with turbid lymph, the membrane over the centre. mur MOXTIIKAL (li:.\KIlAI- Hi )sriT.\r,. SI of tho lumbar riiliiruviucnt h.-ino- mucli (listciidod. Oi, .'xposiim- tlK' piiv mater :i thin layrr ol' vcUowisIi-wliilo lymph covers it iu the dorsal and lumbar rei-ion.s, becom- ing more abundant at the cauda substance bulges out as a soft round"ed mass. Section of the cord shows it to be very soft, but m)t otherwise altered. Lungs.— iim-dW caseous masses in both apices, and in the left an old cavity, the size of a walnut, with iirm dark walls. Kest of organs crepitant, but stuffed with small miliary tubercles, isolated, angular, and translucent. ^/?fe«».— Innumerable firm miliary granulations throuc-h- out the tissue. "^ Kidnei/s.—A few tubercles in the cortex of the rio-ht organ. Liver contains scattered tubercles. Case XLUI.— Meningeal affection slight. Ventricles dis- tended, walls soft. Very feio miliary tubercles in the organs. E. H a delicately built girl, aet. 19 ; symptoms chietly cerebral. ' Brain. Parts about the optic nerves matted together, I •' m V , r }! % I i 1, !' 82 TATllOLOCdCAL REPORT. ; tli and tho arachnoid opaciue. No lymph at the base or iu the Sylvian iissures. Careful inspection fails to discover any tubercles on the pia mater ; but on stripping off the membrane on the ^Sylvian Iissures, and washing it in water, numerous miliary granulations can be seen, chiefly as fusiform thickenings of the small arterioles passing into the convolutions. Veins on the cortex moderately full, convolutions a little ilattened. On sec- tion of the hemisphere, the white substance is of average consistence, but moist. The lateral ventricles are large, and contain a slightly turbid liuid. The ependyma is' granular ; over the ganglia, soft. Fornix and septum very soft, and could not be lifted up. Spinal cord. Veins full. Arachnoid in cervical portion opaque. On the visceral layer of arachnoid in the lower three-iburlhs of the cord there are numerous small carti- laginous plates, thin, flexible, irregular in outline, and presenting the usual glistening appearance of these bodies. No tubercles on pia mater. Z,^^«g•,s. Lower lobe of right, heavy, airless, and contains miich blood and serum. A few tubercles through thr substance of both organs. Bronchial glands enlarged ; one presents several caseous masses, the others, small, firm miliary granulations. No tubercles in the other organs. Case i.xxx.—Menmgcnl affection venj extensive on the cortex, i^light at the base. Ventricles large, ivalls not soft. Large caseous mass in left lung. Miliary tubercles in lungs and on peritonaeum. J. S., yet. 2J, male child, much emaciated. Cervical glands much enlarged ; one over ramus of right jaw fluctuates. Brain. On surf\ice the veins of pia mater look full, and there is a good deal of fluid beneath the arachnoid. A thick layer of yellowish- white lymph exists along the longitudinal fissure, especially on the right side, and on MONTREAL (iENERAL HOSPITAL. 83 separating- the homispheros th.^ same is soon in the region of tho o.cipito-pari(>tal iissuros. On the inner surface of tho left homisphor,., noarthe iissure of Rolando js a thick, tuborculous patch, which extends into the brain substance for a quarter of an inch, and the pia mater about it is studded with small tubercles. Over the left frontal convolutions above there are eioht or ten tubercles, the size of No. 8 shot. On the rig^it parietal Jobe, just above the Sylvian iissure, there is a thick lay(>r lymph The base is comparatively free, the arachnoid dear, and no lymph is seen. In th.^ right Sylvian fissure the parts are matted together, and tubercles may be seen about the smaller arteries. On section of the hemis- pheres, the brain substance is found to be glistenino- ;,nd moist, not hypeniemic. The ventricles aiv moderately enlarged, and contain a clear serum; ependyma clear • walls not softened, and the fornix and septum are tolera- bly consistent, being lifted without tearing-. Lungs. Th.' l.'ft has a peculiar soft pulfv feel. At the lower part of th,> upper lobe is an oval caseous mass, the Hizeol a large cherry, iirmly encai)suled and d.y. The rest of this organ and the right lung are stuffed with miliary tubercles, all of which are small, isolated, and translucent; no cheesy masses in the lalter. Bronchial glands enlargc>d ; two caseous. A few tuberch^s on both layers ol the pleura. Peritonmun. On the yiscc'ral layer, especially over the shrunken small intestines, are numerous small dark tubercles, from size of No. 8 shot to peas. On the parie- ta I fay or they also abound, and on the left side form a /fattened irregular mass, with very dark c>dges. The glands at the root of the mesentery are on^ormouslv enlarged and caseous, forming a bunch as large as the <1osed hst of the child. No tubercles in tho other organs. ihiiM \ m : 1 ffi ■ ■i ■ i I i 1 1 ' i\ W ■ I : " ■*■ O 1 i 1- SI' 1% i" •: 84 PATHOLOCUCAL REPORT. '' iJ Case LXX^•I. — S/ight mening-ea/ injinmmation. One cnseoKs vinss and a few (tiherc/es in Lungs. Old morbus coxcv. A.L., ivt. o|, iui ill-nourisht'd, emaciated child. Brain. Pia matter injected, and of a deeper red colour than usual. No tubercles or lymph about cortex or sides, but the arachnoid over the sulci is cloudy aiul granular. At the base the arachnoid is quite clear, but the pia muter IS somewhat more adherent than usual and matted a])oui the Chiasma. No lymph. On the Sylvian lissures small tubercles occur on the arterioles, and in the riaht there are a few ilakes of lymph. On th.> small arteries over the pons and medulla are numcn-ous translucent granula- tions. At the upper l)order of the (•erebellum,''near its attachment to the cerebrum, there is a layer of thick lymph. On section of the hemispheres the brain sub- stance is moist ; puncta vasculosa distinct. The ventricles are slightly dilated, and contain a clear fluid. Walls not so firm as natural. Fornix and septum tear easily. Velum interpositum aiul choroid plexuses cloudy, and a few tubercles are seen about the arteries. Lungs. At extreme apex of right is a small caseous spot. ihe size of a pea, and in the tissue for an inch about it are two or three dozen miliary tuberc^les. In th(^ left lung, which is crepitant throughout, there are also a lew miliary granulations at the apex. Bronchial glands are large, one or two of them caseous. Head of right femur is rough and ulcerated, no cartilage remammg. General Diseases. Pernicious Anamia. Case lxi. — Profound Anccmia loithout discoverable lesion. Fatty degeneration of organs. Hyperplasia of hnne-marrouK G. A., act. 52, an Englishman.— For clinical report by MONTREAL (JENERAL HOSPITAL. 85 Dr. (Gardner, sre C. M. 4. S. JuurnaL Manh, 1877 A aoscnptiou of the hlood and bone-marrow, by ' Dr (.ardii.r and myseli; occurs in the CentraMatf. / di', meihatmchen Wissenschaflen, No. 15, 1877 ; Berlin A«/f)/As,y,— Thirty-two hours after death nodythatofawell-buiJt num of fair nmscuhu- devel- -PHK>nt. an- grey. No emaciation ; panniculus mIiJ)osus well developed, especially over abdomen. Skin ol extraordinary pallor, Avith slight lemon tint, the shoul- ders marked with patches of deeper yellow hue. A few old psorwsis spots seen in the region of the elbows and knees. No petechiM^ Lhiejc albicantia> in the skin of gronis, and upper and outer aspect of thighs, and on the onter edge of anterior folds of axilhe. Fingers slightly ^Inbbed, and the nails of both hands markedly incur^"lted Kigor mortis moderately well marked. Post mortem stams scarcely perceptible. No enlargement of the super- licial lymphatic glands. No cadaveric odour. i)'mm.__Not examined. On making the preliminary incision a layer of deep yollow lat, fully an inch in thickness, is cut through over he abdomen. Muscles of the thorax of a remarkably Ilea thy red colour. In the abdominal cavity the position oi the viscera normal. Omentum moderately fatty In the thorax a considerable amount of fat over the peri- cardium. The left pleural sac contains twelve ounces of Moody, yellowish-tinged, serum. A few strong adhesions posteriorly. In the right pleural sac ten ^ to twelve "unces of fluid of the same character. Adhesions more numerous at apex and sides. Peri'^anlinm. ConMns six dra.lmis of a yellowish. I'loody serum. No ecchymoses on either leaf .],i^d^;7 l'''^;r u"^"'^^ '^''^^^'- S^l>-P'^ncardial fat abundant about the base and in the anterior ventricular .^loovo Patch of attrition over upper part of rio-ht ventricle in front, and another behind, near the inferior vona cava. On opening the heart in situ' an ounce of \M\ ?fh ) > '" B t 86 PATHOLOGICAL UEPORT. h t m i II r blood, with Olio small coaguluni, in the cavities of the right side, and ten drachms in those of the left. Origan ilaccid, and walls collapsed when on the tabl(\ Right auricle normal, Kight ventricle somewhat dilated, tho endocardium stained by imbibition. Tricuspid valves ;., little thickened and gelatinous at the edges; orifice ol normal size. Pulmonary semi-lunar valves healthy, one segment fenestrated, ('avity of left ventricle large, walls of normal thickness. Mitral > ulves quite healthy, L littl(> stained, orifice of proper size. Aortic semi-lunar valves ;.. little opaqite; slight atheroma at their base, and on the aorta opposite their free borders. Sinuses of Valsalva very distinct. Nothing abnormal in the left auricle Muscle substance of the organ exceedingly pale, having a yellowish, faded-leaf appearance, especially marked iu the w^alls of the left ventricle. Aorfn.— Both arch and trunk of full size. lU'yond the left sub-clavian there is a llatteiu^d ])atch of atheroma, about the size of a half-penny. ZMWg-.s-.— Deeply pigmented ; crepitant throughout ; lower lobes ccdematous and dark in colour posteriorly, The mucous membrane of the Trachea at the bifurcation, and extending irregularly nearly to the larynx, is repre- sented by a num])er of bony plates, lying'immediately upon th'^ cartilages, which are themselves very dense and partially ossified. Spleen.— Weight, six ounces ; soft and flabby, Capsule a little opapue. On section, pulp soft, of a hglit brownish- red colour. TrabecuUi> distinct. Malpighian corpuscle,^ not evident. Very little blood in the organ ; none could be obtained from the splenic vein. Left Kidnei/. —Length, 5". Unusual amount of super- ficial hit. Capsule loosely attached and oi> removal leavea a very anapmic-looking organ. No atrophy of the cortex, which is pale and bloodless. Pyramid.^, excei)t at the bases, also pale. Eifrht Kidney, 4^" long, dark red in colour, uniformly congested, forming a striking contrast MONTREAL (JENERAL HOSPITAL. 87 to the other. Cap.sule easily detached; stellate veins prominent. On section, both cortex and medulla contain much blood. Supra-Renal Capmles.—Tha right is sol't in centre, and somewhat larger than the left, l)ut nothing unu.sual about either. i?/rt«r in transverse and descending colon. Liver.— Yi&t\\Qr small.of a light yellow colour, especially in the left lobe. Capsule smooth. On section a small (luantity of liquid blood is seen in some of the hepatic veins. In places there is a very slight injection of the intra-lobular veins, which relieves the otherwise uni- formly pale surface. Gall-bladder.— FyxW of dark tarry bile. Pancreas. — Looks healthy. Abdominal blood-vessels almost empty. No blood in inferior vena cava or aorta. Intima of both healthy- looking. Thoracic Duct pervious throughout. Mesenteric and retro-peritoneal lymphatic pr/nnds small, the former imusually so, requiring considerable searching to obtain any. The amount of blood in the body appeared remark- ) I ^IHi i 88 PATHOLOGICAL IIKPOKT. ably diminishrd, and if, was oi.lv hy pressin- alon^- tho limbs that suOiciont could !).> obtained to iiU a ."mail homu)opathi<' phial. Piece of the sternum, the ui)p.'r hall' ol' right iibula the inner third of lelt cdavicle. half a rib, and one of the' last dorsal vertebnp were r(>moved for the examination of the marrow. Blood was colh^cted from the heart, and junction of the left .jugular vein with the sub-clavian. A striking feature in the autopsy is i\u^ c-xtreme anromia of the organs, their almost entire bloodlessness and consequent pallor, the right kidney exirpted. HLSTOLOOICAL EXAMIXATIOX. The blood examined during life, and after death, pre- sented the following appearances. (Hartnack, No 9 im and Oc. 3.) About one-half of the red-blood corpuscles run together to form rouleaux. The majority of t' em appear of lar-e size but do not present the characteristic round contours of these bodies ; many are ovoid, others lozenge-shaped or of various forms, with irregular projections and pro- cesses. Isolated corpuscles look of the natural pale yellow colour, but the alternating light and dark centre with the change of focus is not so distinct as usual. On touching the top cover and causing them to roll over many do not present the bi-concave appearance, but look thin and flattened out. A limited number are crerated Jn each field certain small round red corpuscles are seen sometimes as many as six or eight. They are spheres' not biconcave, of a pale yellow colour, ocvasionally crenated or irregular in form. The measurements of some of the coloured elements are given below (Hartnack No. ](i im.), from which an accurate idea is obtained [of the remarkable di.screpancies m size. About forty measurements were made of corj^us- MONTREAL (iENEKAL HOSPITAL. 89 cles taken at random in two or three specimens obtained ii few days before death. Of these one was 1-1833" by 1-2(J1!»", being- somewhat elonj>'ated. Vivo ranged from l-27o0" to 1--11-5", these being the extremes. In twenty- two the range was from 1-3000" to 1-4200". In this uroixp the ordinary-looking red disks oecnrred. In iive the diameter varied from between l-.»000' and 1-!)000." In live the diameter was less than the 1-tiOOO", the lowest being 1-0S74." Prolonged examination failed to di scover a sinirle nucleated red corpuscle. The colourless corpuscles did not appear relatively increased. One or two were seen in each field of the No. !• and 3. The measurements in live corpuscles ranged from l-2.-)00" to 1-1800". They were quite natural look- ing, and displayed a remarkable degree of vitality. In a slide mounted and surrounded with paraihne at 1 P.M., the amccboid movements were very active, the temperature of the room being about 00*.* At 7 P.M. the slide was . corpuscles twenty-four hours after removal from thebndy. The blood was sealc.l in a capillary tube, and remained at the ordinary temperature in the month of June. I m i : : I " ' « I I I I Is; I : It; I if ] 90 TATHOLOGICAL REPORT. here and there a fibre occurs in which the fftviiv arc taintlv seen, In teased preparations numerous short bits occur, together with oil-drops and g-ranules of fatty matter! In places there appears to be a crood deal of interfibrillar connective tissue with fat cells. Mmc/es of the Trmik.— The iihves of the thoracic muscles— whicli were observed to be of such a natural appearance— present no trace of iatty degeneration. Sp/pen.— The ordinary corpuscles of the pulp, togetlier with elongated, sometimes branched, cells of the retifomi tissue are the chief elements seen in teased specimens. The red corpuscles have lost their colouring matter. A few cells containing red blood corpuscles are .seen, but no nucleated red cells. Kidney. — Teased preparations show the ei>ithelium oi the tubules, both in the cortex and pyramids, covered with ftitty matter in the form of minute drops and line granules ; nowhere, not even in the large collecting tubes are the cells distinct. The Malpighian corpuscles also contain many granules and small oil-drops, and the same exist abundantly in the field. Liyer.- Cells are stuffed with oil-drops; none noticed without them, while in many the protoplasm and nucleus are entirely obscured. Free fat exists infiltrated between the cells, and in the field. In a few bile pigment is seen Mesenteric G/ands.— Teased portion:^ present a large number of perfectly normal-looking lymph corpuscles, among which the connective tissue elements occur in the usual proportion. Many of the small vessels and capil- laries have their walls uniformly studded with fat grains, and may be traced as dark branching lines. In others, the deposition in not so extensive. Nothing abnormal observed in the axilliarv Ivmphatic glands. Medulla of Knnes.— The marrow of all the bones examined— sternum, ribs, clavicle, vertebra, libula— is of MONTREAL GENERAL HOSPITAL. 91 a dark violot-red colour, thick, about the consisteneo and colour ot the spleon pulp in lever. In the clavicle it is more diilluenl, of a lighter red colour, and to the naked eye looks a little fatty-an appearance not noticeable in the other bones, not even in the .shaft of the fibula On microscopical examination, the following elements were found : — (1) Colourless corpuscles— marrow cells— of various Kize, with granular protoplasm, and bold vesicular nuclei The greater number of these are larger than white blood corpusdes, and have usually a single nucleus, sometimes two. Others are smaller, more approaching the blood corpuscles in form, while in all the specimens examined, .small round cells, like ordinary lymph corpuscles, are a so lound. The above represent the common colourless elements found in marrow, and they form the majority ot the corpuscles in the field. In eight of the larger cells the extremes oi measurement were l-lo71" bv"l-18qq" and 1-2200" by 1-2895". ^ (2) Coloured blood corpuscles, of which two varieties are seen; (a) ordinary biconcave disks, somewhat irregular in shape, and often, as noticed in the blood durino- life provided with long processes. They are abundant' lorming the large proportion of coloured elements. In the' libu a, sternum, and ribs the colouring matter is retained while in the vertebra and clavicle it has disappeared from most of the corpuscles, aad they are recognizable only as outlines, (b) Small round red corpuscles, non-nucleated Irom one-quarter to one-half the size of ordinary corpus- cles, and similar i!i appearance to the small forms seen m the blood. They occur most numerously in the marrow of the fibula, where they form fully one-fourth ot the coloured corpuscles. In the sternum and ribs they are not so abundant, though occurriuQ- in Pnoh field As described in the blood itself, they do not appear to be biconcave disks, but spheres. The colouration is quite- » ■;; f i ! r ' qo PATHOLOGICAL RKPORT. ti.s ill i'orni a, nnd a l'.>w were ob.sen'ed to be t < '11 I ill ill as iiitciiM' crenutcd. (-5) Nu.-lcatod red corimsclos. the " transitional " forms of Neumann, whicli :nv numerous in the sternum and ribs, lt>ss so m (he til)ali, while in the clavicle and vertebra Ihey occur scantily, or. owing to the general decolorization of the red corjniscles in these bones, arc seen with difh- Gulty. As shown by the measurements given l)elow th'.^v are as a rule larger than ordinary biood corpuscles, but present, like them, a perfectly homogeneous coloured stroma, in which a Jlnely granular Jiucleus is imbedded. They are sj^heres, not biconcaAe, as a rule round, though frequently irregular in outline, or with one end pointed and jiroloiiged. The intensity o»' the colouration in most equalled that of the ordinary red corpu.^les, in some instances being deeper, in others not so marked. The nuclei arc^ either round or elliptical, and occupy from one-quarter to one-half of the body of the cell (see mea- surements). They are solid, granu.ar, and inside th.- corpuscles look coloured, though not so deeply as the sur- rounding substance. The presence of nucleolus could not be determined. The position in the cells is variable ; nx specimens examined within a short time after the post- mortem they appeared to he chielly centric, but in prepar- ations taken the next day very many of them had become quite peripheral, while others had protruded almost through the corpuscle, when it could be clearly seen that the nucleus was colourless. In several instances the nuclei are seen to be entirely outside the cells, though remaining attached to them. In this condition they look not unlike the small lymphoid marrow cells, and it is only the large size of the corpuscles to which they adhere, and the fact that in the same Held others may be seen half-way out, that enables a correct opinion to be formed. In three or four instances dumb-bell-shaped nuclei wen; noticed. C'ells with two nuclei were not uncommon. MONTREAL (lENERAL HOSPITAL. ;):{ and instances with three and lour were o]),servcd As remark.'d above, the nucleated red lorms are numerous in the ,st<^rnum and ribs, six to eio-ht ].eino- «een at once ni the held of the No. 9 ini. and .'5. while iu the filnila not more than three or lour were noticed in any sin-le iield In hlteen measurements of these ibmis, (-h-ven W(>re above the 1-2000"; live being 1-1428". The followin-v moa- surtnnents are of three corpuscles with their contained nuclei:- (1) 1-1774" by 1-2200"; nucleus l-2(il!)" bv l-289«". (2, 1-2200" by l-2:i!.l"; nucleus l-.l.lOO" by ■aOOO. (8) l-20:]7" by MD.U" ; uueleus UmU>" by 1-dLoo. A good idea of the irregularity in outline of these corpuscles and the slightly elliptical character of the nuclei may be gathered from the above. (4) Cells containing red blood corpuscles. These are very abundant in the marrow of the vertebra, three or our occurring in the iield at once, and containing from iive to SIX red corpuscles, the colour and outlines of which m most cases are preserved. lu the sternum and nbs they are not nearly ^so numerous; in the fibula and clavicle they were not observed. (5) Myeloplaques, of which one or two only were met with 111 the marrow of the sternum and rib. Neither in tJie shaft nor epiphysis of the fibula could these forms be determined. (G) Fat cells, which are present in marrow of the clavicle m small numbers, absent in the sternum, vertebra and rib. In marrow from the fibula an oil drop is occa- sionally met with in the field, but here also they are almost entirely absent. (7) The octahedra crystals, first described by Charcot and which always occur in the marrow from twelve to thirty-six hours after death. i mn\' ! \h 94 PATIIOLOOICAL KKl'ORT. if Case \c\U.— ProfoNmt nmrmia, without discoverable ieswn. Fatt,,deireneral ion of organs. Hyperplasia of bone- marrovj. J. 15 iPt. 47, an Enolislumm. For clinical roport, by Dr. J]ell. .S..0 "Transactions of Canada Modical Associa- tion, ' vol. 1, 1S77. A description of tho blood and bone- marrow in this case also occnrs in the Centralblatt f. d med. Wissensc/inften, No. 25, 1,S77. " Body that, or a spare man, 5 feet 5 ineh(>s in hei"-ht • complexion fair, hair light, whiskers red. The skin "pre- sents a yellowish tinge ov,>r the whole body, most marked on the lace, neck, nnd shoulders. Jfigor mortis W(>11 developed. Slight (rd.una of low(>r extremities. Four or five smooth white cicatrices on the right side of the le- Freckles abundant on forearms. Panniculus adiposii's thin. Brain.—SknW nnnsually thick ; marrow of diploe ivd. About 2 ox. of serum escaped on removal of the dura mater. Vessels of the pia mater euipty. Pucchionian granulations numerous, lirain substance pale, of good ;i ! nP <.'nl->.-novi/-.ni./1'.j1 f<»* ^,i^ll ^i • ! = r- '■• aiUidx lai, v-spccially over the right MONTREAL OENERAL IIOSPITAI,. pfi cavitios. V..„i,> .avM. nearly empty. Kiyh, ,uuide e.,,,- tamsSiNs.ol hlood, light claret-colouml, and one small coatmlum, partly decolorized. ]{iffht ventricle .ontainN a small amount of hlood ; Avails thin ; endocardium slain- .-.d Valv.'K h.-althy. Musculi papillares pal., yellow .•oour Leltauriele empty. Left ventri.les eontain very little blood ; hning membrane stained. Walls of normal thickness, muscle soft, somewhat paler than nornuU. \ alv.'s healthy. Aorta of normal diameter LuHfTs ; pigmentation moderate; slight .ongestion (post- mortem ) in dependent parts, and also an excess of yramids. Cones very pah- lU'-ltl mpsute h...lthy. madder healthy. Vesieuhe seminUes contain spermatozoa. Siomach distended wilh o-as ,,,»- tains about 4 oz. of a brownish viscid lluid. Numerous ec aioses along the greater curvature, especially at the cardiac end. Ihe veins contain blood. Mucous mem- brano looks normal. -Duodenum and Jejunum healthy. Coais of the i/rum very thm, translucent, and anaemic. The solitary .-hrnds nre prominent in the upper part; only one pahh of PeycT iound in the lower portion. Large bowel normal. Mesenteric glands appear even smaller than natural. I'ancreas healthy. Liver, a f-w ecchymoses on capsule, a small cicatrix on upper «urhice of right lobe. .Substance pale, in parts »ucn softened.. Weight .3 lbs. 8 oz. Gall bladder con- tains normal-looking bile. •tfi \ ' H^ ? ^ ' OG PATHOLOGICAL REPORT. HISTOLOOICAL EXAMINATION. The h/ood examined during life was very thin, watery, and of pal(! claret colour. It presented the Ibllowinu- characteristics :— Colourless corpuscles appear i>errectlv natural in structure and size, and are not numericairy increased. No lariie granular ones, such as describ(>d by Jitten=^ could be found. Two forms of coloured corpus- cles : (a) ordinary forms, which are paler than mvtural, Hattened out, less biconcave, and very irregular in out- line, some ovoid, others with sinuous borders, others ao-ain with pointed processes, (h) Small red corpuscles— micro- cytes,— (MToneously described by lilichorst as pathogno- monic of this atlection. They w^ere numerous, 8 to 10 occurring in the iield of No. 9 im. and oc. 3. Tha diameter ranged from 1-5000" to 1-9000." They equalled, or even exceeded, in colouration the ordinary forms ; some were crenated, and they frequently presented a pit or cup- like depression on one side. In the repeated examinations of the blood, extending over three months, these forms increased but little numerii'ally. Schultze's granular masses were not noticed. No appre- ciable difference could be detected in the histological appearance of the blood an hour after the transfusion. The heart presented signs of moderately advanced fatty degeneration, the striae in many fibres being obscured by molecular fat and droplets of oil. Spleen. — The normal elements, cells of the spleen pulp, and spindle-shaped corpuscles of the trabecula, together with numerous blood corpuscles, were the only structures noticeable in teased preparations. Kidneys. — In both cortical and pyramidal portions the cells of the tubules appear very granular, somewhat swollen, and a large number of oil droplets are seen in and about the tubules. • Berliner Klinische Wochenschrift, No. 19, 1878. MONTK'KAL GKNEUAI. HOSPITAL. 07 Lirer-CoU^conUxiu oil drops in oxeess. and in many Ih.. n,irl,.i are ol).s,urod. Th-ro is also son,,, latty iufiltra- tioii. ■' Tlir marrow o[ all th. bones examined, stenium. ribs vertebno. radius, fibula, was of a vioJ.t-red eolour ol' i?oo< consistence, and with the ..xception of that of the hbuln. contained no 'Ut. There wre found the ordinary h.rge coars.-ly -ran .r, marrow cells, numerous smalJ lymphoid corpuscles of both sizes : and. in addition, very many nucleated red blood corpuscles, corresponding with those d..s,.ribed by various writers as occurrin- in the marrow m <-ases of leuka^nia, an.l by CV>hnheim# and niyseiif as constitu..nts of this tissue i^ .erain cases of l>ermcious anremia. There were not many in the marrow ol the sternum, few.-r still in (hat of the vertebrju They ^verc> .•onsiderably larger than the ordinary red blood corpuschvs and of about the same intensity of colouration The majority had only one nucletis, but cells with two, three, and four w.'re not uncommon. The jmsition of the nucleus vyas usually c,-centric, often, indeed, protruding halUvay Irom the corpuscle. The nuclei were colourless. ' Virchovv Archiv., Ixviii. 18VG. t Central blatt f. d. Med. Wissen. No. 15, J 877. At ! a i :<{ PI Mi V'^J mm k l„li.,4 XX I I ON THE PATHOLOGY OF THE SO-CALLED PIG-TYPHOID. I..! I- l„i.,l BY flVjiSSO* WILLIAM OSLER, M.D., Physiology and Pathology iu McGill Unheysity, ami the Vcterimry College, Montreal. Repnnlfnwi the Veterinary Journal, June, 1878. BAILLIERE, TINDALL AND cOX, KING WILLIAM STREET, STRAND. ^rDCccLxxvIII. f ' ! M 1..., J^, PATI Pivfissor vf i ■ft! P BA ox THE PATHOLOGY Ol'' THE SO-CALLED i I :S PIG-TYPHOID. liV WILT,IAM OSLER, Af.D., C('//t;-;', iMonlrcoJ. lu'Pnnt/rom the Vetkrixarv Jourxa,., June, ,87^ S n ^ cr It : I^AILLIICRK, TINDALL AND COX, Kl\(; WILLIAM STI^EET, STRAND. MDCCCI.XXVUr. ' • "11 i ' ' i'"J . i 1 J ' u 1 ' t j! i ii. r i ir.i.xll, Walsoii, iir.J Viiicy, Vi Loiiijun ;iiul 1 Aj le • ijiuy PATH The mosf disease ; i of the Co some of o hcadiiij^. conclusion that it be interest ex awa)', to b from the p extended t cHnically, 3 part of hui tigated tlie arrived at ; I'ig-Typhoii in man. liavhig, i witli this u McEachran' had broken * An abstra New York, Jm ^mmmimt m 1 1 ! m \ ; 1 OX THE PATHOLOGY OF THE SO-CALLED PIG-TYPHOID.* The most diverse opinions prevail as to the true nature of this disease; upon these T shall not comment at length. Many of the Continental pathologists class it with Anthrax, and in some of our luiglish text-books it is treated under the same heading. The researches of Pnidd, in 1S65, led him to the conclusion that it was a Typhoid ]'cver ; those of ?.Iurchison, that it belonged rather to the dysenteric affections. Tlic interest excited In the disease by these early investigators died awa}', to be awakened ten years after by a scries of papers from the pen of Professor yVxe, in which he substantiated and extended the views of Dr. Budd, stating that, etiological!}', clinically, and pathologically, the disease was an exact counter- part of human Typhoid. Dr. Klein has more recently inves- u'gated the disease with special reference to this point, and has arrived at an opposite conclusion—holding that the so-called rig-Typhoid has no analogy with the disease bearing this name ill man. Having, in the course of my reading, become acquainted with this unsettled state of the matter, I gladly, at Trincipal McEachran's suggestion, investigated a local epizooty which had broken out near Quebec, in a drove of 300 hogs ;' hoping * An abstract of tliis ].apcr was read Ijcforc t'uc ratliolc-ical .S New York, January Jjrd, 1878. ocu.(\ 01 M ll'Fsi . f I! I 4 0)t f/>c ralJiohi^y of the so-calU Pii^-Typhoid. that, by a scries of indepciKlcnt observations, the truth of nnc or the other of these views might be confirmed. M ETIOI.O(jV. Tiic lilghly contagions and infectious nature of this malady has been known for years— being first cstabh^shcd, I believe bv Dr. Sutton, of IHinois. The following experiments, tho'urri, hmitcd in number, arc, I tl 'nk, worthy of record, as they o'l- firm and extend tliosc of Professor Axe and Dr. Klein. lixpcr ill lent I. September ist.-A sow pig, ten weeks old, was inoculated \\ith lymph and blood obtained by squeezing a portion of ccchymosed skin from a diseased animal, and collecting the exudation on ivory points. No change noticed until the 6th, when the animal did not appear so lively. Temp. 104^'. 7th.— Place of inoculation has dried up, A diffuse sub- cutaneous redness exists over skin of belly, and certain of the hair follicles arc swollen, papular, and surrounded by irregular but circumscribed zones of hypenvmia. These are best ''seen in the groins, where the general redness is not so marked Temp. 105". 9th.~Blush on abdomen not so vivid. Spots about hair follicles persist. Animal feeds well. Temp. 106!'. iith.~A {cw reddened papules on :>!;in of abdomen, Ilyper- icmia has faded. Temp. loGi'. 13th.— No change. Temp. 106". 14th.— Skin looks harsh, and the hairs appear rougher than natural. Temp. 106:". i6th.— Kyes \\aterj- Animal looks ill, but feeds well, and has no diarrhcca. Temp. ioG.| . 17th.— Pack somewhat drawn up. Dirty secretion about the eyelids. Skin of abdomen is of a dusky-red hue, and the papules about the liair follicles arc again very distinct. A feu ccchymoscs about the back of ears. T( emp. 105, I 1 8th.— Skin of whole body of a deep dusl ■y-rcd colour ■^^-iiM^Miw Iioid. "utli of one Ins malady believe, by its, thousii ! they on- 11. inoculated portion of ::ctinc,' the al (lid not ffnse sub- ^in of tlie r irregular best seen 3 marked. bout hair Ilypcr- jhcr than well, and xbout the and the , A few 1 colour. On the Patholiwy of the so-called Pi g.Tyfhuid. brightest on the abdomen. It disappc.. ins very slowly. Over the sternum and dciinitc ccchymoscs. Inguinal gland docs not {cciX so well. No dianha'a ars on pressure, return- in th c axi lI,-o tl lerc are f s arc swollen. Animal , , , ,„ • Mucous mcmbran rectum reddened. lemp., mornin- and cvenin- lo-' I9th.-Much the same. Temp, morning 104: evening 105'^. COth.-Skm harsh. ICycs lustreless. Not so red ' l^^cchv moses have not extended. Temp., morning and evcnino- \oJ 2ist.-Anmial feeds better; redness much diminishcd.'Tcmn morning 104", evening 103'. 22nd.— Inguinal glands still swollen. Temp. 104!^ 23rci,-l/o:>y o Ihc so-caiicd Pirr.Typhoid. T«tli -Other spots of Iiyponx^mia on abdo.nui. They i,v about tin-cc lines in dianictcr. sliglUly elevated, and di.sai)pcar'on prcssua. No general rash. Temp., morning 105 . eveni,,,. 105: . ■=■ 19th.-Ani.nal continues to {cc.\ well, but the skin and hair look rough. Temp., morning 109:; evening 107.'^. 20th._No trace of any skin eruption ; the small erythematous spots have faded. Temp., morning ,0,-,'. ; evening ,o« . 2ist.-Sitc of mjection remains hard. Temp., morniu' evening 106'. ' 2Jnd.-Eyes do not look so bright. T mp., niornin- cvenmg 107^. 23rd.-No diarrluea. No rash. Temp.. ,nu. ning 107 ; evenin- 107.-, . 24th.-Not so well. Eyelids glued together with secretion lemp., mornmg 109; evening 108^. -'5th.-IIas diarrluea. A muco-purulent discharge runs from the nose. A very faint rash exists over abdomen. Trmn morn nig 107", evening 107^. ^ ^ \^7^r''^\ ^"■"^"" ^■^^'•^'"•ties cold, and the nose h!g ;o8r "^ P^'-"ptible. Temp., n.orning 107V , cvcn- -Vth.-Vcry ,veak, and considerably emaciated. Position ic; ^^ 107: ^vhen standing and general appearance very characteristic ; back arched and the hinder extremities seem ahnost unable o_ support the weight of the ' v.Iy. The gait is totterin. Dmrrha^a very severe, and the ... .er noticed a little blood I td.sduarges. Several large ...-puric blotches on the hind- legs r.o cough. Temp., morning io6.{ ', evening loG . 28 h.-Lxtremities cold and nose blue. ICmaciation has nc. ased. Extravasations have extended, and are seen on the f.onWegs as well. Site of injection still hard. Inguinal glands a little enlarged. 1 cmp., morning 105 ^ evening 103". 29th.-No change. Diarrhcea continues. Temp., morning icij;, evening io6-. '^ 3oth.--No extension of the extravasation. Dr. Buller exa- mined the eyes, and reporli, the rctins , 106; , evening io6^'. 231 mornini On ilic Patholooy of I he so- called Pii^-Ty(>ltoh{. q October [St.— V^cry weak; can hardly stand. Dianhuca veiy profuse. Temp. 104. 3iKl.-Appcars completely exhausted. Nose quite blue, and extremities very dark. Temp. loj . Died in the ninJu. yW/.///r;r/.7//.- Kidneys look natural. In greater an-vature of the stomach there is a diphtheritic-lookincj area about i^ in. ill diameter, and near it some small patches of yreyish-yello\J infiltration. In the caecum -::■- several superficial pUuiues .ibout tiie valve, one of which overlaps ,r oatch of Peycr. In the colon are twcl e \o foui len isolated areas, involvin.; only the mucosa, and sht>vir:j p.o k' ths of separation. Mesenteric glands swollc -.i.ii.e of them h.-umorrha-ic. Ilxpcriincnt IV. September I oth.— Mesenteric glands from diseased animal rubbed up with saline solution ; m. xv. injected subcutaneous!/ into right flank. 14th.— No change noticed. Temp. 103. l"- i6th. — Temp. 105 . 17th.— A few rose-coloured spots noticed over sternum and epigastrium. No swelling at site of injection. Temp. 107'. iSth.— Nothing special noticeable except the hyper.emic spots on abdomen. Temp. 104,' . lyth.— Macuke not so evident. Skin of cars congested. Temp., morning 109: , evening loG! . ^^^ JOth.— No skin eruption visible. No swelling at site of injection. Temp., morning 106.!', evening 106 . 2ist.— Animal feeds well. Temp., morning and evening, lofV. 22nd. — Temp. 107! 23rd.--No rash, but skin feels rougher than normal. Tcnin loS '. ^ ■ 24th.— Is wasting, but continues to feed well. T.:mp. \of. 25th.— Appears weaker, and has, for the hrst time, slight diarrhuja. Temp. 107.". ' *" 2Gth.— Diarrhcea worse. Eyes look weak and the oyeliiLs are covered with secretion. Extremities cold. Nose blue. Temp. 107. • V ': ' I I ! i ' 'M' M ro Of/ ihc Patliohoy of flu J t. 22nd.— No rash. No diarrluea. Temp., morning '102:°, evening 104;-; . 23rd.— Temp., morning 106'', evening io6:p. 24th.— Diarrhu.'a for the first time. Temp., morning io7,° evening 107;' '. 25th.— Diarrhiea continues, but is slight. No rash. Temp., morning 107 , evening 107,!'. .-6th.— Is emaciated and weakened. The diarrhcea has been profuse. Temp. 108 . 27th.— Diarrha'a is better ; stools soft but consistent. No ecchymoses. Temp., morning no, evening loS: . jSth.— Condition mucli the same. Is not ne-irly so weak as Ihe other pigs. Teuip., morning 107! ', evening 107^. 29tli.— ICyes are watery. Temp. 107 . jOlh.—Diarrluea is worse. Temp. 105','. October ist.—Kmaciation more marked. No rash. Ex- tremities and nose slightly cyanotic. Temp. 106'". 2nd.— Feeds tolerably well, and looks much better than the animals inoculated on the same day. 3i-tl.-Gait staggering, and general appearance characteristic. Temp. 104. The animal remained in this condition, gettinn- neither better nor worse, until the luth, when it was bled to death. The extremities and ears were purplish, but not distinctly ecchymotic /W-;/A>;Y,w.-lIeart, lungs, spleen, liver, and kidneys, present no apparent changes. In c.ccnui are a dozen or more circular patches, slightly depressed below the level of the mucous mem- brane. The surface is uniform, and they do not look as if I I ( ' 1 2 On the Pathology of the so-called Pig- Typhoid. sloughs had separated from them. For an inch about the valve the nuicosa is infiltrated with this circyish-ycllow material ()„ the ca;cal lip of the valve are eight or ten miliary elevations with translucent centres, looking like small lymph follicles. In the first foot of the colon are six irregular depressed plaques, which appear to be healing: in some there is a distirct hne of demarcation between the patch and the mucosa; in others this IS not marked, but the mucous membrane is apparently encroachmg on the placiues. In the rest of the colon the patches ai-e numerous, and in many of them a central slough is separating-. There is no congestion of the mucous membrane. I'hat the contagion exists in the scrum of the skin had been shown by Professor Axe, and verified by Dr. Klein, who had also induced the disease by inoculation with material from the intestines. Me had not succeeded in producing the disease with the ju.ce of lymphatic glands, as has been successfully done in Experiment IV. of our cases. In his experiment of feediiv^ an animal with the diseased intestines, infection followed • but he explains It by supposing that the morbid matter gained entrance to the blood through scratches in the mouth. In Experin.uU V ., above given, infection also followed : and I think there i .sutficient ground for believing that the disease was induced by the absorption of the viatcncs morbi from the intestinal tract for the experiment was very carefLiUy i)erformed, with the express view of avoiding possible abrasion of the mucous membrane of the mouth. Lastly, the successful experiment with the caseou.s. matter liom the bronchial tubes demonstrates, for the first time that the contagion is al;;u contained in the lungs, and shows us one lruitfi'1 source of contamination, not only in the expired breath, but also in iJic mucus so frequently coughed up In this connexion I would refer to some adinirable papers bv I rofes.or Cla)-pole, of Antioch College, Ohio, published in the Western Fanner, 0\^xo^ in which the infectio"s and conta-ious nature of the malady is abundantly proved. These are of special value, insomuch as an opinion prevails among many in the Western btates that the disease is not communicable. On the PalJiohury of I he so-called Pig-TyphouL .13 Symptoms, Tiicse have already been so fully described by other ^vritcrs, that I shall refer to one or two points only. In the first placed the temperature range is exceedingly irregular. The relation between the morning and evening temperature is not at cdl constant, and very generally there was a niornin-- exacerbation and evenmg fall. L, comparing the charts of tl:e five rases there is an entire absence of the typical curve., of human lyphoid. Secondly, the cutaneous eruption in this cpi/outic was not so marked as in some which have been recorded. The occhymoses were present in all the cases, with but one exception. Ihese, however, though forming by for the most striking cuta- neous lesions, are i.-t regarded by Professor Axe as constituting the typical and characteristic eruption, which he states to con- sist in "small round raised spots of a faintly red colour " Such were certainly p.resent in four of the five animals experimented upon, but I could not find them in a large number examined at Ouebcc in all stages of the disease ; and I should like additional experience before concurring \,x the opinion that they constitute the .specific eruption of this Fever. And, thirdly, diarrhtea cannot be regarded as a constant .symptom, for in more than half the cases examined the intes- tuies contained consistent, sometimes hard, faeces. ■ - - l'.VTiioi.o(;v.. The following is a summary of the pathological changes found nl the nmeteen cases which 1 have examined. SkuL~ln the majority of the animnls definite changes were found in this structure. In the first place, the hairs had a rougher look and harsher feel than normally. The epidermis was fre- quently loosened in the form of fine scales. In four of the animals experimented upon, hypenemia of the skin existed as a diffuse erythematous redness, which was in two instances general, in the others localized on the belly. During the second week there was. on four of these animals, an eruption of iu..f.- coloured spots upon the abdomen and inner surfaces of the extremities. Some of these si)ots were flattened, slightly raised, 1 I 1 1 1 ! 1 ill IP'S ! I I i :i i 14 On the Pathology of the :o-calkd Pi --Typhoid. c.rculai- about two to three lines in dia.nctcr, and disappeared on pre:;sure ; others were more pointed and papular in charactci- siu-roundn.,. hair follieles, and situated upon hyper..mic bases' rvot more than half a dozen of these were noticed on e rh' an.nial, and it was only by careful inspection that they could be discovered. In two instances scabs were formed, from beneath uhich pus exuded. The extravasations of blood into the skin, which fonn so remark-able a feature of the disease, were present to a -n-catcr or less degree in eighteen of the cases. Judging from the?eports o o her epizootics, I am inclined to think that the cutaneous a.lect.on was shghter than usual. The extravasations most coni- nion y occurred about the abdomen and flanks, the inner surface of the legs,_about the hocks, and the ears. They varied fro.n Mnall punctiform and petechkd iKomorrhages up to extensive areas of mhltratioi, giving to the skin a uniformly deep-red or purphsh-red colour, up.n which the impression of the fin-.,, inade no difference whatever. In several instances the whole skin was covered with irregular blotches, and n. cuttin- in thcs^ areas ,t was seen that the luemorrhages lay cl. Vy in tire coriun,^ though often m the subcutaneous tissue. Th . ears were perhaps most frequently involved in this process, presenting a deep purple colour. In none of the cases was the skin much swollc! nor in any of the forty or more diseased animals which I saw were there any of the local patches of gangrene or necrosis Uescribed by some authors. Pharyux.—ln one case there was extensive diphtheria of the nasal passages, pharyr.x. and larynx ; and in another case there ^\el•e ulcers on the mucous membrane of the cheeks and lips ^^(o>uac/u~ln nearly every instance this organ' contained food. As a rule, the mucosa was pale ; and in three cases plaques or patches similar to those found in the intestines w- .^ ^t with /.v/../,;,,,,_I„ fifteen out of the nineteen cas-s :\. nte^tiiics uere alteeted ; in three they were apparentiv b ,-nIt;k/; while in one the mucous membrane was ccchymotic. In two only of the ii.neteen cases did the small intestines present evidence of dis- ease, consisting in a slight degree of diphtheritic-like exudation on tnc mucouti membrane.-once in the ileum and once in the On the Pathulocyy of (he so-called Pii^-Typhoid. 15 rliiodemim. Tlie mucous membrane was occasioiuiIl\- congested in places. I'eycr's glands looked healthy. The lai-o-c intestine is the scat of the peculiar anatomical lesions of the disease, and these we shall brieOy proceed to describe. The mucous membrane is sometimes con-cstcd • but this was found to be a most variable character, for'frequc'nth- even when extensively affected, the mucosa itself was pale,' though the large vessels in the submucous tissue were usually full. Extravasations occurred in five or six instances; in Cases 5 and 17 they were remarkably abundant. In the former the colon presented a dArk colour, from the prene ice of extravasa- tion in the submucous coat, while the whole thickness and extent of the rectum was infiltrated with blood. In ^.ase 17 the same condition of the rectum was found. The specific intestinal affection consists in an infiltration of the mucous membrane, cith-r in localized spots or extensive areas, and the production thereby of larger or smaller patches of necrosis, which may assume ver}- varied forms, and in time separate, leaving definiie ulcers. I will group together the different appearances which the lesions presented :— I. A brownish-yellow infiltrate ,.y like diphtheritic mem- brane, involving only the superficial laj-ers of the mucosa but frequently very extensive. This form was met with in five or six of the cases, chiefly along the ridges of the cecum and colon On section, it extends for a couple of lines into the muco -a, and cannot be separated without removing portions of that inem- brane. 2. Small greyish c'-vatcd spots, ranging in size from a pin's head to a split pea, seated directly upon, and involving the mucosa to a variable depth; fre.;u.:ntly the edges of the pro- jecting spots overlap the mucous membrane. Others, older perhaps, are seen in process of separation, as small central sloughs, divided by narrow grooves from the mucosa, which may even be elevated about them. 3. Patches ranging in size from that of a threepenny-bit to a penny or larger, circular, flattened, intimately adherent to the mucosa, yellowish-grey in colour, sometimes dark in the centre, and usuallj' presenting a concentric arrangement, resembling a i\. :•! If) On the Paf//o/ooy of Ihc so-called Pi;-. T\f!nm!. nattencd-out riii.;a crust, or the cross sectfoii <)f a calciih, Sometimes these plaques are ovoid, and fr- .-.ent!y t.vo or thrc. have coalesced. Tlie concentric arranq-ement is their m<, t pecuhar feature, aiul is best m.irked in llie lar-er ones where.'-, central spot can often be seen -'Vom which the process appears to have extended i,; ;,oncs. ^'oine of the smalK.r ones difer from these, the surface bein- uniform r.iid mcie prominent On section, the patches she;, a ycllomsh-.vhitc colour Ihrr.urrhoH and involve the coats of the bowel to a v-riable uepth •^omc be:„g confined to the upper part of the mucosa, others extending throi-h ns whole thickness; while others, a-ain, involve the submuco;.;. and muscular coats. They are firm and tenacious not fnu..:, resisting the scraping of a knife better than the mucoii.<- membrane itself. 4. Uniform involvement of large areas of the intestine con- verting the mucous surface into a yellowish irregular structure hkc wash-leather, and in some instances extending thr,.u. !,' all the coats to the peritoneum, rendering the waif thick aiiel inflexible. 5. In two cases most peculiar masses were met with in tlic colon, looking like warty excrescences, springing from the mucosa ; they are oval, and lie transversely to the axis of the gut, encircling about three-fourths of the tube, and projcch-,,-.- from I in. to i in. into the lumen. In the transverse direciion they present a rounded concavity, while in the long axis of the bowelthey are convex ; the surface is dark or yellow-brown and sometimes shous concentric lines. On section a firm greyish- yellow structure is disclosed, x-ery dense, and involving all the coats to the peritoneum, which is puckered and retracted over the site of the attachment. One of these measured nearly 1 ' in in thickness, and materially narrowed the calibre of the intestine Now all these lesions, though apparently diVe^cnt, are simplv modifications of one and the same process. ween the firs't four, patches intermediate in character werr v ^ .-ith -xn^X in a larger expe ; .ce I have no doubt co. n,.:„.. forms' between three and fiv ■, add be found. _ Two facts arc very remarkable about ^'^r condition of the intestinal lesions :-i. The absence of ulceration :n most of the Oil the PatJtolor^y-of Uic so-cai/cd Pis-Typhoi very slin;ht l.ypcra.mia or injection of the mucous membrane about the plaques. Not more than four or five distinct nlccrs~i.c., breach ^s or loss of substance in the mucosa-u'cre met with altooether. In tiie few instances when the crusts, as tliey have approjiriateb' ''^cn ealierl have separated, the bases and ed^es of the ulcers are formed by greyish infiltrated tissue. Nothing exactly corresponding^ to these appearances is met with in human pathology; the c(Muli- tion which most nearly resembles it occurs in tlic severer forms of Dysentery ; and a short time a^o. in a case of Pneumonia I met with isolated rupia-like masses, infiltrated and projecti.Vv from the membrane of the colon, which somewhat rescmbleli certain of these plaques. Occasionally the solitary niands of Teycr. in the lar-c bowel were found swollen and distinct. In several instances numerous small elevated bodies, rancin- in size from a pin s head to a split pea, were seen, usually with a small central depression and orifice. These closely resembled solitary -lands, and. indeed without microscopic examination, could not, I think, be distin-' Slushed from them. However, as will be subsequently stated they have nothing to do with the glands of Pcyer. Histological Examiuatio,i.~Vxc^\x portions from a small intestinal plaque teazed up in saline solution, show a finely granular stroma and numerous small cells, irregular in outline solid. looking like fine nuclei, and about one-third the diameter of white blood-corpuscles. In thicker and older masses little can be seen but a granular debris, in which here and ther the shrunken remains of corpuscles are noted. A stud- of sections of small areas the size of pin's heads, where the affection is beginning, shows that the process is confined to the mucosa In the earliest stage at which I have been able to trace it the cypts of Lieberkuhn are filled with loosened epithelium, amon.- which small corpuscles some^^•hat frequently occur. How the latter originate-whether from the epithelium or from the nuclei of the walls of the foUicles-I cannot say. but in the next sta^^e they form the predominant elements in the section. The afil^eted area appears infiltrated with small round lymphoid corpuscles closely aggregated, which destroy all traces of the normal con-' i8 Ou (lic Pafliohs;v of the so-called Pio.Jyplwui. slltuents of the mucous nicmbranc. The muscularis mucosa is also uifiltratcd, and its cicmcuts separated. The submucosa at the same time contains numerous leucocytes. In larger areas, the sir'.e of buttons, it can be seen that Iho densely-packed corpuscles have under-one a chan-e ; their out hues arc less distinct, or alton-ether lost, and the section presents a homogeneous granular appearance. In thin sections, towards the surface, a laminated condition can be seen, depeudinn- an parently, on thin translucent bars traversing the matrix "very like those met with in croupous and diphtheritic membrano Comparmg the appearance with specimens in human patholo-\-' It most resembles the firm caseous material of the central part of a syphiloma. y\ll the greyish-yellow plaques present great uniformity in this respect. Fine hairs and particles of food arc not uncommonly attached to the surface. The deeper parts „f the masses present appearances which vary with the depth to which the disease has extended. When of any size, the sub- mucosa is usuall)- involved, and the mass is then densely atlhercnt to the muscular coat, the inner fibres of which arc infiUrated with the small corpuscles above referred to. In man)- instances the entire thickness of the gut is attacked, and converted into a firm, dry, non-vascular structure, on the peritonc^al surface of which alone is there any cellular activity. liactcria and micrococci were occasionally met with, but not in situations or numbers to be of great pathological importance* None were seen blocking blood or lymph vessels Scvenl masses were noticed in Licberkuhn's crypts ; most abundant in one in which a hair was found, the root of which was surrounded by groups. The peculiar structures like .solitary glands,' noticed in some cases, demand a passing word. They have nothing to do a\ ith these bodies, but are involutions of the crypts of'^Lieberkuhn, forming saccular cavities, communicating with the exterior by a' narrow orifice which is usually plugged.' In sections the content's of the sac very frequently fall out. They arc similar, ai)parcntly to what Cornd described as mucous cysts in a case of dysentery' but Kclsch, quoted by Jh'rch-liirschfcld * « Lehrbucli dcr paihologischcn Anat irst gave the correct oniic,'' 1877. ^^mima^ 0« llu- Pntlwlogy cf ,!,,■ s„.c,Md Pig-Typ/ui,/. ig ic'Zf of°,'L°' "", .'•'PP^'^"-- Kl-" S-- an excellent account ot thcni m lus jxiiocr. Lpu/^/uUic Sjstan.^lu ten of the cases, the mesenteric and re ro-pcr.oneal ,,ands were enlarged and of a de "lun e colour, ou-u,g to extravasation, chiefly into the cortical r<"ions n n any sections the entire ghuKl structure was infdtrated^ v h lood, presenting on section a deep plum colour. In sK c they were swoh.n and tumefied, but not congested. In three of the cases n. which there was no intestinaltaffection the^ a, - pcared normal. -^ ^ in ■111 of the cases in ,vhich the lungs were diseased, the bro clnal and sternal, often the lower cervical glands, „ere swollen and congested. scvtr^TY''"' '''' '■"^"^'■"^••^^^^'^ I-^S^ '-appear to suffer most 1 c If'thlr^ """ "'°''' "■ ^'^^ '^'-^^^"^ ''' '''' °f the cases tic. of these bemg unaccompanied by any intestinal lesions The disease .s a Broncho-pneumonia, involving the air-cells ad finer tubes, which become obstructed, owing^ to an eno m"' prohferafon o the cells and exudation into the air-vesicles. In this way lobules are transformed into firm hepatized masses and by the extension of the process whole lobes are affected A pecuhar feature in this Pneumonia, and one which gave an odd appearance to the sections, is the blocking up of the tubes |n^.c inflamed areas with firm, perfectly white, iheesy-lookh^g nuttei composed of closely crowded corpuscles, which have cither been pushed up from the air-cells, or ha.e originated in t e mflammation of the tubes. In nearly every instance thes. diecsy or caseous casts of the tubes could be squeezed out in the mflamed areas Some of the lobules, owing to'the great increase nd over-crowclmg of cells, become pale,, soft, and friable, either bemg converted into a uniform cheesy mass, or breaking down into small abscesses. ceS"~^^'^'-'''^'^''"'°" °^ *^^" ^P^^^" ^^-'-^^ "°ted. and it utainlyexl.....-s ,n the pig a very different behaviour to that ^ I|'ch we au accustomed to see displayed by this organ in the te eruptive fevers of man. In only one instance wa^ it swollen "v IS 'nfd~"V r ^^^\<^— -Jy-en in Typhoid and other levels, and described as Acute Splenic Tumour. ! j 'H W' ' ' PIH ; vJB ll„„ J r4 20 071 ffir Patlwfos:y of I lie so-ca//cd Pio.Typ/ioid. Kid, ofti O'x.— Tlie kiclnc>-,s also arc but slightly affected. I ic rases the cortical recrio of the tubules, but nothin; 1 nio-ii n was pale, owint; to slight swellin.r was apparent illy Lt :roscopu a granular condition in the epithelial cells. In the pelvis ccchymopcs wcio -ticed in several instances. Lii'ci:—\n Case 14 tiic liver was swollen, soft, dark in colour, the cells very granular and fatty. In the rest of the cases there was little or no evident change in this organ. It looked, in net, remarkably health)-, and on examination the fatty infiltration of the cells was found normal. Blood. — Repeated examinations of this fluid were made in all the animals experimented upon, but no definite changes were observed. The red corpuscles tended to aggregate together into irregular clumps. No increase in the colourless elements; lu. foreign constituents. CoXCt.L'SI.')XS. I. The so-called Tig-Tj-phoid is a disease sni generis, pre- senting anatomical and clinical features distinct from any other affection. II. It presents no analogies, either pathologically c •• clinically with Typhoid Fever in man. III. Neither has it any afanity with Anthra.x, as claimed by some Cor' mental \^-riters. IV. If \..' take the intestinal lesions as charactoristi. , the disease must be regarded, with Dr. IMurchison, as dysenteric in its nature; a'l; ugh the cutaneous and ' ulmonary affections, as well as certain of the clinical features, meet w ith no parallel in human dysentery. IViiilecl liy Hazell, Wats son, ;iad Vin-y, Ljn.iou and Aylesbury. Xxi rel.er die EntHickHH,,^^ von BIufko,.po,.cho„ mark hoi poniicios^.i. An !UliU>!, iin Kiiochen. hei Vou Dr. Osirr, Prof. Der Full, welcliei- aul . . m nicl.ts lieson.leres (larbot;''bet iMcGill Univer.sit;(t in Afontreal. ■or gen.i.uor Sd„,K-rzl,,,rtig]"it lioiuoger.er Substan/u7idd,^^^^''[ "'"*-'" ""*' "^"''^ ^^•■"•''>^ei- ■Iiiichsdieinend -Idol, den, Fr^,™ a / '^'^"P'.'isnia isf bdl, ?wi.cl,en dnien und , td Mm ^^''^''^r- ^''^ ^''^--''i-I i^'t (leutlidi. Die Kerne Tdr . ''' r'^'^"""^''"'^" Bblsdien •'-' grofsen Marked .;X,t?"t'r- ' l. ''f '"^^^^" ^^'^''^ ^^^-^''«" ^. temhah^e rote Blut^ ■ n^o^vZ f s'' ' 'S^'-f^'«^^^ ^^- ^ feld von TY O^ o\ c^" .ciui^ti /.ani («- 10 in eineni Geslchts- sei'st blasse F 3). ^"^ zeigten M^emh Vor^.-hip*?,.,,! schieden durcli Fjirb orni, von den unter 3. b'escbriel iiciten: a sie nur durch Vergldclmng mit ung des Protoplasinas, die oft so fe ebenen Fonnon unter ■; n-erden konnte ganz iarblosen K •*chricbe ; einigo waren selbt no,b i-roi m war, dass orpercbcii entdeekt !nen l<\)rmen; Abgesel len von dor Fiirl A-nliser, al8 di,. cben I )nn<>- )e- ig konnte iiiiu. 1 H : . I 1 ) ii:_ I i i' <(!inon llMtoi-schied ontd.H'ken un.l sii«li loicht iibcfzeui,'cii, ,l.,.s ,., kcu.e Mlils.-luM. wan-M, dio (lurch Tinhihition sich gefarl.t liatCn dot'" di,s ln.t„,,Ius„, /(ii-t.- ('in ,i.loiol.imirsioos, duriU.lkorniK.M Ai.« ' ijuhon, uud xci-f. a.dsenlcm sel.i- aii.-esi.n.clu.n jcie don vaWn Kdi-perclR'n h. ei^'initlhuliclic Iii('irsandv(.'it nnd Illasticitjlt. Al) ii,„l /u tandon si ', ciniuo wcnino Kr.rncluMi in deni /fdlkni-por !)!„ ivcnu' wa.rn -n.Is, ..ft •_>, zmvoilon ;} in einer Zelle. Kmhr^ d(>r Ivonic l.attoM ...hnnl.-h.-ll- Fovin, sic warcij ..ffenhar in Toii.m.r |„, nm"'"' /w'"."- !' 'V'"!" '"'"'"" ■"*''"'" -^'**''"'- I'"- Diu-chmessor war (>,()lo- (),()2.^ dcrd.M-Iv..nu.O,0OS;-i;j.- U,()i;j;{;); l.) tief -efiirbt," Ivor. IKiiThen, dio HOU(".linlioIion .,UoboruaMnstV)nnon". Die Mehrzahl .l,.,- selhon war -rols, zwis,;hen 0,()1-0,()1!)41 Mn... die Kerne kurni-. excentn.eh, aber selton :u.s den. Zellk.-.q.or l.ervoitretend und in,' Mu.el 0,0047- 0,00!).| 1 n,esse,.d. In cinUn waren statt de.s Karnes cMn.i^e un,leutb(.d,e K.n'nchen lu.d in 2 tie^ofirbten, welohe 0.01.> l)is 0,Ol.SoS nial.M-n, kcniten keine Kerne entdeckt werden; c) viele dieser tiefnetfirbten Kihper warcn kleinor, rund oder etwa.s clIintiMh nut blasehcnarti^rcni Kern, der in nm.-hen doppelt conturirt ers,^^Iuen (i^elouentl.eh \varen 1 oder "J kleine sclieibenfunnine KCrper im Innern dioser /ellen m schen, znweilen ini Centrum' dcs blLchen- t(mnigen K(u_ns. DerDurclunesser dieser Formen betrug 0,01, der der Oft war es unnu".i;licb, zu erkcnnen, ob ein Kern in die^en K(jrperchen weld.e zum Teil .chwer von den grulkeren 4ewohn. liohen IMutkurperchen sich untor^ebeideu liefsen, vorbanden war (.( er nici.t. Der Durcbn.esser dorjeni-en, in welcl.en kein Kern erkennbar war, .dnvanktc von 0,0()8-_>4- 0,00941 ; 5. i^^ewohnli.he rote Blutkurperelu.n, v.ele -rofs elliptisch oder sehr unrerrelmilfsiir ^'estaltet, jedoch unmer ab.oei.lattet, von niiifsiirer Farbun-s 0,0047 _b.8 01 n.essend. Miorocyten in gerinoer Zahl und weni-er, als nn Ulut selbst, oihv m der Milz, 0,00176-0,00353 me.^send; (J. Z-eJJen (he rote BJutk(Jrperchen enthielten, in mJlfsiger Zabl Myeloplaxon feblten gi[n^\ch, eben.^o die CuAKcur'schen Krystalle, Pelbist als das Mark Hr-])on in Zersetzmig iiberging. Bei kciner fridieren Unters^uebung von Kno°chenmark im ce- sunden oder krnnken Zustande bin ich einer solchen Heihe v.m Ent- wickelung^formen begegnet, wie liier. In -2 anderen F.lllen perni- cioserAniim.e in 2 Fallen von Leukamie, 1 von P.eudo-Leuk.lmie, und 2 v()n tubenndusen Affeetionen (Phthisis und tub. Peritonitis) war (las Mark hyperplastisch und zoigte stets mchr odor weni-^er zaidreiche kernhaltige rote K(-.rperoben, aber dio unter 8 nnd 4c oben beschriobenen Formen konnte ich nicht entdeoken. Sie schei- nen zwischcn Markzollon T,nd kernhaltigen roten Zellen einerseits nnd letzteren und gewuhnlichen roten Blutkurperchen andererseits zu stehen. In der Tat stimme ich vollstiindig Ni:i?nr.\NN ') bei, wenn er sngt: .,I),c Bezielnmg der kcridialti^ , roien Blutzellen als „Ueber- gangstorm(m" zwischcn farblosen und farbigen Elementcn involvirt aber erne Hypothese fiber ihren Ursprung, in Beziig auf welclic ich ') Arch f. mikr Aiiat. XII. S. 7!)(;, mich Iri.her v.elle..',t m.t m K'-olscr Zuvei-8i.htIi,.l,lM..Tht.n mthjuht, MO M.e (lurch JJ,-enerati„n ,ler Ken.e „n,l Venii,.|,lun.r (le. /ellprotoplastmiH scbliefslich in die ^owuhnlirhen I{lut.H,.|.oil)e« uniKewandch werden. loh halte dios wenigsten. fur ;en abei- fih- die pern. An.'lmio istnoch kemeswe-s klar. Ist die VeWlnilernui; des Marks Ursaeho urn LrsprunK dor Ivrankheit und -iebt es wirklich Fnlle v.m Psoudo- leukamia mcdullans? Diese Fn.gen werden erst nut forts.-hreiten- drr hrkenntn.ss der luinction des Knool.ennmrks und seines Kin- flusses auf das Blut beantwortet werden. ') H>'rliner klin. Wochenschr. 1S78, No 10 ') Arch, der Hcilk. X. w 1 ) J 1 1 1 ^i ' I ; I r \ J 'I 1 1 ! JL r i Sep.-Ahdr. a. d. Contralbl. f. d. ined. Wisseusch. IS78. No. -.'(I. (iedriickt boi h. Sc.luim«clior in nerlin. ! 1 . i. P V '■ 1 ^ , ■;■ h Re-printed from '• The Canada Medical ^ SurgnalJournal," December, 18V9. fH' ti^ >'" * CROUP ORDIPHTHKRIA, WHICH? 13v William Oslek, M.D., M.ll.C.l'., Lond. Professor of the In«titute8 of Medicine, McCJill University: Physician to the Montreal General HoKiiiiiil On M(vuiay inoniing, Nov. lOtli, 8.30 am . I was hastily sum- moned to the Infants" Home by a message that a child was dyin<'. On arriving, 1 found Fritz, a well grown l)oy of 4| years, in a state of urgent dyspneca, atid rapidly becoming cyanotic. I was informed that the child liad had a slight cold on Sunday, but had been about, and had taken his food as usual. In the evenin/. — Face suffused ; lips and finger-tips livid. In thora.x, huigs do not collapse, llight side of heart and great veins gorged with blood. Pharyn.x, laryn.x, trachea and lungs removed together. Uvula and soft palate somewhat suffused. Tonsils not enlarged, and of good colour: at upper and back part of left there is a smnll greyish-white patch, 2 X S m. ; near it are two open liillicU's. with a little exudation in them. In right organ, three follicles are filled with greyish-white soft material. No membrane on jiillars of faucps, or on upper surface of epi- glottis. Entire larynx is filled up with a greyish exudation, which lines the under surface of epiglottis, the true and false chords, and the arytenoid cartilages, completely closing tho rima. It can be lifted as a definite membrane, tolerably com- pact, but loosely composed on its surface. Thickness about 2 m. From the larynx it extends into the trachea as a continuous sheeting as far as the incision. The tissue beneath it is deeply congested and somewhat granular-looking. From the lower margin of the tracheal wound, it extends down the tube into the bronchi, and can be followed in the latter to branches of tho third degree. The membrane here ib not so consistent, and ia more diflicult to remove as a continuous sheeting;. Mucosa 3 beneath deeply injected. Lungs, crepitant in front, dark- coloured, collapsed and congested behind. At hinder part of right up})or lobe the tis,sue is very firm, and in sjiots granular- pneumonic. Heart ; right chambers gorged with blood and jelly-like clots ; great veins distended. Spleen a little enlarged ; pulp not very ^oft. Kidiwi/K much congested ; on section, blood drip irom the surface. No special alteration of substance noticed. Nothing of note in gastro-intestinal tract. Microscopic examination of grey pi.tch on right tonsil showed a network of fibrils, with numerous round cells, loncocytes, and granular debris. The exudacio!i in follicles of loft tonsil appeared softer, and was made up chiefly of very closely-packed cor- puscles. In the membrane from the larynx the same elements were found : meshes of (ibria-librils, large and loosely arranged, with round colls and epidielial flakes. Here and there giwips' of micrococci were met with, and some of the cells contain isolated forms. They are not, however, specially abundant, and the same elements occur in numbers on the fur of th(> toii'nio. The kidney epithelium was granular, and in cortical tubes swollen. No micrococci found. The capillaries wore \ cry full. Juun arks. —Ci-onp or diphtheria, which ? I believe it to be the former, for the following reasons : (1,) The sporadic nature of the cas.> ; the child had not been exposed to contagion, and no cases subsequently developed in the Home, although the conditions for the spread of the disease are most favorable.* (2.) The mode of attack, and locality first affected. Up to a couple of houis prior to the first symfttoras the child appeared in his usual health, though suffering from a slight cold. The difficulty in breathing came on very early, and was the promi- nent feature throughout; the larynx was primarily affected. Before the effect of the chloroform had passed away after the operati(m, the fauces and tonsils were most carefully examined by Drs. Ross, Shepherd and myself, and no membrane seen, not I : f '! i UW )MI • Up to the time of the operation the rtiild was in the same room with tibout 11 dozen children, iVom 3 to years of age. Subsoqueutiy, he was isolated. '•mm-m ^Ju? even injection. (3.) The absence of swelling of the neck and fetor of breath, symptoms rarely missed in severe cases of diph- theria. (4.) The situation of the exudation ; primary laryngeal diphtheria is very uncommon. On the other hand, the slight extension in the tonsils in this case does not invalidate the croup view, as in tliis disease the membrane may also occur in the fauces. The extension of themembiane into the tulits does not tell much either way ; it is seen in both affections. In 17 cases of diphtheria, of which I have poxt-mortem records, extension of the membrane in the trachea and bronchi nccurrcd in eight of them. (.").) The absence of signs of septic poisoning at the foat- morteiii. The blood was clotted and natural-lookinir, no stainint: of walls of vessels or of tissues about them ; only the usual con- ditions met \,ith in death from asphyxia. (G.) The absence of micrococci in internal organs, especially the kidneys. Theii- presence in the exudation in larynx does not go for much, when the same elements occurred on tongue. They were not in the same numbers as in diphtheria, in wliich they swarm in the mem- brane. (7.) The fact that the child had been subject to " croupy" attacks, two of which were accompanied witli dyspnoea and lividity. A younger brother also died of croup. Croup I believe to be a non-specific inflammatory affection of the laryngo-tracheal tract, accompanied with a membranous exu- dation. It is never contagions, is usually sporadic, and rarely occurs in adults. Kills by asphyxia : never by blood-poisoning. Is a local disease, the constitutional manifest itions being those of inifieded respii'ation ; is never followed by pai-alysis. There is never fetor of breath, or swelling of glands of the neck. To this picture the above case corresponds in its essentials. CASE Of OBLITERATION OF VENA CAVA INFEPJOU wnii GilEAT STEX08IS OF ORIFtCES OF HEPATIC VEINS. IJY WTLLTAIM OSLEE, M.I)., M.R.C.r., (From the Joumar of Jnalomy and Physwhvjij, Vol. xiii.) %^ I* i ! ' \ E I) I N ]] IJ li G H : PKI.NTKJ) |JY XEILL AND CO MP 1S79. \ a\ Y. - ' !■ .ri'rifc XXIV CASE OF OBLITERATION OF VENA CAVA INFERIOR. The causes of obliteration of the inferior vena cava in the great 7Zl r"" ^r ^''" '''^''' compression or the extension th ombi from other veins. A few cases are on record in which he closures could not be referred to either of these causes, and have led some authors to conclude that the vena cava may be the seat of a primitive pJdebitis. The occlusion, also, in the Jjority of instances has affected the vessel below the entran of the hepatic veins, the cases of Baillie ^ and Eeynaud^ beino- voLl ''''' '" ^^^''"^' '^"'" ''' ''^''''^ '' ^''^^^ ^^«^ i"- The following case bears, in an interesting manner, upon both hese points, inasmuch as the obliteration can neither be trac oo„,p,ession nor to the extension of a thrombus, and had pro- ly lasted some years, the vein being converted into a firm hbrous cord; and the hepatic veins, where they enter the cavT are so far involved as to be reduced to the condition of ins !ni: i^s iS wr '• ""'" "'^^^ ^^" ^'^ p^^^-^ -^ ^"-^ ' Quoted by Hallett. iPf/mAwrgA J/^rf "^-7 ' ^ . ' I I >. . : I i 6 PKOFESHOH WILLIAM O.SLi:i{. i f I t moderate degive— st;iircely .so evident, perliai.s, ah they woru dunii^r life, according to the description of the uiedical attendant Ah,/o>^im.-Kntive pcritonenni of an intensely livid red colour from injection of capillaries and veins, sxx.v of turbid, brown- coloured fluid remain in the flanks, and a few flakes of ly,„],h float in it. The general surface is, however, smooth and glistm- uig— not rough and dimmed, as in peritonitis. The walls „f the intestines are relaxed, sodden, and heavy, and the mesenturv IS also very thick. Tkoraa,—m fluid in pleurae ; a few adhesions at right apex. mart, of average size. All the chambers contain coagulu • those in the ventricles colourless, firm, closely interlaced' with' columna. carneie, and extend into the arteries. Ifight auricle distended with a firm gelatinous clot, which extends" into both cava\ Auriculo-ventricular orifices not dilated ; all the valves healthy. iMuscle substance of good colour. Aorta normal— u,, atheroma. lH„ys, crepitant throughout; collapsed at bases, otherwise healthy. #«Vd7t, double the normal size, very firm, and cuts with great resisbmce. Capsule not thickened. Pulp dense, trabe'^uku and vessels prominent. mdnci/s are large, exceedingly dense and hard to the touch Capsules peel olf with difficulty, portions remaining on the organs. On section, vessels of both cortices and medulke very full, and the veins about bases of pyramids remarkably large. Ureters and bladder natural. Pancreas is unusually dense and firm (so much so. that when first examined it was thought to be the seat of scirrhus). On section, the induration is found to be due to the great increase of fibrous-tissue about the acini. liver is increased somewhat in size, feels heavier than natural and is very hard and firm to the touch. Surface is not perfectly smooth, but is mapped out into irregular slightly-projecting areas, which are most distinct towards the anterior borden The capsule is not thickened, nor are there any cicatrices. About the anterior half of the organ, on both surfaces, the capsule is studded over with innumerable small, semi-opaque bodies, ranging in size from a grain of sand to a millet-seed. i r CASK OK ()IiI.ITKl!AT[nX oF VKXA CAVA INPKlilOR. 7 They an, littlu lil.rons out-iwths from tl>o capsule, and pre- sented a reinarkal.l(3 appearance on the dark brown surface of the or-an. The .substance cuts with resistance, nn.l the lobnlcs are seen to bo very distinctly niarkeci, of good coh.nr, not fatty and the central veins iu many unusually prominent There is consulerable excess of fibrous tissue in the ,nn, chiefly about niihvidual lobules and alon % «> IMAGE EVALUATION TEST TARGET (MT-3) 7 A ^0 'V e^x A & tA I 1.0 I.I 1.25 |50 '"== IM M 2.0 llitt U IIIIII.6 V] W -^J/ <^ u>^> /J Sciences Corporation fV (v 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 ■^ N> ^■^ .* <^'> k c> Ss ^■^ ^^■^' I tio C/j '^ h \\ ^ cS^ &. I mt ^^HBi u t m (1 wB/m I " I'UOKKSSDli AVn,I,i.VM OSLKR. Venn Cava i>i/.~-h'vom the right auricle to tlie diapjirii-iii mitural-lookino', and tilled with a large consistent clot, 'oiiii,,. looks of normal size. Iniiwa is clear, and the other coats aif not thickened. At the diaphragm tlr" ; portion of the vein terminates in a sort of ad-dr-sar, the floor of which is made up of cicatricial tissue, and on either side two small o'-itices open into it— the hepatic veins. From this point to the entrance of the left renal the vein is represented by a dense fibrous cord, 02 una in length, narrow at the middle (10 mm.), wider at either end" just above the renal measuring 18 mm. The central part of the' cord lies between the lobus Spigelii and right lobe, and lias tolerably firm adhesions to the liver substance, while at either end the connections are not so close. On section it presents a dense, fibrous aspect, with a peculiar greyish translucency, an'l no trace of blood-colourirg matter. It is solid throughout,' and apparently composed of bundles of connective-tissue. A tiny vein penetrates it from below for the distance of 12 mm. The surface of the right lobe in the neighbourhood is rough and thickened, but not more so than is us'ial at the site of attach- ment to the diaphragm; the tissue of the lobus Spigelii is perfectly natural-looking, even to the very margin of the cord. Tlie obliteration terminates at the left renal, and bel.n/ this the cava measures 40 mm., and then gradually widens to the bifurcation, above whicli it measures 70 mm. in circumference. The vessel is opaque, the walls three or four times the normal thickness, and externally marked by a longitiulinal striation, which is specially distinct at the upper part. The iutima is thickened and rough, and above presents one small calcareous plate ; in the middle portion elevated lines run in diHerent directions, giving a reticulated appearance to the membrane, while at the oifurcation there are several sharply-circumscribed atheromatous swellings. The vessel i)resented the following branches:— L(lft Rcnnl, which f(jrms a large trunk, 30 mm. in circumferoiico, with thick, opaque walls. It enters the cava somewhat obliquely. A vessel, nearly as large as itself, enters at the posterior superior border, but, unfortunately, its further course was not traced. A second still larger branch enl angles, and is described hereafter from below, at ri'dit CA^K OF OBLITERATION OF VKXA CAVA INKKKl.Jli. 9 Right Beaal, not so laroo as tb. left, enters the cava nearlv at the same level. -^ ^ Rujht Spermatic, furmi.ig a large branch, 22 mm. in circum- .eronce, which empties a little below no-ht renal oivt"; "T^ "\ "'"'^ or fuur\n.eatly dilate,! vessels. Only three onhces were found in the posterior wall of the cava but the vems on either side may have united, as is not in-' frecjuently the case. These branches as they pass out over the verteoraB are remarkably large; the little finger could be readily mserted for some distanc into them. ///rr.^^ considerably dilated, the left branches rather more than the right. A large vein, almost equalling in si.e the vena cava (measur- ing .1 mm.) extends along the left side of the aorta from the renal to the iliacs. i.bove. it enters the left renal just before that vesse crosses the aorta, below, it divides into two branches, one of ^^ Inch, the smaller, somewhat horizontaKy placed, enters the left common ihac, just below the bifurcation of the cava, the other passes down for a short distance ..uid opens into the external ihac 1 usteriorly, this vessel recei.es tour moderate-sized veins Idnc J ansave all enlarged and prominent, particularly those about the rectum-ha^morrlioidal plexus .^/ Int. Mammanj Tm^s are moderately enlarged. . Vena cava sup. and its branches— so far as they were traced- present nothing unusual. It did not appear much dilated where It enters the auricle. Portal Si,'s(em.—msentevie vein and all its branches are dis- tended with blood, ever to the smallest vessels. Splenic vein also large. Portal vein measures 33 mm. in circumference ri.rht branch admits the little finger, walls healthy. Branches m the liver do not appear much dilated. ffcimtic Veins.-ln many of the lobules the vena^ central's are distended, and one of the most striking features on the cut section ts the numD,n' and prominence of the hepatic veins of all sizes Iwo mam branches, one in each lobe, pass obliquely towards the cava, enlarging greatly in their course, and finally open by the two small orifices already referred to. Immediately behind the openmgs the veins are much dilated, but the walls are thin and not atheromatous. The right orifice measures 9 mm. in circum- terence, and its margins are formed by fresh-looking connective- tissue, which at the posterior part forms a sort of imperfeci valve The opening of the left vein is smaller, 7 mm., and situated at the bottom of a small funnel-shaped depression of the cava. Microscopical Examination. OUiteratcd F.^^.— Transverse sections of the fibro-is cord show (1), an external zone, 3 mm. in width, separated from the central part by a well-marked line of elastic tissue. This, apparently represents the vein wall, and is made up of fibrous and elastic' tissue, the former in coarse bundles, often enclosing irreoular areas,f,wluch appear to contain transversely-cut muscle bundles- the latter an fine fibres, running in different directions and forni- ■ mg at the inner part a dense interlacement. (2) Tlie central portion, composed of closely-compressed bundles of connective- tissue, which even in thin sections, do not present any evident structure, but are homogeneous, staining deei)ly and uniformly in carmine. In places it is more loosely arranged ind distinct, fine fibrils can be seen, often interspersed with fine colourless granules No crystals or melanin grains, nor are there any traces of an old blood-clot. The cut ends uf a few small vessels are seen on the sections. CASE OF OBLITERATION OK VENA CAVA INI ElUOR. ' 11 ZmT.— Sections nntier a low power have a very porous appearance from the number of enhirged veins of all sizes up to half a millimetre. The majority of these are branches of the hepatic vein, but some with thick walls are portal. The intra- lobular veins do not appear so much enlarged, proportionately as the larger branches. Narrow zones of fibrous tissue surround the lobules, in places broad bands are seen. The degree of cirrhosis is not appreciated until thin sections are examined, when it is seen that the connective-tissue within the lobules is very much increased, extending between the columns of cells and surrounding small groups or even isolated cells. It did not seem more advanced in the central parts of the lobules than at the periphery. The liver cells are gi-anular, not fatty, but in many places compressed and atrophied. In the vicinity of the larger vessels they contain pigment. The spaces b.^tween the cords of liver cells appear large, but not to the same degree as in many cases of red atrophy of this organ. Kidnci/s.—Intevstitial tissue between the tubules much in- ci'eased in thickness. Itenal epitb .^lium a little more granular than normal, but not fatty. Tubules in cortex not swollen or obstructed. The condition of the ]\Ialpighian bodies is the mcst striking feature in the sections, iul'y one-half of them being atrophied. The healthy ones are large, capsules somcwha't thickened, capillary tufts prominent, and individual loops dilated. The atrophic ones are not one-third the size of the others, stain deeply in carmine, and are surrounded by a very thick fibrous sheath, with the fibres concentrically arranged. The central tuft is reduced to a granular or homogeneous body, often containing oil drops. They can be seen in all stages of degeneration. The small arteries are thickened, particularly in the middle coat. Pancreas. — The excessive induration is due to an unusual amount of fibrous tissue between the acini; the cells do not appear atrophied. Eemarks.— The question naturally arises in reading the report of this case. Could the obliteration have been congenital? Tlie absence in the history of any acute illness v/hich may be supposed tj correspond to the date of occlusion, and the general backward- ness of nutriticm, favour such a view, but there is nothing else t ■- : li r 1 I fl 1 ' ,,; i i |P i it ' ; W r i 1 12 I . -4 H 1' . I'nOFESSOU WILLIAM OSLKR. o s pport t. Wl.utov.n. ,nay l.ave been the prLuary cause .f the fu.al fransfovniation of which is rei.resented l.y the cord-] kj structure described above. In the absence of any source fe press.on. or of ar.y pathological state in the branches, lei dnven to the conclusion that the initial changes have been lo 1 and confined to the part of the vessel aflected. It is difficult however, to conceive of a localised phlebitis in a trunk like ' nenor cava and still n.ore of an acute process, the eifects of which ^voud have been limited to the short distance found occh.ded A chronic obliterating endophlebitis is not, so far as I know" recognised. In tlie remarkable case reported by A. liobini the hrst symptoms followed violent and prolonged exertion, bein' us lered in with "fever, delirium, increase in size of Mor2 with violent lumbar and abdominal pain." There is no historv' m the case under consideration, of any severe illness except' diopsy. Ihe only possible connection with this attack luiuht have been copious ri..1,f -sided exudation, with great dislocatLi t^-^1^ ''' ''''''- "'- -^^^^ '-^ ^- ^ -^- Fi;om the state of the vein at the site of the obliteration we an infer that_ the obstruction has been of some duration, but how .ong It IS impossible to conjecture, for such a dense, fibrous cord, when once formed, might remain unaltered for years The atheromatous and thickened state of the cava below the'renals inust be regarded simply as an expression of the strain to wliich this part ot the vein had been subjected. Tlie great increase in he eonnective-tissue of the liver and otlier organs is what mi.ht have been expected, and is in itself evidence of the long-standm. nature of the obhteration. ° The stenosis of the hepatic veins lia« affected the portal circu- lation in much the same way as ordinary cirrhosis, interfering uith the free flow of blood through the liver, and keepin^^ he abdominal viscera in a condition of chronic congestion the effect of which is very evident in the ^-nduration of the si.leeu and pancreas. The state of the liver is of interest as showil in an exaggerated degre. , ,i . effects of congestion in the hep^'tic ^ ^trchivMdc I'/iynio/ojic, 1874, \>. S<)7, i^.-44*k4_ .•ASK OF OBLITERATION o, VKNA CAVA INKKKIn,,. J 3 v..i.s. jM^senting also certain peculiarities. The development of hbrous tissue is very much greater than is usuallv me w ,n he most chronic cases of heart disease or en.phvsema. am u. i " to a toleraby advanced cirrhosis. The new grow h is m cl"; more mtnxlol,ular than in the common form of this di eas Contrary to what nught have been expected, the on-an w s not ju an advanced state of red atrophy. The central ^e ns tl obules did not appear so distended as the secondary a d er i rv branches of the hepatic veins. ternary In obliteration of the inferior cava the collateral circulation is usually earned on by the vena azygos, by means of its xfe s-ve commun.cat.ons .ith the hunbar and i.nal veins, b i f sre times assisted by the superficial and deep veins of the^,done; =UK the anastomoses of the lu.morrhoidal plexus with tl Z gastric and inferior mesenteric veins In the r^vJ.L 7^ ^0, this v.n has been the main .^.n^ ^t^::^^:^ he venous blood of the lower part of the body to the 1 e^ and has, in a.Mition, provided accommodation f'r a co sfdenlle proportion o the blood of the portal system. This is 1 e f most interesting features of the case. It certainly mi hthve been expected, with so serious an obstacle to the How of e portal blood as m.s offered by the stenozed orifices of the hem veins, that the superficial veins of the abdomPn ^ \? would have attained a maximum ^JtZ^L^''^ B lilies case, no mention is made of the state of the ortal c/r dilation; in that of Keynaud's the ri-ht binnch 11. -i. ^s phigged. Veins of abdomin^S waU^: ^ L ^ ^t hmcal report the superficial cutaneous veins are statt^l to ^^^J;:: ' ^eam from ^r Howard thl^ll^ Si'l deep abdominal and thoracic vei is e ""^^ ' 'J''' "^^ and we must, therefore, supp:^ ll ^1^1 ^ l^^ " f" ^ vein lying parallel to il ^Z fii^ tr^^L:^;! ^ f ^ ^^ the remainder, with that from the mZ^Z^^^"^^' azygos through the communicating bran'che with h^ /' a..a chietiy through the la^e vessef arisii;^";;:^ ui;::;^ .ij if ' ! i If M-i :, 14 PROFESSOR WILLIAM OSLER. back part of the left renal, wliicli, altliougli its course was not traced, from its jjosition and direction, must be regarded as a feeder of the azygos. The vertebral and dorsal cutaneous veins may have participated in carrying on the circulation. It is not easy to determine the nature of the large vessel which passes from the iliacs on the left side along the aorta to the renal. The situation corresponds to the left spermatic, which has in several cases been found excessively dilated, and no other vein corresponding with the spermatic was found on this side. But why the free comnumication with the iliacs ? The spermatic may have originally sent small branches to the iliac, which have subsequently dilated to such an extent as to appear as the direct continuation of the vessel. It was sug- gested, as some lumbar branches open into it, that it might l)e the azygos minor, which Henle^ figures as connected with the common iliac ; but, if so, why should it empty into the left renal ? The situation and connections correspond exactly witli a small vein, mentioned by Hallett ^ in his interesting paper, " which passes and establishes a communication between the common iliac vein and renal vein," and which, though not always present, may be considered normal. In the case of obliterated vena cava which he reports, it was enlarged and joined the ovarian vein. From the absence of symptoms of obstruction in the portal system up to a short time before the fatal illness, we nuist conclude that a collateral circulation of sufficient activity had been established to compensate for the greatly narrowed streams from the hepatic veins. So far as was ascertained, this had taken place through the diaphragmatic and (esophageal plexuses, both of which were greatly distended. The veins of the falci- form and round ligaments were moderately enlarged. It is not probable that any assistance was afforded to the portal system by the hiemorrhoidal veins through their connections with the inferior mesenteric. The clinical history of this case, though in many respects in- complete, is very remarkable. In the first place, it must he admitted that the obliteration had lasted for some time, and did not occur during the last illness. The cord-like condition of tin; ' Anatomic dcs Mcnschcn, Gefiisslehre, j). 836. = Loc. cU. ^>*m>^i- CASK OF OULITKUATION OF VENA CAVA INFEHIOIJ. 15 obliterated part, the degeneration of the vein in the neighbour- hood, tiie enlargement of the collateral brandies, and the fact that for live or six years his legs were slightly swollen, ]ioint to an obstructio!i of long duration. Caseo of occlusion are reported ^ in which life has been prolonged and tolerable health enjoyed for many years, an active collateral circulation obviating the oilects of the obstruction ; and among such this case may be r. skoned. A ditliculty here arises with respect to the hepatic veins. Are we to sui)pose that the narrowing to which their orilices have been subjected is of the same date as the closure of the inferior cava ? or have the contracting fibrous cord and sub- stHiuont •• hanges induced the degree of stenosis met with at the autopsy ? To suppose that the extreme narrowing of these veins is of quite recent date would harmonise well with the clinical history and explain the rapid ascites, but the cirrhotic state of the liver, and the evidence of chronic congestion in the portal system, as well as the absence of recent changes about the hepatic veins, suggest an opposite conclusion. It is not easy to give a rational explanation of the sudden development of the ascites. From the 12th to the 23d of December the patient suffered from symptoms of gastric and intestinal catarrh, and it was only on the latter date that swell- ing of the abdomen was detected. From this time until his death on 15th of January, the ascites became the prominent symptom, twice necessitating tapping the abdomen, each time with the removal of a large quantity of fluid. There was nothing in the condition of the portal and hepatic vessels to indicate any recent change which would explain the rapid accumulation of fluid, so that we must seek for the cause either in the blood or the state of the vascular walls. It may be that tlie attack of diarrhwa, which lasted from the 12th to the 20th, in(hiced a depraved condition of the blood, or acted upon the portal vessels in such a way as to bring about that increased permeability of the walls, which, according to Cohnheim,2 is the prime factor in dropsy. However that may be, a parallel example is presented by certain cases of cirrhosis of the liver, in which a dropsical cou- ' Robin, Loc. cit. * Virohow's Archiv. Bd. 69. AUganeine Patholoyic, p. S'S. -* l(j PROFESSOR OSLER — OBLITERATION OK VENA CAVA INKEUIOI:, dition may develop with roinarkal;le rajjidity, and even M'itlimit the connnon premonitory symptoms of gastric and intestinal catardi. Such a case has recently been under the crtre of my colleague, Dr Koss, in the General hospital : the patient, a hanl drinker, continned at work, and perfectly well (according to his own account, and after most careful questioning), uj) to Decem- ber 2iid. From this date dropsy of the legs and belly came on rapidly. On January 24,luematemesis set in, from which he dini on the 27th. The liver presented an extreme degree of cirrh(Aic contraction. Tlie absence of albumen in the urine is a point worthy of note, and may, perhaps, be taken as evidence that the renal circulatinn was not additionally cndjarrassed during the illness. Eeynaud,' to whose elaborate article I am much indebted, is the only author who dwells upon this symptom, stating that it might be useful as a diagnostic sign of the situation of an occlusion, whether above or below the renals. And lastly, an interesting clinical feature of the case is tlin murmur described by ]Jr Howard. Tliere was nothing found in the condition of the heart to account for it. Of possible sources the following suggest themselves : — (1) The vena azygos, thougli I am not aware of a murmur ever having been described in con- nection with this vessel; (2) The thoracic portion of the inferiitr vena cava, which formed a sort of appendage from tlie auricle, and into which the blood might be forcibly driven during the auricular systole, being unopposed by any powerful upstream in the cava. Journ Explanation op Plate. (View from behind.) A, Obliterated inf. cava; B, orifices of liopatic veins ; c, loft ronal ; (I, large branch wliich opens into it at the upper and back jiart ; e, supplementary vein lying parallel to inferior vena cava ; /, riglit s])ermatic (represented by the artist as too far posteriorly) ; g, orifices of lumbar brandies of inf. cava, and supplementary vein. , * /Xuu.vcnu Dictimmaire de Medccine et )/r C/iinirgic, art. "Caves." V Sarhi.l, U:< '1 .liHirii of. ///a/ ((■ J'/n.s Vol xm.pi m/ V Saphi.l, ,).;■ F.Huth.L-.th' EJm' \ r-f . \ . '■'ii • t 1; J W ' ■ $■ ; j'i • li Hi ■' ,i*^ v^ 4- ■1 •if i I J t ■ m ' : 1 M 1 i ■ ' 1 -, t'ift ' ( w_ I; If ■ i t i ' Ari' L.I I ! s XXVL CASK OF COXGEXITAL AND rKOGRESRlVE TlVI'i:!!- TJlOniY OF THE JJIUHT VVVVAl EXTUEMITY. I'.y William O.slkk, M.l)., M.IJ.C.P., J'lv/ci.sor of tin' L'sfi/„n., of McJiruir in M'GI/l Unircr.iifij, MoiUmd. 1 IvrKKTitoriiY of one extremity or of one side of the body must lie ranked among- the very rare abnormalities of develo})nioiii. Trehit and Monod in their memoir,' published hi 18G9, were oiil\ able to collect twelve cases, apart from instances of hypertrophii'd fingers and toes, which are mnch more common. Since that date the only other case to whi^h I can find reference is one re])(nti'il l)y Ewald in Virchow's Archir (1872), in which the left luind v,-as affected. Of the cases summarised by Trelat and ^Moiind, iu one it was confined to the right upper extremity, in six ImiiI, upper and lower limbs of one side were alfected (4 on tlie ri'.^lii, 2 on tlie left side), and in all the leg much more tlian tlie p-iu ; in two the leg alone was involved; in one the right side of face, and in one the right side of head and face. With the exciptidii of a cat-i of Mr Adam's {LoicH, 1858) all of these are reporltd liy continental writers. I am indebted to my colleague I)r Drake for the opportunity of examining the following case, and for permission to publish tlie notes. A. B., aged 8 years and 10 months, a well grown, healthy-lookiiiu girl, the eldest of a family of four ; parents healthy. The luothn states that while pregnant her lirother met with an accident bv which his hand was severely crushed, necessitating the amputa- lion of several fingers. She did not sci; him until six weeks before her confinement, when the hand had healed, Ijut the appearance of it gave her a great shock, and, of course, shr :ittributes the deformity to this cause. Dr F. W. Campbell, the family physician at the time, informs me that the enlargement of the arm was quite noticeable at birtli; but his attention wii'^ fliii'lly directed to the haiul, which was deformed, with the fingers strongly flexed, ani! attemiits were made ti) remedv this condilidn by the use of a straight splint. Not hing after the case cam Airli irrs (li'in'ruhs ill Midii'iii. ]8(Jlt. «.«*»^ nVl'I-I!TROPIIY or TIIF. niOHT I'l'l'KU I-XTIiEMITY, 11 into Dr DniJ{)■'.] ceiitinH'tres; left, ir)'7; difference, 4-(), i 4- I i 1 i. 1 i • j 1 1 11 1; I i ]2 IIYrRlITKorilY OK Tin- L'lcHT Ul'l'KK KXTKKMITV. Hand, across motacarpal joints, right, !)'5 cuutimotros; K-I't. 7: diflereiice, 'I'i). Middle metacarpal bone, length, righr, 5 centimetres; left, f., Middle finger, lengtli, right, 8 centimetres; left, Sv'). Index finger,, length, right, 7'7 centimetres; left, 7; dinercm ,. •7. Tliumb, first joint, circumference, right, 9; left, G'o; diCfereiKc, 2-5. The muscles of the humerus are strongly developed, the liioe]i- jiarticularly so, and it stands out in l)old relief when Hexed, ferl- ing also much firmer than the corresponding muscle of the otlur side. The fore-arm presents a very substantial muscular appear- ance, and allbrds a striking contrast to the child-like aspect of the other arm. The wrist is thick and solid ; the hand stpiaiv and thick, short in proportion to its size, with large and prominent knuckles. The palmar surface presents a thick pad of fat, fivrr whicli the skin is loose and more creased than usual The liall of the tlunub is large, and all the muscles are strongly developed, The fingers are small in proportion, and are kept in the senii- fiexed position, which gives a somewhat deformed appearance to the hand. With the exception of the midille finger, they can all be fully extended, and it has a moderately free range of motion, When born the fingers were much more flexed, and the powci over them has only been gradually acquired l)y use. The position of semi-flexion does not trouble her in the least, as slie can at will extend the fingers sutficiently for all practical purposes. Skin on the limb is normal. Temperature on both sides e(]ual. Sensibility ))erfect. Xo perceptible dilference between the ln'achial pulses. Beat of the left radial is if anything nioie distinct than that of the right. Arteries are not apparently en- larged. Muscular power of hypertrophied limb is greatly in- creaseil. Tt could not be accurately nunisured witli the .L., Professor of the Institutes of Medicine, M'Gill Unvvcrsitij, Montreal. Tumours contuiuin- striped muscle fil.res {Mnoma strio-ecUalarc of Vircliow; llluMomyoma of Zenker) are oueolooiciil curiosities IJetween twenty ami tliirty cases are on record, the majority of which have l)een found in connection witli tlie testicles or ovaries. Eberthi iirst described a tumour of this nature in the kidney in 1872, Cohuheim^ a second in 1876, since which (late four other cases have been recorded l)y lAIarchand,'^ Lands- border,* Ktjcher and Langhans,^ and Huber." All the cases occurred in children from 7 to 39 months old. The tumours were large, the weiglits ranging from 587 to 5500 grannnes. In one instance both organs were allected. In two there were secondary masses in the liver, in one of which muscle fibres were found. All of the tumours correspond very closely in histological characters, l)eing composed of a sarcomatous basis ()f round cells, traversed by l,ands of firmer, Heshy tissue, 111 whicli the nuiscle fibres occurred. Tlie following cases liave come under my observation in tlie jiast two years : — Cask \,—Striatr,l Mf/o-Sarromrt of left kidney. Droll vHh f/i'sfro-i/iffsfinrd. sj/vipfnnis. (ieorge H., aged 1!) nioiitlis, patient of Dr Du-'dale Had lien a liealthy chihl. On Jlarch 2;!d, 1878, Ir. wiTs vaccinated 111 the morning, after whieli lie appeared in liis usual heallh At two o'clock- I'.M., be began t,. vomit and have severe -astr..- uitestinal syiii].tnms. They yiehled to treatment, Iml tlu^ child sank and died at two o'clock tlie same evening. At tlie autopsy le following day nothing unusual was found excerpt a tumour Mil rirr/ii ■ic'n Archil-, ill). HM, P„l. Ixxiii. nncfsc/ie Zalschr. f. ( Mr. Ril. II ••^ Ildd, I'xL hv. •• Ikrli w r Klin. Wnchfmchfijl, 1877. VOL. XIV \\\m\ I).'Hfsr/,.s Archil'./. Klin Malirin, VA. xxiii. 1S7S. i| ( , ritOFESSOR OSLKi;. 111! i '^ I" I of the left kidney, wliicli was removed and sent to lue I'ov cxn- miniition. Organ is enlarged and lias the shai)c oi' a lilunt pyramid, tin' convex border projecting, the inner suri^ace, with the hihis, im- senting a tolerably straight line, extreme length over outer border, from one end to the other, IG centimetres. The capsule is lliin, detaches easily, and a large white mass can be seen thruu-h the thin layer of cortex on the convex border. On section, tlu; central part of the organ is occupied by a tumour riioasuiinn about 7 centimetres ia each direction, broadest at the jielvis with which it is in contact, and gradually narrowing towards the outer border, where it is separated from the capsule by a layer of kidney substance 2 to 'A m. in thickness. At the ujipcr aiul lower ends of the organ the cortex and cones are still to Ik! seen though somewhat diminished in volume. In its growth the tumour has ex])anded the ren;d substance in such a way that a progressively diminishing layer covers it from the ends towards the centre. The mass is not encapsulated, but at the margins can be seen penetrating the kidney tissue, strands of Avhich separate the advancing ])ortions. The cut surface of the tumour is greyish-wlute, and has a jiorous spongy ap])earaiiee, t'lom the presence of small iiregular spaces. IJiinds of traiislin'ciil- looking tissue pass in all directions, crossing eacli other aiul dividing the substance into areas wdiicli aic occupied Ity a ruI'i granulai' sul»stance. Some of the strands passing fioni the decpei' parts aie 2 m. in thickness. The pelvis and calyces are sotiie- wliat compressed; tlie ureter o])ens dinuitly Ixdow tlie I'cntre of the mass, arterv and vein noi'mal. Case II. — Siriatetl Miio-Sarcouia of hj't /,idiii\i/. SadihiKJcuili from blockinr/ of indmonary arterif and tricuspid orijin loitli sarcomatous tliromhi dislodr/rd frovi renal rein. C. S., female child, aged o^ years, patient of Di Finnie's. Had been ailing for about six weeks with gastric and intestinid sympt one moiiiing and STKIATKD MYO-SAI^COMA OF THE KIDNF.Y. 231 walking towards hw mother's IhmI, slio was sud.k-iily seized with a "choking fit," and died in a few moments. Autopsy.— Uody well nourished. On opening abdomen a tumour ii seen on the left side, covered by peritoneum and descending colon and occupying the position of the left kidney. Spleen is pushed up, and the end of the tumour projects beneath' tlic costal border in the axillary line ; this superticiiil portion is quite soft, and ai)parently fluctuates. Tumour had no attach- ments, and peeled out readily ; numerous veins course over it in front. It is ovoid in shape, large and rounded below, pointed above where it i-. capped by the adrenal. Anterior and upper surfaces dark and h;emorrhagic-looking ; on the under surface there is natural-looking kidney substance for 2-3 centimetres about the lulus. Henal rtrtcri/ natural. licncd vein of large size, and when slit open, soft puljjy matter is seen oozing from the organ into it. The wall is rough, irregulav, and covered with bits of .soft greyish tissue. Urrfn- is pervious, not dilated; pelvis small; calyces at each end compressed. On .section' through the long axis of the tumour it presents the appearance of a soft rapidly-growing neoplasm. Above and in front, the tissue just within the capsule is dee])ly infiltrated with blood, and in places occu]iied by clots ; tlH> greater part of the exposed' surface is made up of greyish-white, soft, cerebriform material. At the upper part two pynnnids of kidney substance are sur- rounded by the new growth ; the remnants of the organ at the under and lower surfaces are not seen on this section? Tumour measures 15 centimetres in length by 7-5 in l)readth, and is about the size of a cocoa-nut. Hcarf, of normal size; right auricle contains much Wood. Lodged in the auricuhvventricular orifice is a firm greyish-white mass, 2r. m. long 12 m. broad, not adherent, and without .my fibrinous flakes upon it. Kight ventricle contains dark clotted blood; in orifice of pulmonary artery there is another firm ,i,'reyish-white mass about the size of a hazel nut, and beyond it in the right Imanch are two or three smaller bits of the same character. r.inif/.^ somewhat congested at liases ; no secondaiy masses. Histfolof^mU cmmlnntion.—CasG I. Tumour is nuule u}) of a soft greyish-white substance enclosed in irregvdar spaces formed I I i, 1 ^ '-^K ^r ■ IML li i i ■ ■■■'' JKjM^ fML 2m PKOFESSOl! OSLEIi. 11 ! 'Mj 4 .M by Imiids of firmer tissue wliicli pass in vnridiis diroclions throusli tlio nifiss. The former is c()mi)()sed of nniiul cells iiliout the size of colourless blood corpuscles; protoplasm finely granu- lar, and with a single lar-^e nucleus. Some of the cells an; a little irregular in outline, and in teased bits from the periplieial portions renal epithelium is occasionally seen. A scrapino from the tumour or bits picked out from the interspaces consist entirely of the round cells, and the same are seen in sections closely packed together without any apparent intercellular substance. The strands of firmer tissue consist of (1.) elongated spmdh; cells, the majority of which have prolonged extremities ; others are flatter without the long processes and bear a strong re- semblance to unstriped muscle fibres. They are either closelv arranged together or are separated by a delicate wavy fibrillar tissue, which in places makes up the chief part of the bands. The cells possess a single elongated nucleus. They are fi'om 0-OG25-0-1 m. in length. (2.) Stript^d muscle fibres, occur- ring in variable numbers among the spindle cells and fibrous tissue of the septa, usually in bundles of 20 to 40; nioiv rarely isolated fil)res ai'e met with. They do not often cross each other but keep parallel. When is(jlated they form fiattcMied band-like fibres, ranging from 0-0r)25-0%''>73 m. in length, and from 0-007o-0-01m. in breadth. The majority of theni aiv not more than O'OOTo m. broad, wliile some of the less peifect fibres are narrower, 0'00;]-0'004m. Most of the fibres have the same diameter throughout, others are larger at the centre and taper towards the ends, which are either square-cut nr obtuse, less frequently pointed. The prominent feature is llie distinct transverse striation, the substance of each fibre ])r('- senting cross lines, which are seen to be due to alternate light and dark areas in the tissue, the latter being the broadest. In large well formed fibres the striation is as distinct as in ordinary muscle; indeed, I have rarely seen in any specimen the"sarcous elements" so well marked. The majority of the filn'cs are nucleated; in some long ones three or four nuclei are arranged one after the other, and are coniie('teil together by a gi'anidav protoplasm. Scarcely any of the cells are striated in all parts ; the nucleus and a central extension remain free, and the stria- STUIATKD MYo-SAUlMMA (iK ■I'lIK KIDNKV. 233 s in ordinary lion is conliiu'd to tliu outur liurdcrs. In wide tiltrcs a longitii- (liiml striaUon cini be seniU, but thcrs of the same shape were not striated, or had very faint transverse bars near the nucleus. In some places ;^roups of flattened non-striated tiVires wore met witli, whicli resembled closely involuntary muscle iibres. These appear to lie intermediate tnrnis between the fusiform cells, the smootli band-like fibres, and the fully-developed striated ones. Case II. Tumour is made up of soft greyish substance, which consists chiefly of round cells a little larger than ctdourlcss blood corpuscles, and with single large nuclei. They are closely packed together with very little intervening tissue, and do not present an alveola i' arrangement. Bundles of fusiform cells and connective tissue tibres pass through the structure in various directions, but do not form such detinite bands as in the pre- vious specimen. The tibre cells are elongated and have large oval nuclei. Some form tlattened bands like smooth muscle fibres. Scattered among these elements in variable nundiers are striated muscle iibres resembling those describetl in Case I. They are not, however, nearly so abundant, but in almost every specimen taken some examples were met with. In the nuiss which had lodged in the ri^ht auriculo-ventricular oriiici; ihc^' were very plentiful. They present similar characters to those above described ; llattened, nucleated cells, with transverse striation. In some the striie are scarcely ■••isible, in others only part of the protoplasm is striated. In this specimen the fibres did not form such large bundles, nor were they so long. i: } I ■■: .' :■ If ^^ '1;. mi! >' 1 t i 1 1 J 1 'ii^SM^^- '. ii FUS XxV/i CASES OF CARDIAC ABNORMALITIES. ON THE CONDITION OF FUSION OF TWO SEGMENTS OF THE SEMI LUNAR VALVES BY WILLIAM OSLER, M.l)., M.R.C.P., L..m.. Professor of the Institutes of Medicine, MtGill University. Physician to tlie ITuspital. (l''r()ni the Montreal (icnenil Mcispital Iteports, Vol. I., I8811 r-: '•■ 1 "i ^i .11 Ill i 1: IMIIM'Kl) IIV I UK liAZKlTK I'HlNTINd (OMTANY. MONTBKAl.. '« I i ' in i ■■ ■ ^^H 1 CASES OF CAKDIAIJ ABNORMALITIES WILLIA.M OSLliK, M.IX, -M.IJ.C.P., J.ond., Professor of tho Institutes of Modicine, McGill Uuivirsity, Physician to tlio Hospital. Case l.— General Drops// of the Fa/ ns— Drops// of the Pla- centa — Premature Closure of Foramen Orale — Compen- sator 1/ Enlari^emenl of Ductus Arteriosus. (Pliito.) The followino- clinical notes of tho case have been kindly furnished by Dr. Koss : — " Mrs. X. was expectino- to be confined for the second time in March, 1 870. Her first child, born in 1878, is strong and healthy. No trouble with the accouchement, but the mother suffered severely from 8ubs(^quent metritis. Dur- ing the second pr(\gnancy she was always timid and nervous. Quickening took place at the usual period, but she thought the movements nev*n- felt as strono' as with the other child. In the latter months she complained of a feeling of great weight, and sometimes coldness, in the abdomen, and movements ceased. No fcx^tal heart sounds could then be heard. After the seventh month she increased very rapidly in size, until the abdomen at last was as liirge as that of a woman carrying twins. The day before sh(> was confined she had a violent rigor, accompanied by- intense lumliar pains and vomiting ; soon followed by hio-h fever and very rapid pulse. This state of thino-s con- r >'\\ i'^ f . i' H 2 CASKS OF CARDIAC AH.NOl! M ALITIKS. tiiuitHJ duriiii;' the wiiolo ol'thi' next day, iiiid (lelivcry took j>/itj(' with tho patient s teini* 'it tire at lo:5' I",, uiul iml.sc at 14f> The hiboiir Wiis oi' about lour or liv<' liours' durn- tion. The ([uaiitity oi' liquor ainnii wiis very Ljvfiit. At the iirst vayiual exaniination, when tiif os \\,i> not i'lilly dihitcd and tlio head was liigli, it \v;is lliou.jhi that tlic hrtH'ch was presenting-, hnt as the p.irt deseendrd the liead was clearly recognized by the hairs wliirli could be I'elt, but no suture could l)e made out, the sculp feeling thick and indenting somewhat with the Ihiiicr. "When born, it was at onee seen that the peculiaiitics observed were due to general crdenia oI" the fcptus. The cord was much swollen and (edematous. The placenta followed in a few minutes. It was very large, soft, ai.d of great weight ; unibrtunati-ly, it was not preserved lor subsequent examination. I might further state that Mrs. X. Went through a severe attack of trou])lesonie sej)- ticiT^mia, alfecting several joints ni a very i)ainlul manner. but fortunately none of them suppurated. She made tiltimattdy a good recovery, and at the present moment is once more in the family way — and, it is to be hoped, will haA'e 'better luck this time.'" Aulopsy. — Male infant. 4^] cm. long; girth of al)domen, 3'1 cm. ; of thorax, 3o cm. ; of head, -U cm. Whole l>ody much ^swollen and in a condition of extreme alu^sarca. Skin glistening and tense, reddish in colour. At the examiii- ation, 15 hours after birth, rigor mortis i)resenl : limbs were quite lax when the child was sent to me immc.1 ii < <.] / after delivery. Head much enlarged and disfiguiH'd; fcntanelh's and sutures only felt on deep pressure, after which the skin ren Ins pitted. Eyes closed, t^'tdids much puffed ; no.se scart: ' t j be .-een t)U profile, owing to swelling of cheeks. A cic;!,.- N'u.d cm. from th." I..'lly Willi m.-usuros 7 cm. in .•inumH.roiico ; ve.s««.ls in It .listeml.Ml. l',.„is ami srrotum s\\ oil,.,, niid tease. Lv^rn i.iul f.'ot -ivally swollen, tli.> .skin ol' tli,. latter ..listonin- ■Mu\ ii-lit. Anus ami hands in a .similar state of extn-nie (I'dt'iiiii. On i.uikiiio- the pr.-liminary incision, a hw.T ord-d.-nri- to)i< ti.ssm. is cut tl.roun.h 1.5 rni. in thickn.'ss in thorax i.uher 1...SS on ahdomrn, and a (piantitv of dear serum tbl- lous tlie sertion. The pan.iirulu.s adi.x.sus is inlillrated and presents a very peculiar appearance, the i,solated lobules ol lat, opa.pie white in ecdour. hein- seattered through a translucent. gelatinous-Iookino- tissue. Ouopenin- the peritoneum, a considerabl,- (juantity of lluides,,,))ed-a],out two j.ints. Position of viscera normal Iiitostmes pale and shrivelled. Umbilical n-iu lar-e and distended with blood. In thorax, about two ounces of clear serum in each pleura. Heart cnlaryvd ; circunUerenee at base T-.l .-m., of which 5 cm. are iormed by ri-ht ve,ltricl,^ Len"th of rio-ht ventricle, Irom auriculo-veutricular -roove to apex 4-> cm Jl>;rh( Annch mueh distended ; when slit open from tip ot apprmdix to point midway l,etween the orihces of the cavuMt n-adily admits a ball 08 cm. in circumf.'rence (liamber contains Ihud blood and one small .lot miscuh pec-tinati extencl over the whole internal surfaee" vntn the exception of the sei,tum and the part between the onhces of the veins. Wall measures l-o m. in thick- ness. Eustachian valv--' largo and well formed; its inner atlachm.Mit extends as a ]n-omluent rid-e along the lower and anterior wall of the annulus ovalis. From this .haml.er the foranum ovale is seen to be occupied ],v a hn, membrane which apparently closes it completely, i he ios.a and annulus are well marked on the posterior ? ' • It *•' i I I i 4 CASES OF CAKDIAC ABNOKMAI.ITIES. marg-iii of the lattoris a davk spot 25 m. in Ifing'th.whi, h on section proves to be a spot of !ii)op]exy. On earefnllv running- a prob(^ round the margin of the fossa, it is found to pass through a valvular opening at the upper and hack parf. When examined from the lei't iiuriclo the meml)rane closing" the orifice is seen to overlap the marii'in at the u]iper and back part to an extent of from 3 to 4 m. At this part it is not attached to the aniiulus, so that a valvular orifice is left which measures 8 rn. in length and is capable of being" lifted up to such an exrcnt as to m(>asure "> m. in tlu^ transverse direction. The portion of auricular septum formed by this memUiniie and corresponding to th(> foramen ovale, mcasiires S bv 10 m. The membrane itself is thin and translucent, crossed by numerous fine trabecuhe. Thi^ supplementary portion appears thicker than the rest, and the free edge is rouiuled, The orifice of the superior cava measures Vi cm. in circumference, that of the inferior 27 cm Pdght Ventricle dilated and hypertrophied. Chamber m(>asures, from pulmonary ring to a[)ex, 8-3 cm. Cohuniue carneu' prominent and large. Walls thick, especially at the base, where then^ are \-ery thick muscular bundles— here it is 8 m. : towards apex thinner, 2 to 4 m. Tricus. pid valves normal, orifice 82 cm. in circumfercm'e. ('onus natural. rulmonary artery, springinu' from the venticle, is large, and appears to pass as a considerable trunk directly into the upper part of tlie descending aorta, which looks, in fact, like a continuation of it. This appearance is due (o an enormously enlarged ductus art(>riosus, which almost equals the aorta in size: — External circumferiMice of aorta, ascending portion, IT cm.; ol' ductus arteriosus. Mi cm. Length, 2'2 cm. It enlarges sliglitly on enh'iiiii;' the aorta, and immediately above this the vessel is somewhat constricted, measurinii- only l-'! cm. in circuni fere nee. Left yl//»v>/e small, compared with the riii'ht. No Ii\ per- BY \villia:m oslek, m.d. trophy. Nothino- of note, I'urthcv than what is statod above with relevoiice to tho Ibnunoii ovale. ' Left Ventricle also small in coniparisou with tho right chamber; measures from aortic ring to api^x 2-2 cin. Valves healthy. Mitral orifice 2-5 cm. in circumference." Muscle substance ol' whole heart of good colour, and fibres healthy. On visceral layer of pfn-icardium are numerous small ecchymoses. On slitting up the anterior pari of the m^ck to ^q\ out the trachea, a large extravasation of blood is (^xpos(>d beneath the skin in this situation, chiefly in the form of dark, fresh-looking clots, extending from the clavicles and sternum to th(> lower jaw. A careful dissection was made of the veins and arteries, but no rupture was found. Lungs small, pale-red in colour, airless, occupyino- .small space in the pleurte, being compressed by the iluid". Ecchymo-ses on both layers of pleura. Siileen large, of a reddish-purple colour. Measures !• cm. in length by 4 cm. in ^^■iclth. Surface rough and graiuilar. On section, iirm, uniform. Kidneijii and mprarenals healthy and of normal size. Only a trace of iluid in the bladder. Liver h large, extending far into th.> left hypochondriac region, measuring l.i-5 cm a.'ross, 7 cm. in antero- po.stenor direction. On section, healthv-lookin-, but congested, and on examination with hand-lens the't,>rri- tories of the small hepatic— intra-lobular— veins are seen to be chiefly injected. stomach contains a tenacious dark material. Small intestines, nil.Hl in upp.u- part with greyish mucus, below with meconium. Large })<>wel distended with same; material. Testicles.— Leit at the intenuil ring ; right almost in .scrotum. Umbilical arteries look h\rge. U i U ' \l I h\: ^''m RifTT iMi b CASES OF CARDIAC ABNOKMATJTIES. Uml)ili(aly('in admits a probe l-()cm.in circuml'croiico. Duel us vcnosus mii liver; iVom the posterior part of this the ductus passes olf as a tube 1-2 cm, in diameter. Remarks— T\\Q eondition of general dropsy of the Hetiis does not appear to have received mvieh attention at the hands of obstetric physicians. Vt'ry few cases are now on record ; none appear in Tathological Society's Transac- tions; only three in the Obstetrical Society's; none have been re])orted in the Archiv fiir (rynrocologie Mr. Clay, of Mani'hester, has reported two (-ases.' Three olhor instances have been mentioned to me l)y practitioners in this city— one by Dr. McCallum, a second ])y Dr. Ross. and a third, quite recently, by Dr. Kodger. All Avero accompanied with drop.sy of the ])lacenta. The points of interest in connection with this case are the premature closure of the foramen ovale, the condition of general anasarca of fcotus and placenta, and the probable causal connection between these conditions. Closure of the foramen ovale to the extent met with in this case is certainly an abnormal condition in the fa'tus. No doubt, a small amount of blood found its way tlirough th(> narrow slit of communication, but that this was trillinu' in quantity is shown by the dilatation and hypertro])hy of the right chambers of the h(>art and the compensating enlargement of the ductus arteriosus. These condition.s can be explained in no other way than on th(> view that the foramen had been virtually closed for some time, :nul, in conseijuence. the blood from both cava? had to foHow the course of the adult circuhition, n(>cessarily increasinn' the work of the riifht heart, and gradually leading to enlargement of the ductus arteriosus. 1 Reprint iVoiii " Zcitsduilt . I iim miKii iiidchti'd to .Mr. CJiiy Ibr kindly sending uu; a copy of lii.s coininiiniriitidn. BY WILLIAM (XSLER. M.I). 7 Prematiir.> closure ol' the Ibranim ovale has not oi'teu been noted. Dr, Teaeo.-k' was onlv able to rolleet three cases, and since that date 1 hav.^ r,.und Uni one other reported hy Mr. Lawson Tait,' and in it th,. Icotus and ])]acfnta were dropsical. The dropsy of placenta, amnion, and laMus hul doubtless resulted from a common cause. AVas tliis the ])remature closure of fh(! Ibram.Mi ovale ^ AVe ^ .'an suppose that obstructiou in the central or-an would be quickly lelt in the distant placental vessels-just as in the adult It IS iirst manifested in the vessels of the leet— air' a condition of passive ccderaa be brought about Ihe hydramnion could be explained in the sam,' way The general anasarca of the f(otus resembles a renal rather than a cardiac dropsy, which in the adult is never so e.xtensive. In th.' discussion on a case of Dropsy of th,' Fffitus in the Obstetrical Society, Dec. 5, 1,S77, Dr John l\illiams, of University Colleq-e, su-o-ested an in-enious explanation of the fcptal dropsy, as follows :—" As the kidneys app.'ar to be almost inactiNe at this time, it is not unreasonable to suppose thai the placenta acts also as a mia organ, separatino. excr.'inentitious matters from the Ijrtal cnvulat ion. If this be true, anhmia or thickenino. of the placental tissues would interfere with this excretory'ac- tion and o,ve vise to the a.-cumulafion of excrementitious material m the f has been found prema- turely closed. True, we might suppose, as suggested by Dr. Williams, t Oh MdronniiiioMs ot il.u llmnun Heart, 'lad Ed,. 1806. :; Obstotriciil Society's TiiiiimictidiiH, 1875. li s ' i '■ ! il; X CASES OF CAKDIAC ABNORMALITIES. a priinary disease of the placenta by which tlic l)loo(l current in the umbilical vein would he so i.iuch diniinislied in force that on vearhing- the right auricle th,. velocity became greatly reduc(>d, fso that " overcome bv the force of the stream from the superior cava it ilnwed into the right ventricle,"' This could hardly happen, lor the admixture of the two currents is very slight, iuul moreover in our case it would not account for the; great hypertrophy of the riuht heart. Of the other cases recorded, the foramen ovale was. found open in Dr. Bassett's ; ' in ]Jr. Protheroe Smith's - the heart is stated to have been normal, and in one of Mr. Clay's cases the organs are said to have been healthy. No record is made in these cases of the state of the umbiliral vessels, a stenosis of which at any part might im^ire these changes, as in case referred to by Fehling. ' In one of the numbers of the Centmlb/atl, f. d., Med. Wissemchaften of this year, there is a l)rief abstract of a pai)er by Kleb's, in which it was stated that h(> believed dropsy of the fcctus was induced by fu3tal leukieiaia. Unfortunately, the number containing the abstract has been mislaid. I have no memorandum of the coiulitiou of the blood in my notes, but I am almost certain that it was examined for nucleated red blood corpuscles, and if there had been an excess of white it could scarcely havi' been overlooked. The spleen was certainly much enlarged, and lirm ; the lymphatic glands were nornuil. Whatever may be the cause, the condition of general dropsy of the l'(etus is one of very great intt'rest, and it is to be hoped that practitioners who may happen to meet with cases Avill inspect most carefully the condition of the foramen ovale and the umbilical vessels. 1 Olisti'trii'ul S(i( iety's Triiiisiii tions. 1877. 2 ObstL'triciil Society Tniiisii'jtioiis, 1875. .3 Ariliiv. fiir Gynn'colot^'io niiiiil. X. BY WILLIAM OSLEl^, :\r.D. 9 Case U.— Extreme Stenosis of Orifire of Putmonar// Arter/j— Sti, but nothing, special was observed, and he throve like any other healthy inlant. Uurinu' a slight attack of bronchitis he became much more cyajioti.'. iuid died suddenly after a few days' illness. Autopsi/, ten liours after death : — ' Xothing- of special note in alydominal cavity. Ill Thorax, heart in pericardium of large 'size, pushing aside the luniis. Heart greatly hypertrophied. Circumference at base 1:^ cm., of which S em. is formed by th(i right. ,"> cm. by the left ventricle. Rio-ht amide greatly distended, appearing as large as a small-sized orange. Contained a linn avlatinous clot. From apex ..f appendix to opposite wall it measured (i cm. A small billiard ball iits into th.' chamber. Tral)ecuhe much developed in both sinus and appendix. Foramen ovale almost closed, onlv a narrow ■slit remaining. Tricuspid orifice from the auricle looks small, the valves thick and roughened, presenting in spots reddish gelatinous swellin-s. From this side 'only two sen'meuts are seen, a large anterior and a small posterior one. Length of orifice, 1-4 cm. : diamet.'r. 7 m. From the ventricle, sei>-ments appear contracted and thick, the edges rod and swollen; a small, coh)urless, pedunculated vege- tation is seen on edge of posterior segiui^nt. Chordie ten- (lin.';e niu.h thi.kened ami shortened ; only seven exi.st • the two near the septum are particiilarlv thick and short' nio;ht re;//^m-/e-J.ength of chamber, 4 cm. Endo.ardium thick and opaque. At the upper jxirt of septum the cavity i)rqjects towards th.' left ventricle; septum is com- 1 I: i# % 1 i • ! i 1 i! > t • >j! j S i i: 1 * J m ' ifii I 10 CASES OF CARDIAC ABNORMALITIES. plot.'. The coliiiniur carncir aiul luus.uli papillaivs are very slightly doveloped; rmmd and oval pits or (l,.p,vs. sion.sarc seen over the ventricular suriace. The (.•oniis arteriosus is contraeted, measuriii!.' only 1-7 cm. in ciicuia lercnce close to the rino'. Great dillicully was ,.xp... ncnced in passinu- a proli.. throui-h the pn/mo/iun/ orili'ro and on slitfin- up the artery it i.s s.-en that the sl.-m.MUsi of the valve hav eoalesivd, h'avinn;- onlv a narrow orilkv through which a pioh.' D of ;, millimetre in diaiueh.r can pass. The maru-ins of the valves are iibrous, and il.o edges of th,' tiny oriiiee iirm. The siniises of Valsalva are large, appearing dilat.'d. Pulmonary artery a liltli' distance above valve m.'asures 2o .ni. in circumferoii.e Interior healthy, I'xcept at one spot, m>ar ductus arteriosus, which is ath(>romatous. Oriiiee of ductus arteriosus small, and liny bristle can be passed through hito the aorta. Lefl aiirirle presents nothing worthy of note. Left ve.i/ricle appears much smaller than the riu'ht. Lennihof chamber from aortic rinn' to apex, 4 cm. Mitral aiul aortic valves healthy; orifices of normal size. Aorta natural-looldnu-. A small funnel-shaped dilatation existl at orihce of ductus arteriosus. Measurement of the walls :—i2/V/,/ Vcntric/e—OnUn- wall at base, behind posterior segment ot tricusjjid, 1 vn\ Anterior Avail, middle, VS cm. Close to septum, wlioie excision has extended IVom base to apex, '21 cm. Lejt Vefilric/e—AntevioY wall, n.'ar septum. 1 em. Casi-: ui.—Afresin of l^nhnonnri/ OriJire—IIijiievtrojihij of Right Ven/riclc—Imperfeclion of Septum Ventrintlunm — Patent Ductus Artcriosutt. (Plate.) A. B., male infant, aged J:! days, cyanotic from birih. IJody well nourished .and of fair develo])ment. Skin of face of leaden hue, chest and abdomen darker. Umbilical cord at birth vcn-y small. The child sullered IVom paroxysms of dyspncua, and died in convulsions. HV WILLIAM DSLER, M.D. \i Xothino- spocial in Mw,e.. In thora.r. h.art in pori.ar- (huni 0..CU1.,.. an unusually lar^e area iu antorioipart of //...Vlavuv all ,h. ..ha.uh.rs dilatod and lull of dark clcts and blood. Lonol], iv<„a root of aorta to apex 4 cm cnvmnferon.-e at has. 12 cm., of which To cm. formcnl by' nglit ventricle. <■ '^y Right auricle dilated ; endocardiun. natural, l^ramou ovale partially closed, an oval aperture remainino, 5 m long. 3 m. broad ; behind this, separated IVonx it by Tthick process IS another tiny orifiee in the septum. Superior and inferior .av.e large. Auricular surface of tricuspid valves studded with numerous o-.datinous. vegetations about the .size of millet seeds. Tricuspid orilice looks argv. Rt^rkt ventricle : Len^-th of chamber 3 cm cireum- iereuce5^5cm. Tricuspid valves healthy, ("onu";;" "Zs narrowed to a small funnel-shape.l tube which end. in cul-de-sac corresponding, to which, 6n the ext,n-ior of the otholel ol the tricuspid orilic,-, occupying, a po.sition between the conus and left seg-n^ent of the tricuspid, is a massol beaded, gelatinous vegetations, from the ape. of which a cord passes to either wall of the ventricle, anchor- in, It in this position. On inspection these vegetations are seen to spring from a thin mem),ranc which forms the .Wer part of the ventricular septum; on r>ushing t ri back, an orihce is seen in the septum measunng 9 m in nmsverse, 7 m. in vertical diameter. The lowei border of his opening IS ormed by the muscular wall of the sep Z;,t;; r '^r ' "• "^ '^"•^^--' ^^^ endocard^m ut It thickened and upon the free edge are some fresh ds of endocarditis. The upper part of the orifice's St !■: r '""^^"'"^* "^^^"^^•^-' -^--h extend 1 ^ahe-hke lorm into the right ventricle, ^vhere bv its wttT^'^ it ;« -yhored hy the afore-mentfon^ choid.e tendmce. This imperfection of the septum is m ' i*i I 12 CASKS OF CARDIAC AUXORMALITIES. liinitocl to th(» anterior part, tlio ])o.storior portion is iloscd hy a thill monihrano, and to this the adjacent sc^iuciit of thii tricuspid valve is attached. VV^alls ol' riyht ventrieh' measure — anterior wall, middle, 9 m., at baso 12 cm. ]Mii8(le suhstance pale and tatty. Left auricle al)Out hall' the size of the rig'ht. Left ventricle dilated, measures from aortic riiiii' to apex o ocin., circumference G cm. Valves healthy. Mitral and nortic orifices about normal size. Muscle substance not so pale as in right ventricle. Aorta is hirge, 2 cm. abov*; vnlvcs mtnxsures 27 cm. in circumference, Fr(jm iiiider suri'io' of arch a large ductus arteriosus springs, which joins the pulmonary artery at its bifurcation ; the A'essel is 8 ra, in circumference. The piilmonari/ artery after leaviuii' tlic heart passes as a narrow tube for 7 m.. widening graduallv until it reaches the point where the ductus arteriosus joins the main branches. In its narrowest part the artciy admits a probe 1 m. in diameter. INIain divisions ol' pulmonary artery appear ol" full siz(\ Lungs ])ivsent scattered patches of collai)se. Nothing al)normal in tln' other organs. Case iv. — Descending Aorta, willi Left Subclavian, givenoff from Right Ventricle — Innominate and Left Carotid Arteries from Left Ventricle — Ventricular Seplim Imperfect — Fusion of Segments of Semilunar Valrc^. Specimen was procured from a ftotus at the 8th month, which presented uum(>rous other malformations — enorm- ous umbilical hernia, spina bifida, hvdroc(>]>halus, talipes, &c. Heart somewhat larger than the child's list. ]iinosus normal' hem tins ehamber a lari-e vessel is o.iven off, 8 i.i. in widlli :il lli«" root, pusses over the vessel enu'r-in- iVoiu the left venincle, across the left bronchus and then descends as the ihoracK! aorta. Seven millimetres IVom its orio-in il oive.s oil small pulmonary branches to the impedectly doveloped hmos, a.ul. just belong it roaches the spine the l.'lt subclavian, whi.h passes verticallv up to th.' 1st' rib There is no .•ommunieation with the Vessel arisin- irom the left A'eiitriele. Loll ventricle is small.-r than th.' ri-ht, but the walls are thicker-:) to 5 m. Mitral orilico and valves normal A vessel is -iveii off from this chaml)er, which passes up upon the trachea lor 1-2 cm. and tl en bifurcates, iormino- the ii.nomnuit.> and left .-arotid arteries. The vess.'i is only al)out half the size of that given off from the rio.ht ventricle. Thi" sei)tum between the ventricles is imperfect Ihere ,s a small orillce, the sis^e of a goose quill, situated m * 10 uppcT and back part of the septum ; to its upj>er border Ihe left segm.mt of the tricuspid valve is attached, and can be drawn down so as almost to close it. Loft auricle is small ; pulmonarv veins normal. Semi- lunar valves in both vessels are almormal : in the branch Ironi Ihe left ventricle there are only two; in that from the right, there are only two of full size, and a tiny imi>orlect one betw^een them. A'e»m/-/cs-.— Cases ii. and iii. illustrate much more com- mon varieties of cardiac abnormalities. Thus, of 181 '■ases of malformation of the heart, Peacock' found stenosis or atresia ol the ])ulmonary artery in 119. The i)oint of interest in connection with Case ii. is the extreme degree of stenosis without imi)erfection of the 1 On Mill formations of the Heart. 2n(l Ed, 1800. K.; ' I L t M 14 CASKS <)|'- CAliDIAC AUNoltMAI-ITI i:s. Vft vt'iitririilai' septum or pivlciii'v ol' the loriuncii ()\alo. In the u'l'ciit i»i'()p(ii'tiou oi' casos in wliicli this h'sion is iui| \vitli, the si'pitim is iiiipcrrcil and soino ul" the l)l()o(l ciiu pass IVo'ly IVdiii lln' right to Ihi- Id't vciitrich'. Ollfii, too, the roramen ovale and duelus arteriosus are op"ii. in tliis instance, llie lungs reei'ivod blood throuu'h n pul- nionary oriiicc narrowed to •'.) m., the enormously hypcv- trophied riu'ht ventrielt^ componsatiny, in some degri'e. loi the stenosis; the constant lividity oi' the child exprossi 1 the del'ective arterializution oi' the ))lood. Whereas lifo may ho prolonged for ycuxrs with stenosis oi' the ]>vilm(> nary artery, provided the septum ol' the ventricle is open. death takes phice early if the latter condition doe> not co-exist. Rokitansky states that tliree mouths is the longest i)eriod to which he has known lil'e to 1)e prolonged when the stenosis is una( companied with imperfection el the septum. In this case thi' child lived fo" i'our mouths, and was a well-nourished, plum]) infant. In Case iii. there was complete obliteration of thr pulmonary orilice, with imperfection of the septum ventriculorum. the foramen ovale being- almost closed. The lunii's receivi'd blood from the aorta through an enlarged iluctus arteriosus. The ihild lived oidv thirteen days. The valvular ibid which passed from the npper margin of the orilice in the se[)tum, and was anchored l)y two chorda^ tendinete, must have materially inteiiered with the transmission of blood from the right to the kit ventricle. Case iv. is remarkable from the fact that the desecMuling aorta is given olF from the pulmomiry artery, the vess( I el' the left ventricle supplying' only the innominate and left carotid, there being no connection between the two main trunks. This is a somewhat unusual anomaly. It is as il the part of the aorta between the left carotid and the duc- 1 Diu Dcfectc der SrlioidcwiindL' de.s lieizuns. Wicii, 1875. nV WILMAM OSfiEI!, M.I). 15 tnsiirtf>riosus wns dcficitMil. tin- Mscfiuliiio- and desecndiiijr aortn> hi'iiigst'parat.' trunks. ^^\> may suppose tliis ahnor- malityto havo boon produ.cd by an oblit. 'ration and final disai)poarancc ol' (ho ontor i)ari (.1' tiie Jtli lel'l mibryonii; artorial trunk, which normally eomi)l.'los tho aortic arch. This section of the arch, callod by liokitansky tho isthmus aortio, api)oars ospo.ially liablo to errors of d.-vol- opmont or disease, rt'sultiny in a constriction of the tube or obliteration. Many such case.^ are now on record. As to the mode of origin of the malibrmations describi'd in Cases ii. and iii., there are two chief theories, 1st, that they result from inllammatory chanyos— endocarditis- taking- place at an early i)i"riod ; 2nd, that they depend upon errors of development. On tin- iirst view, the steno- sis or obliteration of the pulmonary orilice is brouirht about by inllammatory processes, just as narrowiuir of the orifice occurs in tlie adult by chronic valvular endocar- ditis. W tho change takes plac; before the complete separation of the ventricles, the sc^ptiim is prevented from closing, the blood current being forced to pass through this orilice on account of the impediment at tho pulmo- nary ring. \]y tho supporters of tho second theory it is rightly urged, that, as the septum (doses about the end of the second month, wo would have to suppose an (Mulocar- ditis limited to the pulmoiuiry valves in an embryo not more than 2'.') cm. (an inch) in length, and whose heart cotdd not bo above a itnv millimetres in size. — a supi)osi- tion .scarcely conceivable. On tho developmental view, the obliteration or narrowing of the pulmonary artery depends on an unequal division of tho primitive trun- cus arteriosus out of which this artery and tho aorta are formed. Tht> Si^i^tum trunci grows in such a way as to cut off an exceedingly narrow anterior or pulmonary channel which may subsequently become complot(dy closed. This is tho vi.nv --supported by liokitansky in his last work, whereas he was formerly an advocate for tho 1 1 ' 1 ; ^! 1 ' 1 4 : 1. ■! I i; * M. ^ % '? \ ' liii' i ai. », ^ r- 16 CASES OF CAKDIAC AliNoRMAMTIES. okler theory, llo belioves, howovcv, that tho mal- formed vt'ssol may be tho scat of inllammatory chaiiMcs, which aii'uravatc the luischit't. In Cast- ii. the sleiiosis looked much as if it liad been produced l)y a iiisiou of the sei^ments of tho seniiiunar valves, the rcMilt of an iuMamnuitory i)rocess. The artery itself was ik.i at all narrowed. Tho tricuspid valves are also affected, the maruins havinu" united, and the orilice is, in ("(msequeud , somewhat narrowed. There is nothiuu' in these cases hero recorded have come under my notice within the past three years, and they illustrate s(»veral points in connection with the pro- bable origin and consequences of this allection. Case \.~ Fusion of Anterior and Left Posterior Segments— Ulcerative Disease of United Segment— Hypertrophy of Left Ventricle. (Plate, Fig. 1.) .1. S., tot. 2<;, a stout, well-built young man, was admit- ted to the hospital on August 23rd with symptoms of valvular dis(>ase of the heart. Had worked as a black- smith. No history of sudden attack. Has had shortness of breath and palpitation for more than a year. There vas a doubli' murmur at the base. Left ventricle hyper- trophied. Feet and legs became ccdematous, skin of upper part ot body slightly jaundiced. Duaili with ordinary symptoms' of chroni<' valve disease. 01 I i ■ f 18 MALFOR^fATION OF SEMI-LUNAR VALVES. Autopsy. — Heart : weight, 090 grams. Kiglit auricle dilated and lull of dark clots. Right ventricle also dilated ; measures 13 cm. i'rom pulmonary ring to apex. Anterior wall o m. in tliickness. Left auricle larn-e Mitral orifice admits a ball 14 cm. in circumference. Left ventricle dilated and hypertrophied ; length from aortic ring to apex, 14 cm. ; anterior wall, central portion, 18 cm. in thickness ; towards apex, 15 cm. Mitral valves slightly thickened ; chordtc tendineoe appear of noimal length. ]\rusculi papillares flattened ; apices fibroid. Aortic valves incompetent ; ring measures 8 cm. in cir- cumference, and is unarded by only two valves, between which there is an irregular interval. (Fig. 1.) The right posterior segment is large, 3-5 cm. along its free border, where it is slightly thickened. The liody of the valve, except at one spot, is translucent. Anterior and lelt posterior segments have merged, forming a single, large, imperfect valve, having a free border 35 cm. in length, the end nearest the right posterior segment being loose, only anchored by a cord 1 cm. in hmgth, which is attached to the wall of the artery. On either side of this cord a con- siderable portion of the valve is wanting, and the edues are fresh-looking and sharp. The united segment is thick, especially at the frei^ border, and it is also a little foreshortened. From the external side the sinuses of Valsalva are distinct but the raphe between the seg- ments only extends to their bases. On the ventricular surface a faintly-marked groove indicates the line of sepa- ration. Aorta a little atheromatous in "scending part. Nothing of special note in the o.ini organs. No infarctions. ' ' rom rES. li'lit auriole itricle also ig to apex, ric'lo large, nimft'rcuco. ing'th from val portion, itral valves of normal es fibi'oid. cm. in cir- ;s, betwoeii . 1.) The ng its Tree ody of the ior and left ugle, large, length, the loose, only attached to cord a coii- . the edu'es segment is ; is also a the sinuses ?n the seg- ventricular no ol' s(>pa- iding part, gans. No BY WILLIAM OSLER, M.D. 19 Cass U.— Fusion of Anterior and Left Posterior Segments— Hijfierlrophi, and Dilatation of the Ilmrt— Sudden Death from. Rupture of an Aneurism of Branch of Left Middle Cerebral Arteri/. (IMate, Fiy-. 2.) M. B., ict. 20, a small but moderately well-built young man. Death took i)lace suddenly, Avith symptoms of an apoplectic attack. No history could be obtained from the peoj^le with whom he lived of any previous attack or of heart disease. Autopsi/.—Heart considerably enlai-ged. "Right cham- bers full of dark tdots. Right ventrich; somewhat hyper- trophied ; post(n-ior wall measures m. in thickness- Valves normal. Tricuspid orifice lOo cm. in circumfer- ence. Left Ventricle.— Length from aortic ring to apex, 9 cm. Wall, at posterior part, 2 cm. ; at apex, 1-2 cm. in thickness. Muscle substani'e of a good colour. Mitral valves healthy ; circumference of orifice, O-o cm. Just above the anterior mitral segment, between it and the aortic ring, there is a spot of fresh endocarditis about half the size of the thumb- nail, and covered with small, soft vegetations. Aortic valves incompetent. On slitting up the orifice only two valves are seen, the anterior and left posterior having fused. The right posterior segment presents a normal app.^irance, retaining its shape, though large in proportion to the other, measuring along its free border 3-3 cm., de]>th 1-6 cm. The substance and free edge are a little thickened and opaque. On the ventricular surface are three small iresh vegetations, and at the c.Mitre there is a small depression leading to a tiny perforation of the valve. The sinus of Valsalva is large. The united ■segments from the ventricular surface appear as one valve, whi.h is, compared with the other, foreshortened and shrunken. The free l)order measures 32 cm., de[>th 1-3 cm. From the aortic side two sinuses of Valsalva are seen Jf i 1 pHR !' t ' '' ^ : j % i) ! ^ \ I U ! k * f ^K t \ i ii + 1 ; I ll^B j A '' ihI t ii^jH 1 ', fWB p i PS- m. ■: 20 MALFORMATION OF SEMI-LUNAR VALVES. soparatod l)y a Ti(lu'»\ which extoiids to the base of iho united SL'L>'mt'ut. and us a small line np the aortic suriUce. The Tree border is round and smooth on the ventricular side ; on the aortic margin there is a row of reddish, gelatinous-lockiuu' veg-etations. At one angle there is a small ienestration of the valv(\ The oriliees ol' the coronary arteries are seen behind the united segments, ou(> at the upper })art of each sinus. Anrtn is healthy, wall looks thin. Width, 3 cm.— abovi" the valves, 5'4 cm. Splepti shows traces of three old infarctions. Kldnej/a. — Puckered remains of two infarcts in the left, iu the right organ u large wedge-shaped one undergoinn- fibro-caseous change. The aneurism of the left middle cerebral artery is described in another placi?. Case hi. — Fusion of Anterior and Right Posterior Segmenh. F. (>., tct. 42, a medium-.sized, well-nourished man, blacksmith by trade, a hard drinker, and for sevtM-al years a consumer of chloral. Death took phu.'e suddenly, and details of antecedent circumstances could not be procured, Aidopsii. — Heart large ; left \'entri(de dilated and hyper- trophied. Mitral valve normal. Circumference of aortic ring 96 cm. Two valves only are seen, the anterior and the right i->osterior segments having fused together, formin cin. along the ])order. Nor- mal segment measures 3-0 cm. On the ventricular surface the united segment is a little roughened and thick about the centre. A depression is also seen at the attached mar- gin ; a slit-like fossa is seen at one angle, looking like a closed fenestra. Body of the valve thin in the centre, a littltf thickened at margins. From \\m\ aortic side two distinct sinuses of Valsalva are seen behind it, but the median raphe only extend about tuic-third of the way up the valve, spreading out in this situation into irregular BY WILLIAM 08LE11, M.D. 21 fibre*?. Sli-ht athoromu about orifices ofcorouaiy arteries Arch of aorta noriaal. Kidnet/s large aiicl very full of ]>lood. Oth.>r normal. orgausv Case iy.-F//s.V;« of Anierior and Rigiu Posterior Segments. (Plate, Fig. a.) , " A. B., tet. 42, a strong, robust man, patient of Dr Rcddy who has reported the case in C. M. Sf Surg. Jomnal 1877 First complained on June 8th of uneasy sensations 'about the diastolic murmur over the entire cardiac region. Hypertrophy of the heart has increas.'d. During November he suii'ered with all the symptoms of ordinary cardiac dropsy, and died on the oOth. ylw/o/w/y-Geueral anasarca. Heart wei-hs 7oO ..-rams bemg o,.eatly hypertrophied. Rio-ht chambers dilated and lull of clots; walls of right ventri.le increased in thiekness. Left Ventricle~Q\vA^xxh,n' dilated ; m<'asures 10 cm. from aortic ring to apex. Walls 2 em. in thickness Aortic oril.ce, 8 cm. in circumference. Valves incompe- tent, p..rmitting of frec> regurgitation. Two segments only ave pres,>nt, the anterior and the right posterior haviim- joined together. Th. single valve, the left posterior is large, m.-asuring 4 cm. along the strai-ht maro-in and VQ cm. m dc^th. It is a little thickened and opaque towards the attached border. Its sinus of Valsalva is laroe united gnient is considerably smaller than the oth IS incomplete, a V-shaped piece being ab.sent at The er and one end. I- u 1i* I I ! ] r • t 1 < ! il" m ! I 00 MALFORMATION op SEMI-LUNAU VALVES. The straight bordcv passes lor '3 cm. and terminates in ;> rounded anu'le, which is continuous witli the V-slmpi'd delect. The edg'e of this segnienl is round and tliiikcurd and the Avhole valve opa(jij|^'; measurement along middle of surlac(% 1-3 cm. On the aortic side tlu^ segment pre- sents an indistinct Irenum about the centre of the attached margin, which also serves t(j divide the sinus of Valsiilva incompletely into two, the one behind the imperlect side of the valvt' being small, the other o£ fair size. The arch of aorta is con-sMerably dilated: iutima covered with yellowish mas.ses of atheroma. Heart muscle pale, and on examination is found to be fatty. Case v. — Fusion of Anterior and Right Posterior Segments— Ulcerative Disease and Laceration of Left Poslerior Valve — Aneurism of United Segments. (Plate, Fii^'. 4.) The notes of this case have unfortunately been mislaid, but the Hoiise Surgeon informs me that he had the usual symptoms of severe aortic valve disease. Xavier T., ict. 45 ; admitted October 24th. Autopsy. — Body that of a medium-sized man, of slight muscular development. No anasarca. Heart large and hypertrophied. liight ehambcrs distended with clots ; those of the ventriart 2 cm, in thickness. Mitral valves a little opa([ue aiul thick. Aortic orifice measures 8 cm. in circumference. Valvi'S incompetent; water pours ihrouu'h with great freedom. On slitting ojx'n the artery only two valves are seen, the representatives of the anterior and ritidit posterior segiaeiits having united, forminu' one large segment mea.suring li cm. along the border. From the aortic surface uf this BY WILLIAM OSLER, .M.D. 23 L man. of sliu'ht valve two .small aneurisms arise ; one, near the centre, about the size of a small cherrj-, is filled with })lood dot and pri^sents two perforations : the other, n(Nir the k-ft posterior segment, is not so large, l)ut passes deeply beneath the endocardium, and also communicates with the ventricle by two small orilices, The free margin of the valve is thick(>ned and rough. From the aortic surface two sinuses are seen, separated by a semi-calcareous raphe, which termiiuites halfwny up the valve in a thick tuberous end, covered with small ven',.t;itions. The sinus behind the right posterior part of the united sey-ment is the largest and gives olf the aneurisms. The left posterior seg- ment is torn aci'oss nearly to th(> attached maru'in. When the separated portions are placed together they measure only a little less than tht^ large segment. They are u-reatly thickened by atheromatous dej^jsit, and Jlap up and down when the heart is moved. The sinus of this valve is laru'e. The Aorta is normal. Lungs large, and contain spots of apoplexy. JZ 1 Cash \\.~Fii$ion of Riirht and Left Pofifcrior Sesmenta (George G., jet. 40; a large, .somewhat corpulent man. Death from typhoid fever, after live days residence in Hospital. No heart symptoms. Avtoi>sij.~ Heart a little enlai'ged. Right chambers dis- tended with blood. Left ventricle large ; walls thicker than normal. On slitting up the aorta the two posterior segments are seen to be united, forming a large segment, 4 cm. along free Ijorder, 1 -5 cm. in depth. From the ventricular sm-lace it is smooth, a little thickened about the centre and free border; thin and natural looking in the rest of its extent. A slight indication is seen below of the sepa- ration between the component parts. From the aortic side the two sjnues of Valsalva are seen separated by a raphe which extends as a ridge along the arterial wall. The «?•, j lii 24 MALFORMATION OF SEMI-LUNAU VAIiVES. sinus behind the part formed by Iho riii'ht posterior seu'iin'iit is much larger than the other, Avhich has one coroiinry artery just above it. The intima ol' the vessel in this sinus is rough and atheromatous. The normal valvi' measures 3-3 cm. along the free border, and is ])erfc(jth- natural. Aorta presen.ts scatter(>d patches of atheroma iii the arch. •, Cask vir. — Fusion of Tmo of lite Scmi-hoiar Valves a/ Aorlir and Pulmonary Ori/ices. F(etus at eighth month. Heart and arteries described in Case iv. of " Cases of Cardiac Abnormalities." On openiiig vessel of left chamber only two semihuiur valves are seen— a large one, 9 m. in width, towards the right; a smaller one, 8 m., towards the left. Eotli are thin and natural looking. Behind the larger seguiont a median rai)he passes down oiv thi> arterial wall as far as the attachment of the valve, and imperfectly divides the sinus of Valsalva. The right coronary -rtery is given ol! 4 m. above the margin of the valve. On slitting up the artery of the right ventricle only two valves are seen, carh measuring 10 ni. along the free border. They are situ- ated to the right and left, and posteriorly do not meet, a small space ol 2 m. intervening, which is occupied by an imperfect valvular fold, the margin of which is below the level of the larger valves. Remarks. — There can be very little doubt that this con- dition is congenital, as in case vii. Dr. Peacock and otluMs have also found a similar appearance in the i'dstus, oltcii in connection with other abnormaliti(\s, and cases are reported of its presence at all ages. AVhether due to inllammatiou or some primary malformation of the valves is more dilii- cult io say ; I incline to the latter view. In the blended valves of case vii., a fcetus at the eighth month, iheri' was no trace of endocarditis or thickening of the seyments, «y WILLIAM OSLER, M.l). 25 and many instances are on rccurcl ol' individuals dyini^'at various ages, in whom the i'u.sod .seuments did not show any evidence of past morbid .Imnnv, as, Ibv example, in case V. I do not think tluit any of ihe cnses in this series sup- port the view that the aU'eetion njtty oriu'inate either bv tlie tearing' down ol' the iingl,. of attachment, or by the adhesions of two seo-monis as tlie result of dis(>asi'. JC the condition wa> brought about in this way, we would expect the I'used sei>inents to bo. in most cases, very much larger than the singh' one. In lour ol' the above cases the i'used segment measured about the same as the nornui] one ; in case Hi. it was 1 cm. longer ; in aise vi. 7m. In only one was there any indication at the attached ventricular margin of a separation of the fused segment, i.e., of th(> existence of the souu'what triangular space which normally is seen between the bodies of the se<>-- ments, when viewed from the \ t'nti'icle. In this case there was a shallow groove, coi-respondino' txi)ected if formed by the tearin ,f''.^ ■il .Jo Fig 2, Fie:3. Minteni Br -^ ^-M ' \ M 1 \- ^1 imp. PA M Professor c Froi THE PATHOLOGICAL REPORT OF THB MONTREAL GENERAL HOSPITAL ]sro. II. BY WILLIAM OSLER, M.D., M.R.C.P, Lond. Professor of the Institutcf- of Medicine, McGill University, Physician and Pathologist to tlie Hospital. Wnir -11 i: Lii From the Montreal General Hospital Reports, Vol. I., 1880. MONTREAL : THE GAZETTE PRINTING COMPANY 1880 I* ^ t I ^ J: TllH Jirst ratholouiial Report I'rom Iho Ho:spitiil uas issued in ISfS. The prciseiit comprises a selection Irom i'2o post- mortem a perrormed between October 1877 and October 1S7!>. The autopsies arc made, by the stiidcnts attending the Hospital under my personal supervision, and the notes are dictated on the spot. During the winter session a " Demon- stration Course," in imitation of Yirchow's ceh'braied course at the Berlin Pathological Institute, is held every Saturday morning, at which all the specimens in morbid anatomy collected throughout the week are demonstrated to the senior students. In this way I am enabled to devote more time in the post-mortem room to the instruction of the student in the details of the method of performing autopsies, — a very important branch of his education, and cue too much neglected in the schools ; while at the Saturday morning class, the specimens can be more systematically demonstrated and the material bo made more instructive to a larger number of men. The limited time at my disposal has often compelled me to r(\gard the cases more from the standpoint of the teacher than the scientific investigator. 1. Vouii- tiot 2. Bullet (k'r 1. C".a.ses ( 2. Aucur 3. Ancur 4. Small f). Four C 6. Anouri Cav 7. Two C 8. Pei-tbri Sml( 0. InstaiK 10. BayoiK 11. Fatfy . Deal 12. Two C; 1. (Kdcma trad 2. Iiiteii.se ■i. I'nciinif 4. I'lllMIUi T). Minor's ()'. Note or Hron CONTENTS. I. NERVOIS SYSTEM. 1. Wouiul of Central Part of 1st and 2ncl Left Frontal Convolu- tions. 2. Bullet Wound of Rio-ht Frontal Lobe. Entire absence of Cerebral Symptoms. ir. CIRCULATORY SYSTEM, Cases of Aneurism of tlie Aorta. Aneurism of Innominate. Kupturo of Saeeuiar Dilatation of Aorta into Porieardium. Aneurism of S])lenic Artery. Perforation of Colon. Small Aneurism of Jienal Artciy, Four Cases of Intra-Cranial Aneurisms. Aneurisms of Branches of Pulmonary Artery in Wall of Cavities. Death from I ra'moptysis. Two Cases of Ilj-pertrophy of the Heart. Perforation of Pulmonaiy Artery by Ulcer of Left Bronchus. Sudden Deatli from Ihemoptysis. Instance of Four Pulmonary Valves. Bayonet AVound of Left Subclavian. Fatty Degenei-ation of the Jleart in Diphtheria. Sudden Death on the 13th day. Two Cases of Tiii-ombosis of Pulmonary Artery. III. RESPIRATORY SYSTEM. 1. (Etlema of Jiight Lung; llydi'othorax of Left Pleura. Con- tracted Kidneys. 2. Intense (Edema of Left I.uiig. Morphia Poi>ouing. 3. Pneumonia. Ulcerative Fndocarditis. .Meniuiritis. 4. !'iic;imonic Phthisis. r>. Miner's Phthisis. C. Note on the Occurrence oi Mombi'ane in the Trachea and 0. 10. 11. 12. B ro nciii m Cases of Diphtheri; '■1- li i ' f :1 it 4i IV. DIOESTIVK SYSTEM. (a). Stomach and Intestines. 1. Foreign Boily in (Esophagus. 2, Throe Cases of Cancer of the Stomacli. a. Three Cases of Ulcer of Stomach. 4. Throe Cases of Duodonai Uicei-. 5. Typhoid Fevei-; rapidly fatal with Nervous Symptoms. (J. Perforation of Appendix veimifonnis. (h). Liver. 1. IIy(hiti(l Cyst. 8. Primary Cancer. 9. Ciri'hosis; Colhitcrai Circuhition throngli an i^lnUir-'ed Umbilical Vein in liound Ligament. 10. Pylephlebitis. V. ITRINAUV SYSTK..I. 1. Scald of Thorax ; numerous Fatty Spots in Kidneys. 2. Remarkable Atrophic Kid tuns. 3. Large Cirrhotic Kidneys. 4. Sai'coma of Right Kidney. VI. GENERATIVE SYSTEM. 1. Dermoid of Ovary. 2. Cancer of Uterus— Stricture of Ureter ; Pyonephrosis. 3. Ruptured Follicle in Right Ovaiy — Peritonitis, 4. Abdominal Pregnancy. 5. Cryptorchidismus. VII. I.YMI'IIATIC SYSTEM. 1. Tumour oj" Axillary Glands, extensive Metastases. 2. Sarcoma of Reti-o-Peritoneal (Hands. 3. Sarcoma of Deep Cervical (Hands, involving the Thyroid, and simulating Goitre. PATIIOLOGTCAL EEPOIiT. Enlarged NERVOUS SYSTEM. l.— Wotrnd of the Central Part of tlw 1st and -Ind Frontal Conrolutions on Left Side. H. v., jot. 21, while working a circular wood-saw at 2 p.m., Dcct'inbor ;!rd, negliHted to adju.^t the holts, and tho (saw ilow up, striking him on the left shoulder and head. Ho was unconscious Ibr about ton minutes. "When brouo-ht U) Hospital he was pale and weak, quite conscious, no para- lysis. The wound in the skull oozed. Slept well dvirino- the night of the 3rd. Passes urine without dilficulty. The wound in the shoulder has removed the greater part of the deltoid muscle, the head of the humerus, and the acromion process. The skull wound extends in an oblique direction from above the outer angle of the left orbit across the frontal, through the anterior superior angle of tho right parietal, and terminates about the centre of this bono, iiongth of wound in integument 22 cm., in bone IH era. It has penetrated through tht> membranes, and at the central part the brain substance is lacerated and expo.sod, and can be seen pulsating. December f)th. Noon. — Passed a restless night. Has boon unconscious since 7 p.m. Incontinence of urine. No paralysis. Pupils are equal. Moves tho left arm and leg about in an irregular manner. Muscles of the left side o*f face twitch occasionally. Moves the right leg, but not tho arm of this side. On attempting to separate the lids ol' tho loft eye, groat resistance is oflered. (;//«.— Loss of power on right side, but occasionally moves the right foot. There is hypertesthesia of loft side of the face. Still offers resistance to opening of loft eye. 7\J0 r.M. — Temperature (which has ranged from 100° to 103°), in right axilla 102G°, in left 10()o°. Complete n 6 I'ATIIOLOnirAL REPORT. immobility of (he whole body ; no twitching of musdos. Died at 10-15 p.m. Autopsij. — Wound in skull corresponds with descriidion given above. In dura mater over left frontal region there is a large rent, 7 5 cm. Ioul--, ;5-5 cm. wide, extending frern the longitudinal sinus downwards and outwards lo a point a little anterior to beginning of fissure of Sylvius. Blood clots and portions of brain substance fill up the rent. On slitting up the longitudinal sinus, it is found unaffected; where thc^ laceration touches it there i,s a small mural thrombus. On removing the dura mater, a slight extravasation is seen to extend beneath it. The pia mater is stained, but not much injected. Over the useeud- ing frontal and the parietal convolutions of left side, and over right frontal convolutions, are ilakes of lymph, but the meningeal aHeclion is not extensive. The laceration of brain substance is confiiu?d to the 1st and 2nd left frontal convolutioiis, which are completely 'lostroyed in their central portions. The wound extends obli(|uely, and is from 2 to 8 cm. in breadth, nearly 2 cm. in deptli, and involves more of the anterior part of the 2nd than of the 1st convolution. The laceration in the latter stops short a little before the longitudinal fissure. The central part of the 1st frontal convolution on the right side, in an area the size of a small walnut, presents a number of extrava- sations, about which the tissue; is deeply injected. The pia mater over it is inflamed and covered with lymi)h. Nothing abnormal in central parts or at base. 2. — Bullet Wound of Right Frontal Lobe— Entire Absence of Cerebral Sj/mjdoms. C. Gr., a^t. 22, was admitted to Hospital on March Sth, suffering from the effects of a bullet wound, situated above and a little in front of right ear. It was stated to have been caused by the accidental discharge of a pistol. ng of muscles. Entire Absence BY WILUAM OSLER, M.l). 7 When si'cn by Dr. Drake, shortly aftrium. The pia mater in this extent is also stained, but not so deeply. Several fragments of the inner table is' i: 8 I'ATHOLOOICAL UKl'OllT. are attached to tlip dura mater at ilic site oC tlic Wdund. Tho l)ullet t'litorod the brain subslaiiro in the ri^hl iii|',>. rior i'rontal convolution, just in front ol' the ascciMlinn- branch oi the Sylvian Jissunv I'^roui this [loint the roiiisc ol" thi' bullet was upwards and Ibi wards, i);iN>iiiM' out at the iinu'r .suriace ol' the frontal lobe aiul lo(lL>iii>.' between thi' brain substanei; aiul the I'alx, where it lay surrounded by a lirui membrane. It was sitiialed il ciu in front of, and in a \'uu\ with, the anterior extremity ot the corpus callosuni. A lirm membranous . anal ni nks the course of the bullet, and the brain substiiuee iiljoiit this is somewhat softened. Diis. Fenwk'k and Bkll CIRCULATORY SYSTEM. 1. — Cases of Ane/trtsni of the Aorta. Of a number of cases of Aortic Aneurism, the foUowiiin- present points of interest : — (a.) — Aneurism of Ahduminal Aorta — Perforation (f Dm- (ienum. A. ]}., tet. GO, a patient of Dr. Howard's, had sulfeivd with siivere lumbaifo pains in th> (> As.. Only a few days before death he was examininl, ii ,;is>iim' and lodiiiiiu' :, where it hiy situuU'd (i (111 )• ' xtromity ol s raiitil HI irks .bstiince ulwut Iv AM) 1)1 A A. ■la. th(^ Ibl lowing ration of Diw- , had snll't'ivd uly ait'w days [omiiiiil anrur- lorrhagc i'roin iiiscuhir man. and ;il)domon. se. Ar<'h and yd patches of •rtioii, about 1 rreguhir open- 1 projects from s transversely MY WIM.IAM OSI.KK, M.D. 9 plai ed, and measures ") hy ;{ cm. ; the upper margin in shuiply delined, the wall of th"- vessid appearing to terminate at this part. The sac of the aneurism is about the size of an orani-e, and is full of clots and laminat.-d fibrin, the hitler arranged chielly at th(f ui>|>er and lower regions. The third portion of tlie du'- l^Mum crosses the front of the tumour obliqucdy, and is do: I'^y attached to it. .Alter washing out the sac it if s en to • ommunicate with the bowtd by a ragged orilic >, :, l-y 2 nn., situated about the central part of the transv -y.H. portion of the duodenum. The iliacs pass off immediately bcdow the sac, ami are healthy. both stomach and intestines contain blood. {]).)— Sinal/ Aneimsm of Aor/a, romprexsirifr Left Bronchus. John H., ict 35, a boiler-maker, admitted July 30th, with couuh and diffily at the termination of the arch, an aneurism, the size of a large walnut, projects forwards, and compresses the left bronchus. The sac, which is almost obliterated by firm layers of fibrin, communicates with the vessel l)y a small orifice. On slitting up the trachea and bronchi, the tumour is found to compre.^s the left branch, diminishing it.s calibre at l(>ast two- thirds. At one spot it has ulcerated through, and the fibrinous lamiiue of the sac are freely exposed. The left lung is heavy, upi^er lobe slightly crepitant, and very CEd(>matous ; lower lob<^ airless. In the bronchi there is a large amount of purulent fluid. r i > {c.}— Aneurism of Thoracic Aorta— Rujdure into Left Pleura. David K., ;et. 48, a sailor, admitted IStli of Sei)temb('r, tmdcr Dr. Eoss, with pain in l'>ft side and palpitation of the heart. [las had pain about margins of h'ft costal cartilages for over 1 2 months. Has now, in addition, severe pain in the dorsal region on both sides, but most iiik'ii.^e on the left. It is of a scalding I'haracter, increased by- lying down and relieved by firm pres.sure. Skin along course of lower dorsal nerves markedly tender. Xo tenderness on pressure over the spine itself. On exami- nation of hest, signs oi' moderate efFtision in lelt j)loiira. He was tapped, and three pints of clear serum removed. This gave temporary relief, but the pains soon became as seven- as before. H' art a little displaced to the right, )ecame as HY WILLIAM OSLER, M.D. H Otherwise norm.]. No murmur to l.-ft of spine posteriorly Di-ath occurred sudden Iv, on :21st of October " .4,//o/«^.-In Mhdom.n, vis.-era displaced " downwards and to the right ; diaphrnnrm on left .sid. on a level with .ostal border. In thorax, left pleura lull of serum and clots oz.o the former, 1.4 oz. (by weight) of the latter'. Lung- oi tins side compressed. IJeari somewhat enlarnvd • valves normal. On removal of heart and luno-s ,, h,o.e aneuriMnal tumour is seen to oe.upy the posterior'media's- hiium, inrolvino. al,out two-thirds of the len-th of the thoraru- aorta. The bursting has taken phu-e throuo-h a rent m the pleura, f> .m. in length, situated immediately over the heads of th(. 6th and 7th ribs of the left side On removing the tumour, the posterior wall of the sac is foimd to be the deeply eroded vertebra, 5th, 0th, 7th and 8th together with the heads of the c'orrespondi.H. ribMhatoi the 7th on the left side being almost eaten avvay Ihe bodies ol the affected vertebrae are fully one- hah destroyed ; the intervertebral suhstance is not so much involved. The sac is very large, fusiform in shape and contains numerous lamina) of fibrin with much coagulated blood. The .esophagus is displaced forw.irds but not compressed, nor is there any pvossure on the bronchi. {i}.~Aneunsm of Arch of Aorta-Great H.jpertropluj of the liearl. ' J. M aged 40, admitted July 14th, 1878. Had been a soldier for lo years, serving in various part:- of the world ^inre his discharge in 18(J5, has worked as an ordinary labourer. In April, 1876, began to suffer from couo-h and dyspnoea, and noticu>d a pulsation in front of <"hest • he continued at work until July of that year, when' he nteied the Hospital for the first tune. iL lived a hard hte; never had syphilis ; had rheumatic fever when a lad. «}' ^:h. =■ ' y. 'Ill ! " i I'W'^I u. 12 PATHOLOGICAL REPORT. Since th<> first symptoms appeared lie has not been able to work mucli ; tlie present is his fourth term of residiMice in the Hospital, and he has been two or three times in the Hotel-Dieu. There is great hypertrophy of the heart, apex beat 4 cm. outside of nipple line, impulse Ibrcible ; no murmur. G-reat prominenee of sternal end of right clavicle ; visi])le pulsation in right infra-clavicular region; feeble impulse felt in same locality, stronger one in episternal and sui)i'a- clavicular regions. Complains chiefly of pain ami dyspncca. Latterly he became very much wasted, and died exhausted on ^September 10th. Autopsy. — On opening the thorax, aneurism oreui)ies the position indicated during life, and is closely attached to the chest wall ; the cartilage of the 2nd rib and pari of the bone being atrophied from pressure. Heart greatly enlarged. Right auricle contains clots, some of which are iirm and colourless. Supiu-ior cava and its branches are normal, liight ventricle much dilated, measuring 15 cm. from pulmonary ring to apex, walls 5 to 8 m. in thickness. Tricuspid orifice enlarg-ed Septum bulges V(n-y much towards this chamber. Lett auricle large ; endocardium very opaque. Left ventricle somewhat rounded in shap.\ much dilated and hypertro- phied. Length from aortic ring to apex 12 cm. Circum- ference 19 cm., walls 1.") tc 20 m. in thickness ; papillary muscles and fvabeculae much developed. Mitral orifice slightly enlarged. Aortic valves normal. Anrln. — Ascending part dilated, measuring 11 o cm. in circumference ; intima rough and atheromatous. The aneurism projects from the right side of the arch, involving the vessel as far as the innominate!. The sac is about the size of an orange, and is almost tilled with firm laminated clots. The intima of the aorta is pro- longed for a short distance into the sac ; in the rest of its extent the wall of the sac is thin, and has torn in .-t:.»rt! f1 I, I- y -ot boeu iihle L of residence ree times in apex Ix'at 4 no murmur, ricle; visible L'ble impulse aland supra- I" pain and wasted, and ocru])ie.s the ' attached to and part of •ntains clots, apcrior <'ava tricle much •ing to apex, ice enlarged anber. Loft eft ventricle id. hypertro- tn. Circura- s ; papillary litral orifice 11 cm. in atous. The f the arch, ;e. Tlie sac t ill led with orta is pro- the rest of has torn in nv \viLij.\.-\r osler/m.i). 13 one or two p]a,.es. The posterior wall of the arcli below mnomnmte :s rough, and nnmennis clots ndhere to it Branches ot arcn normal. Descending aorta thickened and atheromatous. Left ^•agus is strotehed, but can be roaddy dissected away from the back part of tire aneurism. Left recurrent can also be easily followed Nothing of special note in the other organs. ±-Aneurism of Unomina,e-Ru,,ture of 8arcu/ar Dilatation of Aorta into Pericardium. .Tames W., aged 40. Has a: ways been u healthy man, h^hasd^me very l..avy lil^iuginhis work as undertaker Admi ted Aprd 14th, with pulsating tumour under ri<.ht clavicle. sev<.v paroxysms of pain in that re don ; cor^o-h and husky voice. Tumour can be felt on deep pressure nr the episternal pit. liadial pulses equal. Vein.s of ric^h^ ann, and right .side of neck, somewhat enlarged. L.^ Hospital and died suddenly on July 4th Pericardium looks large, and on se.-tion the heart is seen 10 be enveloped m a clot ol blood which, when removed al>out hlled the two hands. Surfaces of membrane natuiS Heart liMy; rioht chambers contn in blood and .dots Left ventricle a little iar.v, Mitval valves thick at the edg^aort. valves opaque ami s,i,i;bu, are compl^l:: ^«^/«.--Ascending portion of arch dilated. especLly in ^>«a^uar pouches Just above pulmonary urL-^^ l^h^ w 11. o these dilatations are very thin, and in one there P "n^imn ^h" 1^-morrhage has taken place in(,> the P icadium. Ihc whole arch is consid.^rably dilated- ^''•' ^'^<""" rough and atheromatous Tlie oriHce ol th,: -annate IS slightly dilau.1, that of. he h!;;e:;.o^ rii I ! m i + ! 1? i .ft 14 I'ATIIOLOUICAT- REPORT. very much so. On tracing up the iunoniiiiiiti', a sac- culated ant'urisui is I'ound spring'inu' iVoiii tht; riuht sidn of tne vi^sscl, with wliich it (tnnmuiiiciites by a Uiiiiow oriiico 2 by IT) ciu. Thr sac is the si/c ol' a hiriie orainic, Riul the cavity is more tlum luili"iilled with denso, dcooloiT- i^od larnintc of libriu. The wall oi" Iho vessel ii])i)(>;ivs to cud a short distance IVom th(! orili.c. The riulu piuniniogastric ucrvc is involved in the wall oi' tht> s;\r. The subclavian and rii>ht carotid arteries are normal. Remarks. — This case is interesting- I'rom the i'art that Dr. Fenwick proposed to ligature th(! carotid and suix'la- viau arteries o)i the left side for the cure of the aneurism, but ws unable to obtain the ]nitient's consent to tlio operation. So far as the aneurism itself was concerned, no case could have been more favourable ; the sae was already half-lilled with dens(> lamintc of librin. and the orifice of communication was small; ])ut tb" saccular povtch(\s atn)Vc the aortic; valves would pro' -..Iv have been a serious element of danger, and mi2,-ht iav»^ bur.st with the increase of pressure after the application of the ligature to the arteries. Death took place suddenly, though the opening into the pericardium was very small, just admitting the head of a pin. ■?. — Aneurism of Splenic Artery — Perfornlion into Transverse Colon. E. C , itit ;!0, (\une undtM- the care of Dr. Drake on Oit. 6th. He had been ill for si'veral months, suffer'' •• 'ih attacks of epigastric i)ain and occasional < n •, :'•; symptoms which hnl his i)hysicians in Nev^ \..kto diagnose gastric ulcer. There was a deep-seated tumour in left hypochondriac region, extending lor some distance into the epigastrium, the dulness of which merged with that of the spleen. There was no ])ulsation, but it was thought The chi voinitinj and, wit bowels, ■ Aiitops when Of from i)er ered in s| loft hypo navel, be: transvers adh(n'ent l)arts aiu aneurism greater c the upper through t dense, laii l)y reci'iit and poste the aorta, mtinicatin through tl the site of the wall, I wall of th normal. 0: is seen at transverse piuggetl w are smooth has given ^ spleen is sn Heart pres( liemnrfcs. 11 BY WILLIAM OSLKR, M.l). 15 thought on one o.-casion that a bmit was heard ovev it The chief symptoms, while under observation, were vomiting, se^-ereepigastrie pain, occasional heinatemesis, and, w>thin the last week, severe ha^morrhagv IVom the bowels, which carried him oil" Ataopsjj, 24 hours after death.-lVlly much swollen, and, when opened, about two pints of iluid were removed from peritoneum; coils of intestines distended and cov- ered m spots with Hakes of lymph. A tumour occupies the left hypochondriac region, and (^xtends to the level of the navel, being situated between the stomach above and the transvei-se colon below, both of which organs are firmly adherent to it. It was removed in connection with these parts and the spleen. On section is seen to be an aneunsmal tumour, about the size of a cocoa-nut The greater curvature of the stomach is closely adherent at the upper part, and the sac was o,)ened by a free incision through this organ. The peripheral part is oc.-upied by dense, laminated hbrin, the central and dep ^^ntreo-ions hy recent clots. The pancreas is adherent co the lower =uul posterior part. On tracing the splenic artery from fh-" aorta, a probe passes directly from it into the sa.' com- municating with the central portion by an oblicme 'canal hrough he lamnuo. The artery is somewhat dilated at he site o rupture and presents an irregular dehciency of the wal beyond which the vessel is thick and runs in the wall 01 he sa<.. The proximal part of the artery is normal. On cleaning out the .sac an oval orific.-, 2 by l-o cm |-s seen at the lower part, whi.'h communic.ates with the transverse colon near the splenic- flexure. It is partially puigged with a fibrinous dot. The edges of the orilic-e ji'o su.oolh. and for a short distance about it the sac wall Jias given way so that the intestine is freely exposed The «pl."en is small and flattened, clo.sely enveloping the .sue' tl''art presents nothing abnormal. Remarks.-Xnemi^xa of the splenic arterv is very raiv PATHOL* i(H( 'AT, REPORT. In thivty-iiinc instiiuccs oi" aneurism of the braucho- of tho abdominal aorta collected by 1a bcrt, it or. mcJ ji, ten. In the present instunee, the situation and lari;' size of the tumoiir, toueth(>r with the absence of pulsation iukI general characters of the syinptoms, did not point tov.iivds aneurism, and the tumour was believed to be splenic. After hearinu' a bruit over th^• mass oi; one ocui was discussed. 4. — ^:maU Amnrism of Renal Arter/j. In a case A't'i stmie arterial degeneration ;nid sliuht contraciion here looks larger than the right, the convolutions are llattened. and not so vascular On section, at th«* level ol the corpus callosum. a larue clot occupies the brain substance immediately externa! to tho lateral ventricle in the left sidi'. involvinjr the i( iilar nucleus, internal capsule, small part oi' the > iiiui.>< opticiis. aiul latc-;'!!y reaching nearly to uuj C". olutions of the central Icb Ft does not penetrate tl'^' curicle. At the base, vessels of the circh' of Willis not •,<•':. romatous. youim- mail. f of the 25th HY WILLIAM n.sLi:i{ M.I). 17 Oi. Iracino- the vcs.spJ.s in ),li,. i,.f( Sylvian 1 1.- 1 i"t with until far in on th 1uIm> close to tilt' anule hef e under surface of tin is.sure, nothini ween 1h parietal th e c» ■ntr; loDc II •Mionvoiutioii.ofthisand appears adherent, and "'i-e a main branch of th on dis.scct e vesse suironndfd by bi'ain sub.sti lou a nodular mass is 111 \vi thin IS 111 contact with the ce in part of its extent, but carefully washiuij;' and r apoplectic reniou Aft er emovinq- it from the brain sub- stance, an oval body is l.-lt, about the si/,> of a cherry and into this th(^ artery appears to pass. On in jectin-v vvat^r into the artery, it escapes from the anterior and upper end 01 the mass, at which point there is a small rent 4 m in length. On slitting- uj) the artery, it is found to 'expand into a small aneurism, about the size of a p.-a with very thiii walls. A braiu-h pass(^s out to the riq-ht not lar Irom where the main vessel enters, so that the aneurism appears as if formed at the fork of a ^•essel The oval mass, which is situated immediately l)evond, and in close connection with the aneurism (indeed, the latter occupies the anterior end of th,> former), is soft, iluctuatin.- with tolerably firm, opaque- white walls. AVhen opeu"ed the contents are reddish-brown in colour, jnilpy, and look like brain matter mixed with blood. After removal of the .-ontents, the cyst is about the size of a ch.^rry • walls 2 111. in thickness. At the anterior end the aneurism projects into it, and the central part of the projection is rough and fibrous, but no communication exists' between the cyst and the aneurism. The Heart is hypertrophied, and there is fusion of two ol the segments of the aortic valves. Described as case u at page 235. U 18 PATHOliOOICAIi REPORT. 'h (b.) — EmhiTteritis and Anenrisnial Dilntalion of Left Verte- bral and first part of Baailar Arteries — Rupture. J. B., agod ;](). a ssaloon-koepor ; Ibund dead in his 1)od. Eighteen months bolore he had been attended by Dr. Roddii'k for a hard chancre, \vhi(!h was followed by- severe secondary symptoms. He had, however, coia- pletely recovered. Body that of a well-bnilt, mnsciilar man. Brain. — In the removal of the organ, a large extravasa- tion is seen at the base, and a considerable amount of sernm escapes. A uniform coagulum extends beneath the arachnoid, from the optic commissure in Iront to the lower part of the medulla l)ehind, concealing all the parts beneath save the ends of the nerves, which pass out through it. Laterally, it extends into the Sylvian fissures ; posteriorly it encircles the medulla, and fills the hinder part of the 4th ventricle, and at the back part ol' the cerebellum it forms a large baggy swelling beneath the arachnoid. It also follows the course of the posterior cerebral and cerebellar arteries, infiltrating the meshes of the pia mater along these vessels. On removing the arachnoid, the clot is found to be thin and superficial o.cr the pons, thicker over the perforated spaces, while over the crura and medulla it forms a thin sheet. On tracing the vessels a very great disparity in size is seen between the vertebral arteries. The left is very small, only 7 m. in circiimference ; the right large, 1-2 cm. in circumference, and with thickened walls. The first part of the basilar is also dilated, and its wall thick and opac|ue. On injecting water into the left vertebral, an oozing is seen just at the i)oint of union of this vessel with the basilar, on the outer side, at a spot where there is a slight promininice on the wall. When the left verte- bral is slit up, it measures at its widest part 17 m,, the coats are thick, intima smooth, liut beneath it are patches of o[)acit; transluce' basilar is; of I his is sized bris artery, th^ the tube i The ca niatous. of ()i)ai'it) Heart i Aorta 1 viscera no On raic features i; conclusion (e.) — Aneu'i Apnph \i. ('., J. over eight( At aixtops) and in nei< aneurisms, cyst. Vesf just beyonc there is a si conununica wall of the th(^ tunics c and inon' i branches of diseased. "T ]{Y WILLIAM OSLEl!, .M.D. 19 of opacity. In soirio places thoiv is a ])eculiar greyish traiislucciicy. Just above where this vessel joins the basilar is a sliallow dilatation on the wiill, and in the centre of this is a small perforation throu-h whi.h an average .sized bristl." can pass. At the central part ol' the l^isillr art.'iy, the interior is much thickened, and the lumen of the tube is considerably narrowed. The carotids are a little stiff, but not evidently athero- matous. The middle cerebrals present a lew small spots of opactity on the intima. Iledrl, is healthy. Aorta not atheromatous. Small arterii-s of various viscera not affected. On microscopical examination there were no special foatur.-s in diseased arteries, which would warrant the conclusion that the process was syphilitic. ■ I {i:.)-Aneurism on Left Middle Cerebral Artery—Old Apnpletic Cyst— Numerous Miliary Aneurisms. \l. ('., ict. f);!), patient of Dr. A. A. Browne's; ill for over eighteen months with obscure cerebral symptoms. At autopsy, old apopletic cyst, with firm walls, in which and ni neighbourii)g brain tissue, were numerous miliary aneurisms. No large dilatations in the vessels ncnir the cyst Vessels at the base very stiff and atheronuitous • just beyond the first division of the left middle cerebral there is a saccular aneurism about the size of a large pea, couununicating with the vessel by a round orifice. The wall of the sac is thick, and appears to be an extension of the tunics of the vessel. It had not ruptured. A smaller aii(lni..iv irregular dilatation exists in one of the main branches of the right middle cerebral. Heart valves not diseased. : W llii! m I .« ^ 20 IWTHOLOniCAI. REPORT. (d.) — Aneurism nj An/c.rior CommiinicnUnii Ih-arir.h of Cirrfe Willis ; Rttfi/ure. Mrs. G., irt. 40, dii'd sixddenly in a shop, and \v;is bioiiuhi to till' dfiid-housc ol th(^ Ilosnit.l. No history v\ ii>i obtaiut'd ol' Ivi iui'Diis > I' lil'v Atdopsi/- — Jjody that ol' a well-iiourish( d woman. No- thiiif? ol' note on external examination. On removiiiij' ihc calvaria dura mater looks natural. When stripped oil. superlieial extravasations are s(»en bouiulinii' Ih" lonoitu- diiuil lissiirt' and extendiim along the sulci. They aiv numerous in the Literal reii-ion in the course ol' the bram hes ol' the Sylvian arteries. When removed, ihf base of thf org-an presents a uniTorm elot extendiiiu beneath the arachnoid from the medulla to th<' oUactory bulbs. The white ends of Uie nerves in-oject throusrh. aiul relieve the otherwise uniformlv dark-red colour. The elot \ asses out the Sylvian lissmes, and covers the upper and latoal surfaces of the cercbcdluni. It forms a thin sheetinp", thiekt'st over chiasma. It has not Imi^t throuy-h the ara( hnoid at any point. The dot wuh eare- fuUy brushed away ami tlu- v.'ssels inepeoted. They are not thickened, but present one or two small spots of atheroma on the i isilar uiid mi die cerebrals. A slight fulness was notict u about the anterior communicatiiis- artery, and on injecting- water with a hypodermic syrintiv through the carotid, it Uowed out in a tiny f-tream from the front of this vessel, revealing at the saun> time a small aneurismal dilatation springing fr--, . it. The circle of Willis was then carel'villy rei* oved. washed, and sprt-ad upon a glass plate ; the anton c( iraunieating '"vy is seen to be very wide, and pr cti Irom it, between the anterior cerebrals, is a aneurismal pouch, about tin- -ize of a small split pea. Its walls are very thin, and on its under surface there is a small slit-like ruiiture 15 m. m length. When opened from the anterior communicating artery, i tow rds small apt muuicati them sm Other iouiid : i Xothii Abdomen intestinei Tlvrax, \ Hearf of laru-e, 13- frcni ath( Kiilneijs i loosely a I displaced liemnrh iial arter ten years collect an Thus. Dr. Dr. Barth( and lastl) The point coiuiectioi •'oinparati disease, a; stati'uient persons is intra-crau: 1. I'i'iiti vh 2. Am. .J..II ."!. S(. Tiion 4. tiiiv's \' • V'l m WILLIAM OSr.HIJ, .\LD. 21 ( of rirr/e iiud Was lan. No- oviiiu,- 1 he ippt'd (»II. !' lon^'itu- They tivc 3t' of the [)V(!(1, the >xtendiiiu olIiK'tovy thvouirh. d coldur, ;ovors the [t Ibnas a not hiii'st WHS I ■lire- They are spots of A .slia-ht uiiicatiiisi' ic syriimv earn IVom le a siuaJl circh' of id spread •■■ry is twt'eu the the ^i/e of ud on its la m. in luuicaliiig artery, a small smooth-walled sac is seen, very thin tow ids the anterior part. On the npprr wall there is a small spot of atheroma, and another on the anterior com- municating; they are srreyish-whlte inVolonr, intima over them smooth. Other vt>s.sels carelully examined, ])ut nothing special found : the strio-lenticular arteries were much eoilerl. Xotluug special was IWund in the dissection of the Ah'/omen: la.teals beautilully injected with chyle over intestines— duodenum and jejunum— ai.'i mesentery. In Thorax, vis,era normal ; right lung univrsallv adherent, //^rtr/ of iMtural si/.': valves normal. Tricuspid orifice huge, 13-5 cm. in '•ircumter.n.v. Aorfa rou-h and uneven fr<.ni atheromatous change; branches not much allected. Ki)0 I'ATIlOLOt^ICAI, IIKI'OKT. 8('(iut'nt observers; ami in Vnsv a I remarked to my class bel(»re proceedinji" v 'tli I lie Mutopsy. on I lie prol)iil)ility ni lindinu' ii ruptured eerebiul aneurism, as the lad was kn(»\vn to have heart disease. The embojie oriiiiuol' these aneurisms has been discussed of late, and is probaldy true in those associated with endo- carditis. The frequency with which they occur withh^art disease, — -J.") out of ,Si) in Dr. Peacock's table, the prefci- enee displayed for the arteries of the left side, and the occiirrence of accompitnyinu' embolic lesions in the spleen aiul kidneys are su^iicstive facts. The way in wliiih embolism causes aneurism has n(»t been determined. The view commonly advanced is that the arterial wall is softened at the point of pluLi<.>ing- and i^-radually dilates. Vonlick thinks that the hard particles of a calcareous embolus injure the wall and weaki'ii it; Goodhart,' on llif other hand, believes that the embolus is, in the majority of cases, derived from an ulcerative endocarditis, and carries with it infective properties, leading to inllamniaiicui and sol'teninii' oi the arteiial wall. In Case a the connection of the aneurism with a cyst is worth notinii'. Was this cyst the result oi an embolus ,' It looked very much like a spot of redsofteninu' in process of healiim-, and the sac of the aneurism projects directly into it. while passing- out, somewhat at right angles, is the continuation of the vessel. It is too large to have be 'ii caused by the i)ressure of the aneurism itself. I am inclined to think that it preceded the ibrmation of [\u- aneurism, in which case it has probably resxxlted from ;ui embolus plugging a branch of the vcsstd at this point. Of live cases of intra-cranial aiu'urisms which have come under my notice, Case a snii 2. Path. S«if. Trunsiictioiis. 1877. \% i n\ NVIMWAM OSLKR, M.I) 28 I) my clusK. >l»iil»ility of ' liid Was I discussed with <'ii()(i- with hi'iirt the pn'ti'f- lo, iiiul lllr the spleen in w liirh lined. The iid Willi i,s dly dilates. calcareous lart,' on the le majority rditis, aiul ilammatinii .villi a ey^t II embolus .' >• in process cts directly iig-les, is the have be; '11 •, —Cavities at ai)ices: that of left luno' the size of a lara-e orano'e. thin-walled, and presents at its lower and n.Mer a.spect, dose to the root of the lun- an aneurismal dilatation ol a branch of the pulmonary artery. It is as lai-e as a marble, and is quite close to the main trunk of the artery, beiny o-jven olf directly from one of the three mam sub-divisions going- to the ujiper lobe. The oriliee ol th.' sac is laro-er than a goose ,|uill. It lies in a deiinite hollow, whi.-h looks as U' it might have been luriued by the constant throbbiugof the sac. It measures 2-8 em in leiiuth, 45 cm. in circumference. The portion near the root IS covered with the lining membrane of the cavity and two small trabecuhe cross it. The auierior portion'looks arhM-ial m character. At th.> apex there is a small lacer- ation throug-h which water jlows into the cavity when "ll'-cted into the sac. On the under surface of the sac " a small spot of ulceration with a yellow base. 31 1: ! * . t \-l /«.f/ **/ .r*»..^c.^ . ^ ;^ ^^z/' rirC ;/!, S^f i « '! 'f 11 24 PATH,■) cm. in length, 1-S cm. in width, lying with its long axis transversely to that of the thorax. Its anteri(n' surface is .smooth, rounded, and internally is thickened by laniiiKo of iibrin. The posterior surface is very thin and presfiiis several small openings, through which the ha-morrhauv had taken place. 7. — Two cases of I]/jpf'rfm/)hij of f/ie Heart. (fi.) AVilliani B.. ;el. (io. a large, powerfully built man, carpenter by trade, was admitted \nU> the Hospital Sept, 18th, complaining of cough and dyspnuni. Has been a healthy man, accustomed all his life to hard work, and until about two years ago had drunk freely. In Octolicv. ISTT, cauu'ht I'old from wearing wet clothes, and was oil wmk for live weeks. In May was laid uj) with cough, and had, at the same time, swelled feet. Was in Hospital lV)r iivi' weeks. Has worked (■- fully 1-5 cm. outside of nipide line. Action rapid; sounds mutlied ; no murmur. Uritu? rather dark-coloured; no albumen. He has a trou])lesoine and lVe(iuent hacking- cough: expectoration of a livight red colour and lik^ currant Jelly. Sits up in bed most of tln^ time. Logs thisis. 'ath ^v. at I he apt'x. el ol' tlie loot, .1 ol" sol't rlois. ail aueurismal il in f^liapt', 2-.') its long- axis nior t^ui-riici' is ed l>y laiuiiia> u and presents e htrmorvluiuv Ilearf. lly built man, Hospital Siipt, ,. Has been a work, nnd until . Octolx'v, 1S77, [ was oil work 'ougli, and had, ospitai for livi' that time uiilil o'ivo ui> on elk'd foot. n. ; expansion, ;iou ovor hums 1 extends fully iai)id ; sounds k-coloured; no .Mjuont hacking olour ;nid Hko iu^ time. Li'gs BV WII.I.I.VM OSMiR, M.D. 25 •and feet rodematons ; (small amount of fluid in the belly. On 24th dull and heavy ; dyspnaa more urg-ent. Expecto- ration bloody. In evening became in.sensible, almost pulse- less, and extremities cold. From this state he was roused with stimulants. 25th.— Insensible and quiet. Oedema is ext(>nding. Expi^ctoration remains the same. Dyspnoea bi'came more exaggerated, and he died on the 20th. At/ tops,//. —Body presents the appearance of a man dead of heart disease. In abdomen, small amount of Ikiid. In right pleura, GO oz. ; in left, 30 oz. clear serum. In pericardium, 8 oz. Heart large, weighs 710 grams, (ca. 25 oz.) Right cham- bers distended with large, jelly-like clots. Ventricde dilated, measuring from pulmonary ring to apex, 12 em. Circum- ferenee, midway between pulmonary ring and apex, 12 cm. Tricuspid orihoe dilated, 15 cm. in circumference" Segments of valve healthy; pulmonary valves normal. Left auricle large, and contains blood, with clots. Left ventricle dilated and contains gelatinous clots; those about the trabecule are colourless. Length of chamber from aortic ring to apex, 10 cm. ; circumference, at middle, 17-5 cm. Anterior wall, central part, 22 cm. in thickness! PapiJiary muscles a little fibroid at apices. Mitral orifice 12o cm i!> circumference; valves a little thickened at edges. Aortic ring 82 cm. in circumference; valves competent, a little thickened, and one calcareous nodule at attached margin. Muscle substance is somewhat pale ; fibres are moderately fatty, and present also many brown granules. Aorta is not dilated; 5 cm. above \aWe it measures 87 cm. in circumference; intima smooth, not atheromatous in as.-ending part of arch. A few patches in transverse part of arch, and in thoracic portion, and a large one in right common iliac. Lungs present large spots of apoplexy. Anterior borders emphysematous. Tissue on section presents coarse appear- ance of brown atrophy. Ij: ? >■=■ J i , h' rMi I'l « s i JIJ 26 PATIIOLOUI("AL llEPOHT Kidnei/s. — lli<>'ht 130 grams.; li^l't, 17;'). Ctips^il.'s (litnch with slig-ht difliciilty ; surlacos a litlli^ piick^i'Md :mi,1 irrogular. Several cysts the siz(> oi' iiiar])lcs. ( )u s.( i|,,)i rorlii'fs not diminished; vessels full; small ;i:t'iiis moderately distinct. Liver, nutmeu'. Brain pri's^'nts notliing rd)normal ; arteries at lui^o opa(|ue, hut not rigid. {h.) Tlionias L., ;el. (if^, a slr(niu', Avell-built man lor his age, carpenter by trade, was admitted to hospital Mav Uih, with shortness ol breath, cough, and amisarca. Has always ])oen a healthy man ; worked hard at his ti'adi> ; no hisiijiv ol' intemperance, llogan to be troubled with short iicsxil l»reath upon exertion about a ye;ir ago. Six months jnist feet began to swell, and he had oiten to sit up at nidii in order to breathe freely ; spat a little blood at this limo, Becoming worse, was admitted to hospital in Sep'ci'nil)rv for heart disease, and ^vas discharged in six weeks much improved. Has not been ai)l(^ to do much Work duviii;;' the winter, on account of the shortness of l)reath. About a mouth ago liis legs beo'an to swell, and since ih.)i ili.' dropsy has gradually extended. When admitted, diop.-y of legs, scrotum, and belly. In chest, signs of eHiision into pleura behind Percussion dear over antei'idv pints of lungs. Heart dulness extends as high as ii])jicr bi»i'il'r of third rib; diastolic inuiinur heard at thebasf. Aiieriis atheromatous. I'riiu^ in normal quaiitities ; iiiu'f of alliumen. Chest was ta])ped on two o<'casions, and lu' hd't the hospital on Aug. lOtli, much improv(Ml, On Ort. 11th, he was admitted moribund, ami died the nr; libres are iatty and m a state of brown atrophy. Z««/neps.~\li^ht wei-hs 173 grams. ; capsule not adheivnt ' surlace smooth: on section, cort.-x in good proportion' small arteries at base of pyramids not very distinct , no cysts. Lelt oru'an smaller, weiu'hs KJO grams. Tapsulo detaches readily : surface presents numerous small cyf ts On section, certain areas of cortex are riddled with small cysts. Pyramids look natural. Liver, nutmeg-. Nothin- special ni other org,-,ns. Smaller arteri.^s of the body atheromatous, not calcareous. A'mrt,-/.-,s-.— Fatal cases of heart disease are met with now and then in which it is exceedingly diilicult to accoiuit, in a satislartory manner, for the occurren(-e of the hyper- trophy and dilatation. The patients die \vith all" the symptoms of chronic valvular diseas.'— dy.spn(pa, dropsy, li;f'Hi..ptysis (S:c. At the autopsy there is no alfection of the valves, perhaps only moderate arterial deu-eneration. th" kidneys are not specially fibroid, and there is not .^ufhcient pulmonary trouble to account for the general 28 PATHOLOGICAL KKPORT. hypertrophy ol' the heart. Three such eases have come under my notice in the past three years and I have another at jn-esent under observation. In th(> two cases just reported, neitlier the condition oi' the valves of the heart, of the hina-s. or of the kidneys, afford satisfactory ground for sui>posino- that rhe hypertrophy and dilatation were caused by any interference with the functions ol' these organs. In the first casj one kidney was reduced in size, and the surface of both were a little puckered ; the lun cm. neither cuse. I the increased > oi' th(>. usual Dns are there rise to hyper- iases ^ There 'hich appears an, as in cases se. and keep up, a niiiy lead to It is in this Li! explanation :ircumstances HV W II.MA.M OSLEIJ, M.l). o\} severe muscular c-xertioii takes a p,,,mincnt place, and the writings ot Albutt, Meyers, DnC'ostn, Seitz and others on the subject leave no room lor doubt thnt hypertrophy oi the heart may arise IVom this cause. J have dealt with the question at length in commenting on the lirst ease referred to ', which resem])l..d these in the absence of valvular disease and the method of termination, and which c'curred in a very powerfully built man fad 38) of mtemperate habits, an old soldier, and a blacksmith by oc'upation. In the .'ases here reported, the patients were large, muscular men, carpenters by trade; one of intem- perate habits, the other doubtful ; no history of syphilis and It appears quite legitimate to connehy of the heart are abs.mt ; more particularly with th.> eviden.e collected in favour of this view by the above named gentlemen. Having so recently written on the subject, in thepaner ivteri'od to, I will not again, at present, enter into the .,-i,;s. ii-.i^^t U...I. — :/hlood. In trachea, there are small clots and frothy blood. The mucous membrane is thickened, rough, and irregular, particularly towards the bifurcation, and whole tube looks unusually thick andstilf. The orilices of the mucous "•lands are very distinct. On slitting up the bronchi, the left is found filled wath clots and blood ; the riyht is almost free. When washed, the mucous membrane, parti- cularly that of the left, is miich thickened — 2 to 3 m. — and rough from the projection of little masses like coarse granulations, which are more numerous on the posterior than tlie anterior parts. The nudn division of tht^ h^ft bronchus, with its branches passing to the upper lobi; is specially ailected, and the granulations are very numerous and large it the points of bifurcation. On the upper and outer wall of this division of the left bronchus, just before its bifurcation into the tubes for the ui)per lobe, there is ii reddish spot on the mucosa. 7 la. in diameter, projpi'tiiii^- slightly towards the lumen of the bronchus, and lor a i;y willia.-\i osi.kh. m d. ;]1 [ \vill only .ight he r(!- th Traiibe, tnon cause, f miiscuhir ' Left Bron- ronic Bron- 'cral years, I dyspuu'a. Never had ^pril, 1879, )ver a pint, lood. The irregular, ^holo tube ;he mucous ronehi. the le right is rane, parti- i 3 rn. — and like coarse e posterior of the left per lobe is • numerous upi)er and just before ', there is a jirojeftini:;' , and lor a millimetre or more about it the niu.o.sa appears ulcerated. The re(hlish spot is comiws^'d of a soft yielding membrane, the surlaee of vvliicii is alitti > rough, and when de])ressed it is below the level of the bronchial niueous membrane, and looks like a small ulc-r upoi- it. The loss of .substance is b(^st seen at the edges, and here the cartilages are seen to be delicient. On in.speetion it is found that this reddish membrane forms a septum between the bronchus and the pulmona.'y artery, and, at the lower part, rupture has taken place by a slit-like orifice 2'5 m in leno-th. From the side of the artery -left branch, main divisLi, clo.se to bifurcation— there is seen a circular reddish spot on the yellowish-white intima,5 in. in diam(>ter. a little depressed, moml)rane roughened, but not covered with lil)rin, and at its lower margin is the slit above referred to. I/^w^"*'.— The left presents a thickened pleura over upper lobe; on section this part presents three cavities of moderate size, in communication with dilated bronchi • and all containing clots. The anterior margin is firm' contains groups of tubercles, the surrounding tissue being 111 a state of gelatinous infiltration. J.ower'lobe in latter region presents an infarction the size of a walnut, some- what triangular in shape, brownish-red in colour, dry, not softening, and the pleura over it inflamed. On slitting up the branch of the pulmonary artery i)assing to this part, one or two roughened spots are seen on the intiina, but they do not look recent. The embolus was not discovered. The rest of this lobe is emphysematous. The right lung is large, borders rounded, tissue sponoy and soft to the touch. On st^ction there are a few croups of tubeivles scattered through the lobes, and the^tissue is extremely emphysematous. iZear/.-Right ventricle moderately hypertrophied, and tricuspid orifice dilated. Spleen enlarged, weighs 383 grams. I I ., 3S I'ATllOLt)(lU!Ali REI'ORT. it. — Itishtniv. of four PuhuDuar/j Valves. Till' case iVoin wliiili this speciiiicii was obtaiiKMl, pri'- senti'd no I'catures ol" s|)('c'ial interest. Pulmonary riii"- measures 7 cm. in cireumlorenee, and is provided with lour well-tbrnied valves. They ;irc smaller than normal, measxiring- respectively 2, 1-8, 1-S, and 14 cm. alonu' the Ireo border. The largest one is a little thickened ; all are fenestrated ; two of them present at both ang'les very large perlbrations. {1 10.- -Bayonet Wound of Left Subclavian Artery at its Orlfj^in. J. McE., aged 24, stal)bed with a bayonet on the eve of the 12th of July, by one of the Volunteer guards at the City Hall. On external inspection, the only i)oint of note is a wound 2 by 1 cm., situated in front, and a little to the outer side, of the external axillary fold. The edges are contused and lacerated, and, on pressure, blood exudes. On removing the sternum, left pleural sac is found lull of blood, partly coagulated, of which two qiuuts wcic removed. The lung was compressed and llattened. On tracing the exteriud wound it is found to penetrate part of the deltoid muscle, passing just in front of the axillary vein, then beneath the pectoralis minor, and enters the chest immediately below the 1st rib, 7 cm. from the ster- num, grooving the border. It then i)asses directly through the upper lobe of the lung, i>enetrates the pleura covering the posterior mediastinum, aiul cuts across the left sub- clavian artery 12 cm. from its origin on the arch, severing the vessel in three-iourths of its extent. The tissues ol' the i)osterior mediastinum are iniiltrated with blood. T? HY \VII,I,1A.M OSLEi;, M.D. 33 «l Jucd, ](ri'- ■ence, uiul They iiiv J, 1-8, VH, one is ;i m present ils Origin. the eve of fds lit the note is a '. little to riie edges 'd exudes, "omul lull irts were ued. (hi ite piirt of ^ axillary uter.s the tli'^ ster- f through , covering lel't sul)- , stn'ering tissues of lood. in phlheria—Siidden W.— FnUif Degeiieralion of He, Death on the thirteenth dai/. I-:. A., iPt. 11; iuluiitted. under Dr. R„s8, on lOth of January, with diphtheria ; meu.bran.. upon tonsils, uvula, uiul pillars ot iauces ; i)ulsi-. 120 : teini)eraturo 104° ]]v the 24th the. throat had almost healed, temperature norm. ; voice is uasnl, and there is u slij^ht regurgitation ol JIuids through nostrils. 25/A.-Not s(, well, is irritable and restless : skin oI' le-s l)articularly on I'ront ol' thighs, Ayy/.e,,.,Me<^V,•. Temperature normal. At 5-30 P.M., after sitting up on the bed-pan lor a few moments, gave a long sigh and fell back dead. Autupsy.-Uxrynx and pharynx free from exudation Heart moderatcdy contracted ; valves normal. Rio-ht auricle contains a large, white, tolerably firm clot, which almost Iills the chamber, and extends into the correspond- ing ventricle. It does not pass into the pulmonary artery Muscle substance of fairly good colour, but when exam- ined ^vlth the microscope is found in a state of advanced latty degeneration. Very many of the fibres appear made up of closely set, dark, flit granules, no trace of contractile substance remaining ; in others the process is loss advanced, but I have never seen more extreme dcoeneration than is shown by numerous fibres from the ventrich; in this case. Kiilneys moderately congested. n — Tioo Cases of Thrombosis of Pulmonary Artery. {^Fracture of VateHa-Pleuro-Pneumonia (?) seven ^oeeks after— Thrombosis of Pulmonary Artery. Dr. iJodger. und furnished note bet'ii condensed er whose care the i^ati of the case, from which the foil patient was, has owing has I! HI I w :i 34 I'ArilOLoCK'AF, UKl'OUT. J. 13., ;pt. 4 ■") ; ;i tiill, ijoworfiilly-bviilt man. Fnicturt'd his patt'llaou the i>()th ol' Decern I »(!r. On 4th of Fobniary initial .symptoms of pleurisy : moderate lever ; respn-a- tions 40. On the 5^/<, faiut pleuritic friction on riyhi side posteriorly and a few rales. T//<.— Temperature 100 8': Is restless ajid complains of a sense of sullbcation or tightness in the chest, and difficulty of breathing has incroas('d. No duliu'ss to be deterted ])osteriorly. lOiii. — Still complains of sense of tiu'htness on chest, lias continued feverish. Temperature to-day 101'. Pain in side very severe ; had a hypodermic of morphia in the evening'. K'espirations 40 in the minute. 12//*.— Had a bad niuht. Temperature, 102-8'; respirations, .10. Diminished re.sonnnce at angles of s.'apuhe ; breath sounds indefinite. Heart's actioji tumultuous; no murmur. Hud a slight syncoi:i! attack in the afternoon on sittinu' up. 14^//. — Summ<. size. Right auricle contains a gela- tinous clot, dccolovTi'ized at upper part. Chambi'r does not appear distended ; endocardium is stained, liight ventricle contains a small, tolerably firm, bull-coloured clot, closely interwoven with the chordic tendinetc ; there is also a small quantity of dark blood. Valves normal. u ; sci'-iiu'iits tains a g'chi- m WIIW.IAM ()SL|. K, M.li Triiiispid orilicp of uuh\ nul I 'rule MX |)ulinonary urtcvy a lirin throml bciiiy adhrrcnt to iln' ] right and Iri't brand On slitting- up the it>- o(TU|,i,.s lli(> trunk, "W.'r wall; it rxtcn.! into ih.'^ hut is closely udhcivnt wl "'s, not <'ntiri'ly lilliii- tlu.ji- J umina. i''iv It i.s i)i cnni-.ui with ll intinia,. On lurtlior dissect ion, thr thrombi can 1 10 nilo )c Iblh nuany ol' the bran. -lies ol' the P.vd and 4th dou They tiro all reddish-brown in adherent to the walls, not 1 consistence ihrouii-hout. Lelt '■"lour, iinu, more or less iniinaJ.'d, and of k-all lev amount ol' Ijlood. Notl auriili' contains a snmll small clot fills the mitral orifh-e In liiohi Pleura, hall' iini>' s])eeial aboui loli ventrich over low<'r lob(^ ol' the 1 [)arit •tal 1 lyr. One (,r I I'ini (.r turbid unu- and on the c !iim. orr. i rymj)h U])per lobi'. two siiial pa the corrc's])ondijiy er lobes fi'cj.ilaiil and (.r Jiig'ht lower lobe is 1 On section a quunlitv ol" bh icavv, am snrhice. . ami i liuhter red col suh-plcural ini 1 dark md i'ood colour in colour posli-rioriy n one or two spots iheii serum oozes IVom th( our, as il'b ■ssue is lirm and ol' a u ccomino- hepalized X,» localized ,sli ihtly ctions. Lelt hnvei' 1 obe als( cr( Nothinti' ol' not pi taut. No hepatixati > o lymph. I black col the upper Lf-fl Lu serum. 1 w 'Ige-sh; artery i)i i Both orj Kidneys the cortict Arteries dilated. Remarks interest, and on loc and Tram l're(|uently a healthy and did wi of pleurisy of tightnef continued heart's act: must supp formation < breathing i by it, as th trouble. In the .V kidneys, sti to the Hosi lung, and c satisfactory perhaps, in dislodged fi HY WILLIAM OSLEIt. M.l). 37 si e raoruiDu' Pleura covoring- it is turl.id and pres^nls a f.-xv llakos of lymph. Oil section, th(> iissue is lirm, of a de..p. purple- black colour, and in a state of liMnuorrliao-i,. infarction • the uppor margin of the lo.).' is slightly crepitant. Wt LuKf/ is crepitant, and contains much blood and .serum. At th(> anterior margin of lower lobe there is a w dge-shapcd infarction, and the branch ol' the pulmonary artery in it contains a thrombus. Both organs emphysematous. Kidneys small, fibroid, and pr.vsent numerous cysts in the cortical regions. Arteries are atheromatous ; arch of aorta is slin-htly dilated. ° ■' Remarks.-Those two ,;ases present several points of interest The cause of the thrombosis in both is obsure and on looking over the reports of cases in the Journals' and rransactions, I have been surprised to find how h-equently the same admission is made. In the first case a healthy man fractures his patellt, on December 20th' and did well until the 4th of February, when symptoms pleurisy set m, with moderate fever. On 7th, sensation of tightness in chest and difficulty of breathin- which continued for a week; re.sp rations 40 to 45 per minute • hearts action tumultuous. Death sudden, on 14th We must suppose the thrombus to have been in process of iormation during the week preceding death, and the rapid breathing and sense of suffocation were probably caused by 1 , as they were quite out of proportion to the pleuritic trouble. In the sec-ond case, an old woman with contracted kidneys stitF arteries and hypertrophied heart, is brought the Hospital with consolidation of lower lobe of ri-ht lung, and dies in 36 hours. In neither case is there a'ny satisfactory reason for the occurrence of the thrombosis porhaps, in Case b., a fibrinou.s <.oncretion may have been dislodged from between the musculi pectinati of the ri-ht (■■ V 88 PATIIOLOCICAL REPORT. auricle, iind pluggt^d th<' branch of the piUmonary artiMv passing- to the right lower lobe, but the appearance of the obstructing cbt was that of a thrombus. The occurrence of h;emorrhagic infarction in one c ,ise and its a'osence in the other is noteworthy, but ii: would take too long to enter here upon the eonsideration of the explanation oilered of this interesting but not unconinion peculiarity. ItESPIllATORY SYSTEM. A.— (Edema of Right Lung; Il/jdrolhorax of Left Pleura— Contracted Kidne//s. R. F , a stoitt, old man, was sent to the Hospital from the House of Ilefug<\ suffering from dyspnoea, which became more and more itrgent. He refused all treatment. and died within 30 hours of admission. AutopsT/. — Slight (cdema of legs. Five pints of clear fluid in left ph^ura ; on right side membranes are intimately united. Heart.— Chamhn's on right side filled with par- tially decolou/i/ed. Tricusjnd orifice dilateu. Loft ventricle moderately hypertrophied. Valves compettnit Lnngs. — Left, emphysematous at apex and anterior border. Lower lobe collapsed, and dark in colour. On section, a moderate quantity of serous iluid escapes from upper part of the organ. Pleura o^-r it smooth. TJight, large, heavy, and sodd»m, pits on pressure, and when handled crepitates faintly. The pleuritic adhesions, which entirely cover it, ani infiltrated with serum. On section, entire organ from apex to base intensely ccdematous, quantities of clear fluid flowing from the cut surface. Blood vessels are not injected, but the tissue has a trans- lucent gelatinous look from the amount of serous infiltra- tion. BY WILLIAM OSLER, M.l). 3!> Kidneys -Bimhxish.d \n size ; sub.staiue xwy firm Cortioes sli^hdy wasted. Small arteries moderately pro- miuejit ^^Aorla very atheromatous; small arteri.vs thickened and 2.~(Eaema of Left Lung-Morphia Poisonin ^'■• ufh i-" '? f I^i^appeared on Saturday, December 14th found m his own shed, lying coiled up at the bottom ; f^sK on Im left side, u'ith a sheet drawn over him Auops^.-Uody that of a tall, museular man. l.imbs stiff rom the frost. Faee suffused. Sli^U post-n^orlent discolouration of the skin. In thorax, a few adhesions hetwn the pleural m.-m- braiies on both sides. //e«r^ of normal si.e ; right chambers distended with ul, joint. Right ventricle is dilat.d, walls relaxed ; c-lots a e partially dcH.olourix.l, and extend into the pulmonary aituy. Left chambers contain very little blood ; ventricle contracted, walls thick, cavity small. Valves n;rmal Aorta contains !>lood ; inlima not stained J!'T~^i^^'' ?T'''' ^^^^•^^^^^^-"t ; some cBdema in blood Left, heavy, dark-purplish in colour, non-crepitant except a anterior margins. Pleura smooth. On inflation,' air A esicles expand m places. Portions excised sink On section, an extraordinary quantity of bloody serum scapes and the tissue has a gelatinous, infiltrated appear- a».e Surface is smooth, not granular, and of a deep- duret colour. It presents a remarkable eontrast to the other lung. Bronchi contain frothy serum ^^:i^:'' "'"^ ^"^^^"^^ '' ^^^"^ ^-^ --- ^^-^ Nothing special in the other viscera or in the brain. 40 rATlIOLOdlC.Vh UEI'ORT. 'ii In the antilysis of the contents of the stomach ■& small amonni of morphia was found. Remarks. — The condition of the left Inng in this case was remarkable. I have never before seen an oruan .so infiltrated with bloody sernm ; it had a uniform purplish- red, Li'elatinous appearance, except at anterior border. Death undoubtedly was caused by morphia; and the only explanation which sug-gests itself of thc^ condition of the lung is, that, lying coiled up on his left side, he wont to sleei) lender the influence of the drug and death took place slowly. The gradually weakened heart propelled feeble charges into the pulmonary artery, and })y hypostasis an increasing quantity reached the left lung, until a state of extreme congestive ccdema was produced. Medico-lcaally the case is interesting. In a subsiHjuent case of mor])hia poisoning — during a pneumonia — there was no special cx?dema at bases of lung's. S'l V 3. — Pntvmonia — Ulcerative Endocardilis — Meningitis. Mary — , tct. 20 ; admitted October 22nd in an uncon- scious state. History of attack defective; but she had been drinking hard. When examined, on 28rd, she was unconscious ; pupils moderately dilated. No twitchings or paralysis, t^light dulness at right apex, with rales. Temperature, 104^ She remained in this state on the 24th and 25th. Systoli<* murmur over heart. On the 2(Jth temperature went uj^ to 107°, and death took place in the afternoon. ♦ Autopsy. — Lungs. — liight, heavy and firm, particularly in uppi^r parts. On section, upper lobe, with exception of extreme apex, in state of red hepatization ; surface bathed with a blood-tinged serum, and ai^; v sides filled with visible granules. Tovva>'-'' the anterior border the process is more advanced, the :is.sue grey in colour, and bathed with a 'iS, T m WIIJ.IA.M (iSI.Ki;. M.u. 41 8.TO.purulojil llui.l. Uppoi- part .,1' i„w..r lob,, also hopa- tv/A'd; lower part coiitivstcd aii(l,i>,UMuatou.s, and srattcred areas of consolidation an' sen in it . Leir or-an cropitant throughout; con-ested and (rdcMuatous in p..st,.rior parts. Hear/.—U>l\ ventricle oi" normal size, walls a little thicker than natural ; endocardium smooth and olistonin- Endocardium on ventricular surlUce of antcrio"- segiuent of mitral valve is granular, being covered with minute vegetations. Towards the right side of the valve they are larger and extend to some of the chorda- lendine;e, passino- down the entire length of several of them. On the auricular surfa<>e of the valve there is a soft, white patch, 1 by 1-2 cm., covered in part by a thin membrane, and in rest of extent rough and divided into a number of (devated pro- je sinuses of Valsalva are several small pouches of the arterial wall, the largest the size of a marble. The intima about them is swollen and translu- cent; that of the arch is normal, with exception of patches of g»-latinous sw.dling in neighbourhood of oToat vessels £mm.-Nothing of not.> about soft parts'^or calvaria ■ dura mater normal. On removal of organ, tissues at thJ base appear somcAvhat matted together, and there is a slight opacity and thickening of the membranes in front ol the commissure, and along the longitudinal fissure. Over perforated spaces arachnoid is clear, ])ut the pia mater is (edematous. Sylvian fissures opened with difficulty. No lyini)h at the base ; arteries are full. On removing dura mater th(> cort(>x presents patches of lymph arranged somewhat symmetrically on the hemispheres, chiefly in neighbourhood of longitudinal fissure. Elonii-ated patches exist on the ist and 2nd frontal convolutions of left side, and another along the fissure of Rolando. On the right side, in the latter situation, is a much larger patch. About :! * ^i ! ' ' I ! a 42 PATII0LO(iU".VL UEPORT. hM them thovo is a good dfiil of <>vliitinous oedema of the membranes. Vessels of pia mater are full, the small ones over the convolutions very distinct. The sulci are hntiid and the memliranes covcn-ing them aKlematous. At pos- terior maryiu of corpus callosum and extending on to the upper surliiee of cerebellum is a thick layer of lymph. On slicing the organ, substance moist, of good consistence. Nothing special in the ventricles. Remarks. — The occurrence of miMiingitis in pneumoiiia is, in th(> <>xperience of English writers, a rare eomplica- tiou. Huguenin,' however, states that it is not uncommon in Zurich. A similar case to the present is reported in the Pathological iieport for 77-78. In both the inflam- mation was of the upper part of the right lung, and in both the patients had been subjected to depressino- influences. It is a common experience here that ajx'x pneumonia in debilitated j^ersons is very often accom- panied with delirium, usually of an ai-tive character, hi the cases referred to it was more of the nature of deep stupor ; no special head pain was complained of in eitlier ; and they bear out in this respect the diagnostic projio.si- tion laid down by Traube, ' in comrai'uting on a case very similar to the one here rejwrted, that " in the course of pneumonia a meningitis may develop without headache, and which gives intimation of its presence only through deep stupor." Huguenin deals with these secondary inflammations of the meninges under the term " metastatic," and suguvsts that in pneumonia "the puriform, broken-down material gets into the arterial current, is carried by it to the pia, and there sets up purulent inllannnation.' in the majoritv of cases, he states that the i)neumonia was in the stage of purulent infiltration. In the instance here recorded the 1. Ziernsscu's Encyclopedia. Bd. xii. 2. Gesamellto Beitiagc. Bd. iii., 42G. 18T8. 1!V WIMJ'M osi.Ei;, AI.D. 43 affoc eel purf ol thHun,. xv,..s .hiHIy iu .1.,. «u..x. ol' .vd l..Ta.x.n.>n;nMh.M.,h.rc.s.n.(VM..d,o, entirely so. It m^ '- ' -^ ^i- m.M.n.^.tis vvns s.c..ndary .o nuMil -emtivo .uiooaMjn. n. .1..,. .... ,. .,,,,,,. .,,^„^ ^^ ^^^^^.^ For another a.ul, perhaps, n.oiv plau«ii,i. view of th. natun-o those s.-oudary meuinuoal alii-ctions, s,v papor In Dr. (.nvMlu.ld ,n S,. Tho,aas-s Ho.spital Kopo.ts. 1878 4.— r„ettnwmc P/ilhisis. Cfeorce August 20th^ with lover, ,.ough and weakne.ss. Que SIS or diod of oonsumption. Was .olorahly well up to thr .; weoks l.oloro his adu^ission, whou he g-ot a severe wetting, smoo whzch time ho has boon foohno- verj^ 11 He did not '■ lay up," hut attended as an out-door patient moma ot the ordinary type. During September he had high lover, night sweats, cou.hed a great deal, and unde, Dr. koss s care, there wore signs of a large cavity t he apex while over the rest of the lung there were dulnossand leeble blowing breathing. Th!> lever per- sisted and the prostration bocanie more marked; dtath took place on Octol,or l!)th from ha-moptysis J«.o;.s^. Nothing of special note in inspoetion of abdomen and thorax. Luugs.~Le^t, pleura thiekoned; layers united at .ne^ cove,., with .cent ,y„,h in laU^l Je,io„"" ot™ m , .' 1 nd heavy, wo>8h„,o. 1.490 gramx. On .section a large o tj ,s e^cposed at the ajx-x, containing clots and a h:*t7 ^^™'■^ Slutino„.sp„.. Tl:e wdl. areexceedt Sb m .8.„h,r, hued by .ongh. .a^eotu masses, and crossed on any of the vessels detected. The cavity oeenpics about 44 PATlIOhOdli' \l. REPORT. a tliivcl of iht^ u]ipt'r lobe. Tht rest of tin* ori>';m is linn iiiid airlt'ss, witli ihc exception oi' ii small margin at Iowit part. On section it presents a unilorm, opaque-whito coloiTV ; ,>nriiu'e is dry, tissue breaks readily. Ve.ssels an,l bronchi pervious, and about them there is a little Geln- tinoiis-lookinu' tissue. On close inspection the individual air colLs can ))e seen, but in most jdaces very faintly. All parts present the saun^ dry, cheesy appearance. Right hmg, weight fAO grams. ; full in volume ; crepi- tant, except at part of apex, which ]>resents a small cavity surrounded by infiltrated, gtdatinous-looUing tissue. Tis- sue of middle lobe near root is in state of gelatinous oedema Lower lobe contains several small caseous masses and a few firm nodular bodies like tubercles. Bronchial glaiuls enlarged, tumid, moderately pjo- mented, not caseous. In ileum, glands of Peyer swollen, some as large as small peas. Remnrkn. — This case is one which presents .several points of great interest. I had never before met with exactly the same morbid appearam-e in the lungs, and the question at once arose, Is it a sequence of pneumonia, or is the process tuberculoiis .' Tln^ entire illness lasted somewhat over two months, and began after a weltinu', but not with the symptoms of ordinary pneumonia. "When he entered the Hospital there was consolidation, with signs of breaking at the apex. The history is defec- tive, and if the primary attack was pneumonic, it must have been subacute. A sister had died of phthisis, so that a family predisposition to pulmonary disease may be pro- sumed. As to the condition of the left lung, the teviu caseoirs pneumonia best describes it. I have never seen such an extensive area of cheesy degeneration as pre- sented by the lower lobe — uniform, solid, amemic and dry ; no trace of normal lung tissue (except narrow rim at border), and no nodules. In the extensive excavation of !W I5Y WIMJA.M r. The disease in the right apex may have been secondary, or there may have been oriuinally trouble at the apices. •"»• — Miners' Phthisis. J. T., set. 60, native ol" Cornwall, admitted April 16th. Father, a miner, died at the age oi' 63, of consumption. Has worked in mines since the age of 14 ; in lead and tin until lo years ago, when he cami> to America; and since then in copper, zinc and plumbago mines. Has enjoyed good health during the greater part of his life. Is a moderately temperate man. About three months ago noti<-ed a slight cough, which has persisted ever since. He has failed gradually in health anu i.rength, and has not been able to resume work. April 18^/t.— Examined for the first time. An elderly, moderately emaciated man; appears to prefer the sitting posture. Face and hands a little suffused, as if capillaries were over-full. Chest.— On inspection right side somewhat sunken in front, and does not expand so freely as the lelt. On per- cussion, dulness for thr<.^e lingers' breadth below right clavicle, clear over 3rd and 4th ribs, dulness again below% merging with that of the liver. Clear note at left apex in front and over both bases behind. On auscultation, cav ; U I .lit; fl ft 4ii I'ATHOLOOICAh UKl»OI{T. onioius bmithino- at vi<>ht ap.-x, with a loiul cli.k at end ofiiispiralioii. Exiuiatioii is prolong.-d.and actompauicl by whistiiiii.- rales at tlie lel't apex and at the bases. Breath scmnds are i;'el)ler iii lelt than in riirht scapular reg-ioii. Expectoration viscid and -lairy. Heart's impulse cannot be felt, dulness much dinunished. Sounds noi- nial. Pulse HO, leisble ; teni[)erature normal. 15o\v.'l,s rey-ular; urine dark-coloured. Dnring- ih*. evcnino- he sank rapidly, respirations became shorter, heart's action i'eeble, and he died al)out midniii'ht. Antopsj/. — In alidomen, liver depressed, reachiny' nearly to the navel. In thorax, lelt lun,i«- extends over beycjiul the middle line ; right lung universally adherent. Heart.— llighi ventricle dilated and hy])ertrophir(l . chamber measures from pulmonary ring to apex l.j cm. ; wall, about middle, 7 m. in thickness. Lel't ventricle appears of normal size. Valves healthy. Weight of organ, 445 grams. Lung's. — ]Moderately daik in colour. Left crepitant, except at one area ])ehind. rimira covering tht' huif uniformly dark, excei)l at the posteiior ])art of lower lobe, where it is thickened and of an opaque-white colour. Entire upper aiul anterior part of lower lobes emphyse- matous. A number of small firm si)ots can be felt, and these on section of the organ ar(> seen to be dense libroid areas, excessively pigmented. Except in these spots, and about the vessels and bronchi, the lung tissue is not of u dark, but rather of a slate-grey colour. Behiiul in an elongated area, extending through both lobes, measuring 18 by G cm. and 4 5 cm. in depth, the lung tissue is cou- A'erted into a iirm fibrous mass of inky bla.kness. Ou section it cuts with resistance, surface smooth, but in places there are small irregular spaces as if the tissue were breaking down. They contain dark-coloured !l nid, but could not be traced in connection with bronchi. Ill W1I,I,UM o«l.l;i;, m.I). aj . ano™„u.,U,d|.nil,.4„.inMMnul,.ntm.u,.nh'|'l u .■xneme ap..x „,,a tl„. clii-o anlorio,- ,„„,.„ , ,.„^'. I.O.SO, o ,1,.,,.,, ,„,„. ,..„„»i,,, i ,?,,„,« ti™ ..llK MuUI.. I„l„. ,.s ,.m|,l,yH,.,„at„„.s, |„„„, 1„|,„ <»"! na so,.„„„ nu,u,.n,u, fil„,,ui „,.a pio,,,,,,,,.^;, . '" I" "III"!- limg. Al ils antei-i,,,- ma,-..in I Ts J 't > .. ™cap.„,,a,.a p,.„,,y. ,,„ ..»;.::,'';. :";;::;, :,^ Ilii'y .omajii a -00.1 ,1,m1 of .M.,.THio,i nm,„.l,r , I'i? ""•'• ii-l hani, „„„e ea. „ x" ' " ''"'"'" not,, in th,. olhor oraai.s. ' '^°"""S »' M'fc.al fo»m,fo,_Tho .avitics wl.i.h Ibrm in the lal,- sta....s „r .1. d .vas,. appear to arise by ,|i,. disiu(„„,.,ti„„ J), t^o lung us conservativ,, and motvciivo Jt ^'^^^^■^^'•l ^afr:f:!;:i!;nr':s/:-'''Crr^:,T-^'- oiuliiin-M-ivl^f 1*^70 r-- ^ Ajui.s, Joi the two yours or Iwo L di " \' rrb™" ""t"'" '° «»^'"'"'' uiLu. It must bo roinomborod thit m^ ., ^. It .. only the sovoro ca»es wl>iol> are brou-lu to Hos' pita , and a considorablo number wore sent i,,l . tra,.he„tomypevlbr.nedasa.„„,-„:::;,r '° """ i i*t I, ,1 48 PATIIOLOGIUAL REPORT. laryno'cal membrane ; in one it was confined to larynx and trachea. (This case had come from a houso in wliich other cases had occuned.) In one the membrane had cleaned away; death having- occurred suddenly on the thirteenth day. In one case, which recovered, the mem- brane extended over the entire mucosa of the mouth, involving- the lips. In eight of the cases the membrane formed a continuous sheeting-, extending down the trachi'a and into the bronchi, to the tubes of the 3rd and 4th degree. This is the point of greatest interest in connec- tion with the series, and explains, to some extent, tlie high mortality. The membrane in the lironchi was not so firm as that in the tvach(>a, and the tiibes passing to the middle and lower lobes were, as a rule, more involved than those passing to the upper parts of the organ. II DIGESTIVE SYSTEM. (a.) — Gnstro-Intestina/ Canal. 1. — Foreign Body in (Esophagus — Ulceration — Perforation — Retro-pharyngeal and (Esophageal Abscess. Jane Gr., tet. 50, was brought to the Hospital in a dying condition, and, being friendless, no account could be obtained of the onset of the illness. During the 18 liours she was in hospital, she did not complain of any special difficulty in sv/allowing. Autopsy, 24 hours after death. — Body that of a large, corpulent woman. Face and upper part of body swolleiv and emphysematous, and dependent parts very dark in colour. In abdomen, signs of old peritonitis, particularly in pel- vis. In thorax, tissues at upper part of anterior medias- tinum infiltrated with pus, and a similar condition is seen about the structures at the root of the neck. Tongue, pharynx, oesophagus, and larynx removed together. The ^J to larynx in which rauo had y on th!> the mom- e mouth, lombraue 10 trachi'a and 4th 11 coniioc- xtont, the li was not )as8inii- to ! involved an. HY WILLlA>r OSTEii. M.I). ^erforntion n a dying could be e 18 hours ly special >f a large, .y swollen y dark in rly in pel- )r niedias- ion is seen Tongue, ther. The 49 a eA< I with th.. bifurcahon of the trachea ar.> infiltrated V th pus, and ,n a loul. slouu^hy state. It also ext d lat.'rally about the a.ophagtts and the sheaths o the great vessels or the neck, passing- Ibrwanl beneath t e muscles. On slitting open the pharynx and ..s^pW-^^ a bone IS seen imbedded m the anterior wall of the lu ' nnmedia ely below the crieoid eartilagv. It i.s a p/jce of mutton-, hop bone, measurino- :] by o ,,^ ,„hV i imb^ded ; the sharp end, towards the^i^^^.S ated the mucous membrane only ; the othei^e^-d, the « i e wall, which IS ulcerated at this part At pyloric end of ,s7o.m./, are several minute loss<.s of substance m the min-ous membrane Nothing- of note in the other organs. -—Three Cases of Cancer of Stomach. fa.)--i)^.. 8,b-Mucous Cancer of Stomach -Small Patch of Ulceration- Perforation -Secondarn 3Iass in Left Snpra-renal Capsule. " ^ l^bt. C, .nt. 43. History of hiiling health for months ^^tric symptoms not at all prominent. No tumou^^^t f^l- (xieat emaciation. Death from ])eritonitis In abdomen, intestines dark and relaxed; .six' pints of dn-ty, ollensu e tluid removed. A ^es. Uake of hm on pontotieum : very little iiijection of the vessels, 'in .a pei oration is se.m in the anterior wall of the stomach midway between the greater and lesser curvatJe ami rather nearer the eardia than the pylorus iho Lngest are in the fundus and greater curve. On . It IS seen that the sub-mucous tissue between the sec II tfijif \''. ^l lliu m I m M iili KH) gQ PATHOLOaiOAL REPORT. the organ. On the aui ii thnM'-uoimv bit. l-.r involved in oancovous (lisoaM.. About i small lirm nodules. , w f -1-, 111 for SIX months with all th. Sarah W., ^^^t- 4o. 1 to ^^^^^^^^ ^^^^^^^.^^^^^ ordinary symptoms ol ( an. ema..iat.on. ^^-^^ ^S^-^ ^^ *-^'^^^™ In «b./omen, parietal P^^^ « ^^^ ^^ ^^^ t,,,|,id Ihud in epiu-astric region. ^^«^f ;^\^;^ ';,k,,ed Left lobo ^1 nmcntum retracted and ]nnKO«-u. removed. Umt ntum . ... too-other. S'""•»'>« -^-/-^ : ,,,„i„,„, „„„,,..■ the py.,» aliteiiov Wi.U and lessei ^^j ,|,, ,,... the eardu. a.d a^c^^^^^^^^ l,and m ex ent. On porno ^^^^^^^^^ ^^^^^ ^^^^ lel't lobe ot the ^^^ ^ ^ Ws are in a soft, sloughy state ^.hile the peripheral P^^^^/; ";^^.^^. ,,, iniiltrated ad The walls at the margins oi the uleei ai , J u ,f ,,nt to -i very g^"fe^»t extent, thickened, bnt not to a ^ er> „ No secondary masses in oil 101 gans. ^ . . ^tonach-Flatiened Mass, not Ulcerated- Gall-bladder. . MaryJ.,-.-t,«0. Fairly weU-uouri.hed, Aduutud,. — ^y m ■*,|iww yj | H B _. BY WILLIAM OSLER, M.D. 51 the Hospital March 14th. Ill for ten months. Oastri. symptoms not marked. Gr.at pain in ep^u-astrium, i which region a prominent tumour could be>elt. Jaun- diced for some weeks l,.fore death, which took pla.-e ten days after admission. .iu(ops,.-On openmo. abdomen, transverse colon crosses just above level of navel and is full of hard feces I 8.eat part of the tumour, evident externally, was due'to this cause. There is a nodular mass outside the pyloric end oi stomach, composed of enlarg-ed o-lands. Tin- head ol he pancreas is larg., and the mesentery forms a pro- .lecting imvss, containino- numerous cancerous glands and IS especially thick al the root and in reaion ti' the 2 creas. ^ '■ Shmach.-The pyloric /one for a distan.-e of 5 cm. from the rmg is hrm, thickened, and the seat of cancerous disease The orifice is a little contracted, admitting he udex finger with difficulty. The disease occupies the lesser curve, and the anterior and posterior walls leavin^^ oiily a narrow portion, 2 cm. in breadth, unafiected. From 01 rr • ^',i^ V^'^"" ""■"' '' ^'"^'^'^ "^*^ the duodenum foi 1 cm. in the form of irreg-ular fringes. The cancer is flat, with smooth, unulcerated surface, but here and there crossed by small fissures. On section it is seen to involve intaa. The allected area forms a sort of flattened o,.oove passing tovvards the pylorus, while the unafiected portion oi mucosa forms a deeper and narrower channel, sharply bounded by the edges of the cancerous mass ^ In hepatico-duodenal ligament, common bile duct is pervious, bile enters duodenum on pressing along its urse. Portal vein is a good deal narrowed clo!e to "l-;. ^^^ *^'^' ''''''''' "^ '^'^ ^^S^^^nt are matted - ' T tl *", '''" ^^^"'^ ^^ t^^" ^i^'-- there are «Ae,al enlarged glands, which press upon the hepatic 4 '"J '1 If 'II h nil ' II ' f I I ! ! I mi 52 PATllOLOaiOAIi REPORT. (liTcts. The neck of tlie gall-bladder is involved in a secondary mass. The Pancrean is enlargvd, very lirm and dense, and is the st'at of sei-ondary disease. Liver presents several small nodules at posterior border Mesentenj greatly enlarged, owing to the presence of nmnerous cancerous glands, somi' of which are as large as small apples. Some are undergoing caseous degciu'ra- tion ; othrrs are lirm and hard. Only a few have a true cancerous aspect. g,— Three Cases of I'Icer of Stomach. (a.)— Sm/^/e, Round Ulcer. A. R., a well-developed man, patient of Dr. James K.tv, sutlered for ovin- a year with well-marked symptoms of ulcer of stomach. Several attacks of htrmatemesis ; death occurred during one of them. Sloinack of averau'e si/e. On lesser iiirvature a thick- ened mass can be felt, mad(^ up of indurated omental tissiie and fat ; beyond, in posterior wall, there is a sliiiht puckering. When the organ is opened, this is Ibund to correspond to an oval loss of substance, situat(>d in the lesser curvature, 7 cm. from the pylorus, and extending more towards the posterior than the anterior wall. Its long diameter, which is at right angles to lesser curve, measures 2S cm., breadth 2 cm. ; edges are rounded, cleanly cut, and formed by mucous membrane. They are under- mined to a variable distance, 2-G m. The ulcer is toler- ably deep, the base made up of dense librous tissue, rough and irregular from the presenci> of bauds, and the ends of obliterated, as well as open, vessels. These are very numerous, four presenting gaping orilices. On injecting water into the gastric artery, it Hows in a full stream trom the larger of the orifices. Thi' base at the cuirvaturo is thick fr posterioi the outli clearly s The z ring but of the n No affect No thin (h.}—Mu. Old . D. M., years ; n( months. apparentl StomacI posterior of a grey i I Mucous 1 surface is towards tl the large i a three-pei toueal sur] other j;)arts cious muc in posterio in the left No caseous groups of . very dense most part i niiiny in ot caseous ma HY WILLIAM (JSLEi;, M.d. 5^ jed in ;i e, and is r border seuce oi' ■; liii'ice as log't'iu-ra- re a true ities Kerr, iptoms ol Litemesis ; i a t'liiek- l omental is a sliii'ht 1 found to ed in the extending wall. Its ser curve, id, cleanly are under- r is to lev- sue, rough the ends ;e are very I injecting ,ream I'rora rvatiire is thick from the condensed tissue behind it, but on the posterior wal it is thin and translucent, and at this part the outline of a biiureation of the gastric artery can be clearly seen. The zone of pylorus, extending- for -5 cm. about the ring but not involving it, is thickened by an hypertrophy ol the muscular coats, in some spots 1 cm in thickness iNo aftection of the mucosa. Nothing of note in the other organ.s. (h.}-3InHip/e U/cers {simple) at Cardiac End of Stomach- Old Fibroid Tubercles in Lunffs. D. M., oDt 55. History of dyspepsia for three or four years ; never ha-matcmesis. Had had a couah for some months. Died somewhat suddenly during an attack, apparently, of congestion of the lungs. Stomach.-lmmediately below the cardiac orifice, on the posterior wall, is an ulcer 1-4 cm. in diameter ; base fibroid of a greyish-white colour; edges firm, not much elevated' Mucous membrane about it puckered. On peritoneal surface is a firm mass of fibroid tissue. In the fundus towards the posterior wall, at a distance of 2 to 4 cm from the large ulcer, are five smaller ones, the largest the size of a three-penny bit ; edges firm, ),ases greyish- white, and peri- toneal surface a little thickened. Mucous membrane in other parts of the organ healthy, but covered with a tena- cious mucous. Lungs.-An excess of blood and se.um in posterior parts. At apices there are fibroid areas, that m the left lung large and tissue about it much pigmented No caseous masses. Throughout upper lobes numerous .roups of firm miliary granulations, grey in colour, and very Uense. Ihey exist in groups of from 50-80, for the most part isolated, only a few had merged together. Not many ni other lobes. Bronchial glands not enlarged No caseous masses. Ji I ■h :i !rTr-~t i» III Ci^ iS 54 I'ATHOLOOKIAL REPORT. Examination oF the ulcers yave no evidence ofa tuber- cnlotiis orijxin. {c.)— Ulcer in Stomach— Fibroid Phthisis— Hypertrophied and Dilated Right Heart. Katherine H., tet. 39. History of cough ibr over 10 years: always worse during the winter. For the past three years has had oceasional attacks of hicmoptysis. Admitted sulFering from dyspnoea, with dropsy of legs and belly ; enlari-ed liver and spleen. At Autop. morrhao-ic infiltration of the mucous membrane. Aboiit the middle of the posterior wall is a yellow slough, G l)y 10 m., involving the mucous coat. Its surface is soft, and is on a slightly lower level than the surrounding mucosa. At the pylorus, close to the ring, there is an ulcer, 25 by 8 m., and extending to a depth of from 3 to 4 m., exposmg the muscular coat. No pluggc>d vessels c-ould be traced ni connection with either of these spots. Veins of the sub- mucosa are much enlarged. ^ / 4._7Vtree Cases of Simple Ulcer of Duodenum. (a.)_W. B., ict. 40, patient of Dr. V. W. Campbell. Chief symptoms : vomiting, dilated ; lower coils of small intestine dark-coloured. Nothing special in thorax. Stomach somewhat dilated ; walls of moderate thickues!^. c ? w'-oU' tx.» y.'-TV),: •' i.t-ca »-.7 cm About 10 m. irom the pylorus there is an oval ub'er on the mucous membrane 25 by IS cm., extendinjr in direction f !r ? k"'''*' r"'^ ^^'■••"I'y'"^' d to be gastric. Death took place slowly, alter many months illness 4«to/M7y.-Body much emaciated. In abdomen, peri- toneum dul and lustreless; two pints of turbid lluid. mixed with lymph, removed. Stomach appears dilated O^soj^^a^us presents in its terminal part an oval area, rfo by 11 cm., from which the mucous membrane has beeu il ill 1 I I I i I 11 I '! ! I I iMd 56 PATUOIAKHCM- llHl'OKT. complet.'lv r.'movi'd by the action of thr gastric Juico. In the c.Mltl■e^l thin external hiyer alone remains. Stomach moderately dilated, and contains a dirty-lookin-, highly acid lluid. :\rucous membrane pal<> ; that of the fundus thin, owing to i>ost-morlem solution. At the pyloric end it is'thick,lind presents numerous mammillations. Th.- pylorus is greatly narrowed, admitting only the top of the little linger as far as the root of the luiil. On slittmg open the ring and the duodenum, the following condition is observed : pylorus not thickened ; ring promment, but not more so than is often seen. Immediately external to it is an irregular ulcer exteiuling round the greater part of the eircumfereuv . of the gut, and presenting an imper- fect division into two portions, the larger of which occu- pies the lower part of the tube, resting upon the pancreas, the other being placed above and to the right. The extreme length of the ulcer is ;V7 cm., the breadth ranges irom 6 to 13 m. The edges are round, and somewhat undermined. The base is formed of firm fibrous tissue, of a o-reyish-\vhite colour. Close to the lower edge there is setm, on the iloor, a small nodular body, looking like the end of a closed artery. Th(; mueous membrane ot the duodtuium near the uker is greatly puckered, particu- larly the upper part. The bile papilla is about 5 cm. below the ulcer. Nothing of special note in the other organs beyond the atrophy of extreme emaciation. > (r;.)— Mrs. II. S., tct. 48 years ; a stout, well-nourished The following notes have been furnished by Dr. kodger, under whose care the patient was :— " She had been married vipwards of twenty-four years, but never had been pregnant ; had always menstruated reo-ularly, but had ceased about three years ago. " The only illness of consequence that she eyer had was about fifteen years ago, when she was laid up in bed iJr' Ci.'.. in V\IIJ,1A.M (»sj,fc;i;, M.i). 57 lor ahout SIX works, with what was called an attack of inllaunnalion of the liv^-r. No jau.uli.v was per.vptihlo al that tin.... Ever sin.v, however, she lias he.-n Irouhh-d with dyspepsia, ohstinate constipation, and nioiv or Ics.s pain or leehny of di.seon.lbrt in the n'o,,,,, of the stonuvh Her eondition to- coated ; loss of appetite • no increase of temperature. She states that she has not Jolt well all winter, hut was alwavs ahle to attend to her household duties. "Patient canu> to my oliiee lor about lour weeks; still at the (.nd of that time, symptoms had not improved " On A])ril 2-lth, visited the patient at her house. l-Lxam- ination revealed no enlaroement of the liver, and only slight tenderness on lirm pressure over the organ. Heart and luuiis healthy. "Has noticed considera})le blood at stool duriiio the past lew days, and lieees still pipe-clay in colour.' No haemorrhoids. Dr. CI. W. Campbell saw the ease in con- sultation, and gave a very unfovorable prognosis, thouo-h the exact nature of the disease was doubtful. '^ "All treatment adopted proved of no avail ; the patient rapidly became emaciated, and continued deeply jaun- dieed. Several severe attacks of epistaxis have occurred lately, and to-day (May 30th) has passed more blood than usual by stool. "At three p.m., May 31st, commenced vomiting blood and continued to do so frequently all afternoon, in spite of treatment. The Incmorrhage from stomach and bowels bocame excessive, and death followed in a few minutes " AulopsT/.— Body that of a well-nourished, moderately stout woman. In abdomen, coils of intestines, dark- AT11()1A>«ICAI. WKl'OHT. r-f'' duodenum are closoly adh.n.nt to tl.o umlor surtar.ol i .. anterior uuu-o-in. Nothinu' special in thorax, stomach duod..uun, ,.anon-as an ukiu- brane ; ii ;ind, in p towards t pirt is ( ul(!eratioi The asi to the gf circniar c rounded or the gal disease. Liver i distinct t gall -blade throughoi Ijresentini only is us disease, tl tore readi dition. C removed, the naturi .).- T//p/,( Ellen ( Hos[)it!il, Illness be ihills anc Employer days i)revi state of e: .spoken to, dull, hea^ equal and extremely m WILMAM (»SI,Ki;, M.I). 59 CtMlf its tomaeli, Slom[ liiltercd marked am, is a \. It i.s ,'hich iiii surlacc lu' odtjcs ) liuyt'vs 11(1 joint Lodeiuuii, lus mciii- ist ol' its DU of the )rti»l \>'iu pervious, the ulcev, ic-poiiitod •e at this 1. It hiis art' thick- ystic duit can pass n the wall s natural- (', inserted Lich parses j[ the ,^■all- ;o bo ulci'V- ,(d eounmi- ,• ^vus thou ion. Only LCO;.S UK'IU- hrano; in the rcstof itsoxttMit Ihewnll is roug-h, uleeratcd, :ind, in phues, slonL;hiMi»-. There is ii d»M'p proh)nuiili()n towards the hilus of liie IIv.t, the tissue ol" whicli at tliis pirt is exposed and shm'.^iiinall-blad(h'r, iind the i)arts al)ove sire cicatrical. Scattered throut>-hout the ori«-an are numerous .small isolated ma.sses linvsentiug- the characteristics of secondary cancer; on<^ only is as Jarye as a walnut, hi lookiniv for the primary disease, the parts about th(^ ri^ht ovary are Ibund matted, tore readily on removal, and appeared in a disfjised con- dition. Only a very small hit covdd b' surreptitiously remov(^d, and this, unlbrtunately, did not yiv.. miy clue to the nature ol" the disease about the ovary. ').~T//p/i()i(/ Fever— Rapidly FalaJ, willi Nervous Si/i»ptoms. Ellen C, jct. 24; ch)m(vstic servant. Was admitted to Hospital, under care ol'])r. Koss, March 14th. at midnight. Illness beg-an tvventy-lbur hours before admission with v hut veu-ular. ICvory l^nv miuuWr thoiv iiro convulsive j.M-kiims oil lu> head and limbs Docs not complain of any l>iiin. Ttnnp.'ratuic, 104 '. l.r,,/, _U,„.ons.'iousall tlu> «li>y. Voniitini^' and pul•,^•ln-•• continue. Thv limbs arc in a scmi-riyid state aiul resist Ilexi.m: jerkino-s not mark.-d. I'upils dilate.l. I'ulso extremely I'eel)!*'. Temperahuv, IO^k^ She remamed ni this state until 11 p.m., when .loath took place, Just 4H hours al'ter onset of severe symi>toms. Aiitopst/, VI hours alter death. Body that of a smi)ll- si/."d, well-nourished svonuin. Nothin- of special note in inspection of abdomen and thorax. Heart normal ; blood lluid. Lunga crei)itant; a ^•ood deal of blood in .lepeml-nt parts. ,y/;/ee« somewhat enlarged, w.ndis 185 grams. ; i)ulp, solt and dark-coloured. Nothing abnormal in stomach. Duodenum and. leiunum .•ontain /ellow, semi-lluid, contents ; mucous m.nnl>rauo healthy." Lower half of ihuim i>resents the Ibllownig appearance : BoW(d no! very vas.-ular, submucous vessels moderately lull; capillaries ol' mucosa not injected. Solitary glands are enlarged and prominent ; many are :is arge ai^ split p(>as and of an opaque whit(> colour. Fever's patches are enlarged and swollen; live or six Tipper ones, from :'. to 5 cm. in hmgth, are greyish white m colour. Surfaci's unbroken or only pitted in one uv two spots. I'ivc patches, within a foot of the valv-. are n, : more advanced state; the largest, cm. in length, has an irre-ular cribriform surface,, the pits redd.med, the mari-iii. an:' unruptured follicles greyish-white. The others aie not ^ <'-n. Very little swellinu- or injection ot the mu'-s.; .bout ; he patches. Mesenti'iic glands very little, if i f ■•!, vv.i'ilen. Ln' je bowel normal. In iVa/..-Vessels ot pia mater full ; nothing special in the substance. in \V I I.I, I AM oshKlt. M.l) (il Ivery I'^w uullinil)^ 104'. 1 1 purlin i^' iiiid resist (1. I'lllsi' luaiiicd in •(', just 4S r il smnll- iiil not*' 111 (l('l)('iiil'nt ; pulp, .soli d jejunum mmnln'imo rollowiiii;' OUS Vt'SM>ls ; inject od. lany arc as itt' colour. ivc or six shwhitiMii out' or ;\v«- i>'th, has ail ;he inaru'iii^ others are tion of the s very little, g special in (]. — Piufofiilion iif A/i/inii/i.r VHnni/onnis — Cimniisrfihefl Ahfiress — Pfffora'ioii of llnnn — llinii(>nihii>e from /ioioe/s. A. 15.. !i't.45 (under lareol Dr. .\. A. l)r()\vn('). In l^-hru- ary, lS7b, had a si-vere '• hilioiis attack,"" lastinii'al)out three weeks, and l'ii>ui which he i>'ot (jiiite well. On April 24th, W-l 'I'ul another attael\, cliiersyniiitoms l)eini>' severe vom- iting', llatulenee, eoiistii>aliini, and a lhi(kly-liirre(l, iiiuist, brown lonyue. The attark yieldi'd to ordinary remedies, ;iiid by ^lay 24th, the loiiL!ue <\ is elc;iii, the a|)i)etito much improved and the bowels a'tinii' ))(>ller, olthouuh the stools were still A'ery clay-colourod and oH'onsive. The llatulenee continued, althouiih not so distressing, and tin; hcUy remained considerably distonded 'i'here was no piiin on i)ri'ssure over thf distendi-d bowels at any lime or at any point. l''rom tliis time (24lh) his -symptoms b'came aijgravated ; that is, the llatulenee was more distressing and the bowels Ijecann' loose, with yeasiy. clay-coloured, very oll'eiisive motions, lie now l^i-uan to lose llesh very rapidly. Symi)toms continui'd much the same up to morning of the !Uh of June, when, about S o"clock, he passed a large quantity of blood in bed ; it was florid, mixed with dark clots, and loose f;pcal matter. He com- plained of ])ain in lower part of belly. At 12.30 he lost again a still laryvr <[uantiiy and sank rapidly, dying at 4 p. in. the saiue day. Antops//, 24 hours after death. Body that of a large, well-nourished man ; no signs of post-mortem decomposi- tion ; belly greatly distended. In making preliminary inc-ision a coil of intestine Avas accidentally wounded, and a (jUantity of very fcrtid gas escaped. Small intestine is enormously distended and very dark-coloured ; the coils are as large as the thick part of an average si/ed forearm. This condition exists in all parts, with the exception of the first few inches of the 6 m » M mi 62 PATHOLOGICAL KEPORT. jpjuiuxm, and the tevmiiial part of the ik'um. There is no fluid in peritoneum, nor is the membrane inliamed. On tracing down the coils of bowel, they can l)e ibllowed for four or live feet, and then the lower ones, in ihc neighbourhood of upper part of pelvis, become matii'd together, so that it is impossible to separate them without tearino'. Lying upon the promontory of the sacrum, and extending towards tlje right side, is a llattened pundent sac, the size of the palm of the hand, and to this the coils of the ileum and the mesentery are closely adherent. On dissection the following condition was discovered;— CoDCum and large bowel normal. Appendix vermiibrniis is long, passes horizontally out and is firmly attached to the purulent sac, with which it communicates by two openings. AVhen slit open, the mucous membrane of the outer third is rough and in places dimuded, while at Iho extreme apex are the two round perforations. This pavt of the appendix is very closely united to the wall of the sac. Several coils of the ileum are in close union with the sac, and when slit open two j^erforations are seen. In the neighbourhood of these are several ulcers on tlic mucosa. The intestinal ^vall is so softened that the dis- section withoul tearing was impossi])le. The mesentery is also iirmly united on the upper wall of the sac, and mr of the vessels in it is plugged with a firm thrombus. Tlie origin of the fatal hannorrhage was not discovei'cd. (b.) Liver. "j.—Hi/ilatid C/jst. The specimen was found in the liver of a subject in the Class of Operative Surgery during the Summer Session Patient, a tramp, had been admitted to the Hospital with Pneumonia, of which he died. No information could he obtained from him as to his past, history ; so that it is not T^' There is inllamed. e Ibllowcil les, in ihi' ne matii'd m without icrum, uiid d purulent is the coils lerent. ( )ii covered :— ermiforinis ittached to es by two rane ol' the hile at the This pavt wail oi' tlio union with i arc seen, •ers on the bat the dis- lesentery is and jne of nbus. The ered. ihject in the ner Session ~,spital with )n could he hat it is not BY WILLIA^r OSLER, M.D. 63 known how long he had been a resident in the country. The cyst occupies the posterior part of the right lobe of the organ, and is in close contact with the diaphragm. On nnnoval, it measures 10 by S cm., and is about the size oi' a large orange. The ibllovving parts app(>ar on dissec- tion : — (1.) The external cyst-wall, intimately adherent to the liver substance. It is hrin, dense and librous, in some phices of cartilaginous consistence, and here and there covered with soft cretat.-eous matter. (2.) Lining this is the interiuxl capsule or proper sac; a translucent membrane, lo m. in diameter, easily torn, in phices bile-tinged, autl on the inner surface presenting a hiudy granular appearance. (;5.) AVithin tliis are four or five secondary or daughter cysts with exceedingly delicate membranes, so that they burst on being turned out, and gave exit to a qtiantity of jelly-like fluid; and numerous smaller grand-daughter cysts of all sizes, from a pea to a large walnut. In colour they are opaque white or perfectly translucent. All are partially collapsed. On exainiuiition some of the cysts contain only granular matter; others, the majority, con- tain innumerable hydatid heads. These are free in the Ihiid of the cysts. No brood-capsules met w'ith. In some of tiie larger cysts, a fourth generation is seen in the form of small l)ead-like projections from the lining membrane, ranging in size from a pin's head to a pea; some are pedunculated, others free. They consist of a laminated sheath, enclosing a dark granular mass. Remarks. — Hydatid disease is very uncommon in this country. I believe on(^ case occurred in the General Hos- pital some years ago; and Mr. Mignault read a paper, at a roeent meetinu' of the McGill Medical Society, on a case of hydatids of th(^ liv<'r, which he met witli last summer m the Eastern Townships. These are the only examples of the disease in this country with which I am acquainted. p' k i 1 1 I. J 64 PATHOI/XlK'Ari REPORT. i! t,-Hi v.\ ill a I do not think thnt any mso has been ivcordcd in th,' Journals. In my h<-iminthoU)«jiral studios, I have examined some s''ores ol' dogs, and havr not yet Ibund a specimen ol' the T;enia ocrhinocoecus. M. — PrmiD-i/ Cdricer. , A. II., xt -U. I'atient of Dr. Drak(^'s. A temperate mail, of spare habits. History of dyspepsia for over two yi'ars. Up to .'iu'ht Wd-ks before his dvath was abk^. to attend to his work as usual. Since this time he has be.'U laid up— th.^ chief symptoms being- pain, enlargement of the liver, u-astrie disturbance, and rapid emaciation During- the last week of life, jaundice supervened. .^,,/o/,s/y.— Liver could bo felt as a firm, hard structuvc nearly a hand's breadth below the costal margin. On opening Abdomen, nothing special observed beyond the (Uilargement of this organ. In Thorax, moderate elfusion in right pleura. Heart, small. • LM/ii,'-s— Cheesy masses and small cavities at api.'os. together with mu.di libroid tissue. Firm miliary grami- lations in nciu-hl)0urinu' Iuiil;- tissue. Liner much enlarged ; weight .3,000 grams. ; normal shape retained. Adhesions, recent and old, to diaphragm. Upper surface smooth, but pr.^sents many Ihxttened and rounded eminences of a yellowish-white colour or mottled with red. They project but slightly, and only two of theai present shallow depressions. The masses range in si/e from a i)ea to a large wahiul. On the under surfaci' the masses are not so numerous. On makinu- a section through the organ the greater part of the substance appears occupi.'d by the cancn-ous m-asses, the limits of which are often ill-defined, blending- with the bile-stained liver tissue. In addition to the usual areas of an opaque white colour, with vascular ies at npii'os. raug'e in size or suvracc iho BY WILLIAM OSLHR, M.D. 65 borders, there ore others of a pale-1)rown hue, particularly miinerous on the under suri'are of the organ. There is no single larg(^ mass, but all parts ol' tlie orti'an appetir etjually involved. Tissues i)i hepntico-duodenal ligament thickened. Glands a little enlarged. Vi'in in its primary branches com- ])ressed ; riuht hranrh only admits the top of tlie little linger. Stomach — ^Mucous membrane much mammillated, espe- cially at the pylorus, where the little lissures separating the mammilla; are unusually deep. The membrane is tougn, tearing with difficulty. Spleen, pancreas, and kidneys, normal. Nothing of note in large; or small intestine. Xo other cancer found, after careful search in all organs of the l)ody, except the brain, an examination of which was not allowed. 9. — Cirrhosis of Liver — Co/ lateral Circulaiion h// Means of an Enlarged Umbilical Vein — Death from Pneu- monia. Body that of a small, but well-nourished woman. So far as could lie ascertained, she had never suffered from ascites or any symptoms of cirrhosis. On opening abdomen a large tortuous veii^ is seen, passing from the liver in the round ligament to the umbiHcus, where it is continuous with the deep epigastric veins of the left side. It does not communicate with the superficial epigastric vessels, but unites at once with the deep, the two main branches of which, on the left side, are nTcatlv' enlarged and can be traced down beneath the peritoneum to the internal iliai', where they open by a single vessel, which also receives branches from the wall of the pidvis and the bladder. Veins of left ovary and in broad ligament of this side are much enlarged ; right, not to the same extent. Inferior 6J tit f I 1 ■ f ' i| r Its 1 m 66 PATHOLOfilf'AL REPORT. ciivii is iiK'veascd in size, luul ineasixres oo cm. across, just abovo tho ronals. liver woighs l,7o5 u'rams., and is very irreg'ular in shape. Capsule is smooth but opaqu(\ There are no superlicial .tiranuhitions as in the "hob-naiU'd "' org'an, but the surl'ace is mapped out into hirge hemis])herical areas, separated by shallow grooves. On tlic* under side there is ronsid.'i- able deformity from the projection of a large mass, lialt' the si/e of the left lobe, and apparently formed by ihr lobus Spigclii and lo])us caudatus. On section the increase of the Hbroid tissue is chiefly in the sheath of Crlisson, large areas of the liver subsluncc benig compressed, and but very little excess of connective tissue between small groups of lobules, as in the ordinar form of cirrhosis. In the hepatico-duodenal ligament, bile duct is pervioiis ; hepatic artery is natural. Porial vein admits index linger; when slit open its branches in the liver are found considerably contracted, the largest going to the right lobe only admits an ordinary sized lead- pencil. Passing off from the portal, towards the anterior border, is the large vein described above, as running in the round ligament to the umbilicus. At its origin it admits the tip of the little linger. Inferior cava, where it passes through the liver, admit^^ three lingers. Upper and middle lobes of right lung in state of puru- lent infiltration. Kidneijs moderatidy fibroid. Left ventricle hypiM'tro- phied. 10— Pylephlebitis. J. r., jct. 20, a commercial traveller, patient of Dr. F. "W. Campbell, who has kindly furnished th(> following notes : — Ilud in-en ill for several weeks in July with ai' attack of inflammation of the ca'cum, and in Auo-ust, across, just 15 V WIUJAM OSLKK- -M.l). n>u..h .H...a.., w;;;;!.: ;.;:-; :r :.:i":;:; part except transverse ami upper vnvt of ,1 v^ r.nlr.11 n 1 • n , ^u'l't- ' p.iu ot uescencliii"- colon. Ccnplams of shooting pains, which a,-,, .oli ™1 by l.ass„„. „.n,,l. lias n„ app,.,it,., i;,,.|3 sick at sio, , h and oc,a»ionally vomits. Un,l,.,- nidn-muriili,. .J.°a i 1-epsm mixture, with p„ul,i,.,,, to b-lTv h ' sontowhat, but oarly in Sept,ml« 'il, Y"'^ --■ned, tho pain h Jame morsT!:;, , ZT^Z :ic^r-::;t„*^'"t" -'--'- '^-^ Intho ,.n,I '."'''"^"'^"'y •>■■''"> supporting treatment. in th,. uid of ^,.ptemb,.r lie appeared somewhot better Kl was able to sit „p each day for an hour or so On th,, monung of the 10th of October he wa.s ,„„nd dldt |l«to^^y.-IWy much emaciated. No jaundice, lixter- i.a abdomn,aI veins not enlarged. On openinn- abdome, entire penloneum of a deep slate-colon, .,,,,1 '""""[""' SM. with soft, easily remoJalde'llatr^ ^^'^Z .:^y° ,';;; fm^"'T '" ^'^^ '^^ »-i ^' ^o"- ^ i.n ity a hltle more than an onn.e of pns. On .arelVillv -1-cfng the coils of intestines from the duode mm downwards, the ...,;ntral part of iejunum appears spe ill ly dark, and the portton of mesentery ■ orrespondino-' t„ £ much swollen and lluctnates. All the coils are're a.ed md ot a very peculiar colour. Sio^us of ^,<,^i i>ovU^ ■, ;.. the form o,- old bridles in ne.ghb.nt.lrd of n;^ olon. On pelv,,. per.toneun,, a little to the right of the ough tJre s,ze of a sixpenny bit; the base ..L a^ mgy. the fs.^.e about it discol,,„red and a little In™,. I'us had lodged. No n,(l„med veins can be traced in ™nnect,„,r w,th it. Stotnach, liver, .nesentery ,, ^ortio 01 jeiunnm removed together. Mucous mcnbr^an, o 68 PATlIOLOdK'AIi RKI'ORT. li > ri stomach pale, and prt'souts on anterior wall two or three roniid swellings, the largest the size oi" a small walnul : and IVoni this one, on pressure, pus oozes at a suiall orilic'' In duodenum, bihs Hows IVoni the duet on pressing the gall-l)ladder. Throuu'hout th*? small intestine the muecsa is sodden, dark in clour, l)l(.od vessels not distinet ; no uleeration. In e:eeum, orillce oi\«/Y^e«r/i.7; is obliterared. It is lirmly adherent and presents on its upper surtaec a small siiperlieial slough involving the pi,>ritoneal and muscular coats. Tissue in neighbourhood injected, but no great amount of lymph. On slittinu' up the tube, mucous membrane dark, not ulcerated ; no peribratioii at the slough. Ciccal end obliterated ibr G m. No supi)ui- ating vein could be traced in connection with the slough. The mesen/erj/ in its whole extent is thickened and inhltrated, and in the central pait has a boggy, lluctuatiim' feel. In places it is covered with flakes of lymph. When cut into a large ([uantity of creamy, inodorous pus escaped, and was thought to come from a mesenlerir abscess. On squeezing the nuunbrane, however, the ])us is seen to ooze from several points, and on insertiiiu' ilic probe-pointed scissors and slitting in the direction indi- cated, distinct i-hannels are found, which can be followed towards the root and also towards the intestinal border. In the former direction they connect with the mesenteric vein ; in Ih.' later it was not i)0ssible to detenaiuo accurately how they ended, most of them apparently by blind extremities at the intestinal border. They commu- nicate freely with each other, forming a series of elongated cavities filled witli pus. No mes* 'Uteric vessels Hlled with blood can be seen. A few lymphatic glands noticed: none suppurating. On tracing up the mesenteric vein, the snppnration extends into the portal and gastric veins. The splenic vein is closed at its junction with the gastric. The trunk of the latter contained pus, and its branches passing from the greater curvature along the anterior wall are nuico.sa the par ft rmrndinj. and the shreddy commenc On slit are I'ouii colour, ai niembrai veins ore look like be traced The vess( of the lei Hepatic c bile. Li-\ of a deej tissue in i for from 1 limited fr 1. — Extern Spots A. B. ; chest and pueumoni Kidueijs. mottl(>d. appearanc o or three [ wabiiii : all oriiic, 'ssing the 111.' mucosa sliiu't ; no era red. It siirracc a jucal and (K'ted, ])ut tilt' tube, Ibratioii at [o siippur- hc sloui^'h, ;ened and luetuatiiiii' )h. When orous pus nescnteric M', the ])us crtiiiii' ihf etioii indi- e followed lal border. iin'8outeric detenniue arently by 'y comrau- r elongated tilled with s noticed ; itoric vein, stric veins. ;he gastric, s branches le anterior I!V WILLIAAf OSLHK, M.l). 69 wall arc much dilated and tortuous— the .swilini.' on the niu.'osa being in conue.tion willi tli.'ui. The walls ol the porta/ iriu are thiek.Mied and mailed x,viih the sur- rounding ti.ssues. It contains a d by thc amount of molecular i'at and oil drops. The tissue in immediate neighbourhood is not altcrt'd, and nothiim- abnormal could be detected in the blood vessels. 2. — Small Contracted Kidnei/s — Left Organ affected to an imusuaf deforce — Ri<;;ht onl// involved in the lorver part — Ilf/pertrophi/ of Heart. Ann T., ti't. 40 ; a washerwoman. Admitted January 4th, under Dr. Ross. Five years ago sutl'ered with pains in limbs and severe headache, w^ith a pemphiuoid erupt ion, probably syphilitic Has enjoyed fair health xintil last iSeptember, when, after exposure to cold, she had a l'e])rilo attack, followed by general dropsy, headacht>, i>aiiis in back, bloody urine with casts. Remained in Hospital six weeks, and was discharged much improved. When re-admitted, at above date, had general dropsy, anannia, cough, dyspncea, headache, and pain over cardia. Urino scanty, 10 to 20 oz. ; lowsp.gr., 1,003; contains 40 per cent of albumen. A few granular casts. Heart enlarged; systolic murmur at apex. Patient improved rapidly under digitalis. Jan. 21s/. — Worse again. Urine diminished in amount. Condition varied from day to day, severity of the symptoms being in inverse ratio to amount of urine and of urea elimi- nated. Variations in 10 days, 24th to February 4th :— Urine, 24 to (J4 oz. ; urea, 94 to 1 G i grains. Towards end of February eflusion took place into both pleurte. Cough ,'^. n BV WII.LI.Ul osi.Kli, M.I). ^2 and dysp„,ra ino,o.,s,.d. Pali,,,t „„,I,u,llv lost con^oiouv iioss, iiiid diod on th,. 2iid or Maivl, <^"nM.ious yl«(,V«;y.-Iiody that of an a,,.,-aov ,[■,„] n,o,],.r.,l,.lv cavity"""' "''"" " ""' "'' °'™'' """" '" ""'■ "'^•"™' A7,tej,s._|(ight mnoh mis-.hap.n. mnsirtint; of a laro,, natural looking, upper sogment, still lohnlated, and°a dnnttrntv,., greatly shrunken hnver portion. Caps.,Ie poels 1 e.,s.ly ; snrla.e of npper part i„ »„,ooth and inanral look,ng; thator the atrophied portion is darker n colour, finely granular, and in pl„e„., pnekere,!. /.in betweett these two regions very sharply d,.lined, ext ,d g arther „p on the anterior than the poste io, ido an cuts hr.nly tissue of upper part normal, 1, u l..de. a,„o reehe alo,„. visible. Vessels at bases of pyramtds dtsfnet. I„ the lower atrophied r,.gi,.n Ih -re i nly a narrow .one of eortex. very granular'and coa r. ^ o»k.n-; pyramids small, llattened, in places senvel^ .l.sj.ng„isha.,le. The s.nall arteries have ,4,: Lk wall^ ™l stand out prominently between the two Lvas.lln rtery firm; wall^ thi.k. Pelvis and ureters no m Weight of oroaii, 7"* o-rams. It tf. ^'''^^'^^^'^'^°; ''' '^^'^^ ''^ ^ ^<-«ti<-l. ; woio-ht, 20 o-vams t IS ooinposed almost .uti.ely of a thin c^.ti..! re.ion -i m. m thickness, and scarcely disting-uishablo' as Kinoy substaneo. Pyramids vev/ much 'ilattone in pots not recognizable. Pelvis and ureter small an hrunken. but pervious. Capsule thick and dense p^ oil readily, eaving an excessively g.-auular surfaee. Hear en arged, due chiefly to hypertrophy of h-ft ventricle. Valves healthy. Left ventricle, 10 cm from -^.e ring to apex ; eircumierenee. 14 cm. Anteri^ w^ middle part, 2 cm. in thickness. Aoria presents numerous atheromatous patches. Small V . ' J- 111 72 PAYHOridfiK'ATi KKI'oIiT arti'rics of Uw Ixxly — mt'sciitcvic, sj^li'inc, gastrio and nulial, uiodorately still. Linigs (rdi'inatous in poslcrior i)Mrts. 8. — L(iri;e CirrhoHr Khlnfj/i {Ct)nges/r(/) — If///nrfro/j}ii/ nj Ili'Uit — Apoplv.xi/. Adinitlcd undiM' Dr. Koss, Maivli Kitli, paralysis ol' thrcr wooks duralinn Susan (r., tot. 40. \vith riiilil laciai Coinplaiiis ol' weakness, short breath, and violent action n> the heart. Is antrmic ; supi-rlicial arteries linn and tortu- ous. Heart larije ; inipirlse .stronn-. Api'x heat indistinct : no murmur. First sound distant ; second strong-, sharp, jind loud. Urine about 40 oz. per diem ; contains 20 to -'10 per cent, of albrimen. Bowels loo.se. Symptoms did iio( vary until the l^)i\\. 2 A. At., when she was suddenly seized with riuht hemiplegia, becamt^ comatose and uied in two hours. Ther(> was constant tossing- of the left arm and leg' during the attack. Antopsij. — Body that of a well-nourished Avoman . no dropsy. Nothing of note on inspeeiion of thorax ov abdomen. Kidneija. — Left, organ f)f full A'ohuii(\ but loni)' and narrow. Capsule detaches without dilhculty, exposing an irrejTular, coarsely a'ranular surfac(^ of a deep red colour. On close inspection, small white areas are seen on tlu> projecthig portions of the surface. On sect .n, organ lirm ; substance deeply congested. Pyramids somewhat darker than the cortex, which in places is thin, but for the most part looks of normal thickness. At bases of pyramid.s m numerous prominent arteries, large and small. Tissue of cortex is coarse, and on examination with a lens the medullary rays can be faintly seen as opaque lines in the deep red back-ground, running up from the cones. M;ii- pighian bodies not visible. Calices and infundibnla are large ; ureter normal. Right kidney a little smaller, and UY WILLIAM OSLKK, M.I). 78 presents precisely (lie sain., uppe.irance. No cv.sts in either Renal arteries stiff and larue ; U) measun.;. at its (eiitral i)art, 1(» by 7 m. Jlrart much enhuovd. Considerahle aimmnt of blood m rig-ht chambers, l^^rht ventricle large; coIumukp eanu.e laiich dev.>lop,.(l, ransini.- -.vat increase iu the thickn(>,ss of tho walls (7-8 m). Tricuspid orilice dilated; heart cone 15 cm. m .ircumroreiiec passes freely throu'-li Septum })uloes a g-ood deal towards this side. LHt ventricle dilated; measures |ir, ,m. from aortic rin-' to apex circumlerenee KJ cm.. Contains only one small clot. A\alls very thick; anterior, close to septum, 3 cm • !>eptum, 2 em. ; ,a>ar apex, l-S cm. Muscle substance „f g.)od colour, but still"; no deg..neration of intima. Arch of aorta healthy looking; buitou-like masses ol atheroma in thoracic and abdominal portions, and some opa(|ue white areas of fatty degeneration. Smalh-r arteries moderatek- lirm. •' Jhain presents a larj^e extravasation in the left Jiemis- phere omside the v.-ntricle, involving- the anterior limit of the internal capsule, the anterior part of lenticular nucleus and the white substance between these parts and the con^ volutions of the central lobe. The caudate nucleus is not luu. h affected, but is pushed forward and to the right. 4.~Sarco77ia of Left Kidney. A. B., ict. 47. Had suffered for over two vears with .symptoms of renal disease, the hijcmorrhage beino- one of the mo.st marked. In May, 1877, he passed a remlirkablv long blood c'ast of the ureter. About a year after the appearance of the first symptoms a tumour develop.nl in the left .side, and gr(>w slowly and painlessly, while his .Jtrength and flesh progressively decreased. A remarkable tuatnre of the case was the entire absence of pain, and up 7 I' I; I k ■i l. ' , ^^ I\ t i\i >4d^^ 74 )'A'Jll(»Ii()(H('.\l, lUiJ'oliT. P, ■' to within Icii (lays of liis di-alh tlic diyt'stioii rcinaiiKwl good. A/ili>j)S//. — Uody iliJit ol an a\criVLi(' sized, yrcatly v\ui\t i- utcd luaii. Oil iusp'cliou, Ict't side ol' abdoiiion presents a considerable enlaruenieiil, lirin. ininiovablo, and resist- ant to the touch. On opening the eavity, peritoneum .smooth, no exudation ; viscera arc i)ushed aside by a lar<>'e tumour which occupies the hypochondriiic and hunbin regions of the lel't side, and extends to the lel't beyond thi^ mickUe line. The diaphragm is ])ushed up by llie tumour 1o a level with the ^th ril) on the lel't side, while l)elo\v, the mass is in contact with the si)ine of the ilium. Smooth, Lilisteninu' peritoneum covers it in front, tin' transverse colon crosses it obli(|uely al)out the u])])!')' third, and near the middlt^ the pancreas is stretdied across it to the duodenum. At the upper end the s[)iecii is closely adherent. The tumour readily turns out, not having any very firm attachments. It is oval in shape, measurinn' 71 cm iR length, tJO in transverse circumference. Weight, .Vtuii grms. (12 lbs). Lower end is pointed; upper end nioiv obtuse. Numerous superlicial veins cross it in all direc- tions ])eneath the i)eritoneum. Anteriorly it is smooth and round, mapped out by superlicial furrows into irregular masses of a greyish-white coloiir. Posteriorly, and a little to the riu'lil, there is a deep groove correspond- ing to the point of attachment to the spine. At the lower end of the mass the tissue looks of a reddish-brown colour ; here, on section, there is a thin layer of renal substance, nowhere more than 2 to 4 m. in thickness, and in immediate continiiity with the soft medullary tissue of the tumour. At the inner border, close to the groove, for the spine, are the aorta and inferior cava. The former is closely connected with the grow^th, and gives oil' a slightly enlarged renal artery, and two smaller branches, all of which penetrate the mass. The inferior vena cava is of tioii remained HV WIMJVM oSLKlj', M.I). 75 nonnul six.MuMo ,1m. point where the n^ vein enters About 4 cm. al,ov.. the iliues, a v.-in, .he size of the litil.. In^^or e,, ,,,,,.,,,, ^j^,. ,^.,,_^,^, ^^^^^j is .list..nde,l wi.h . J^e>.sh-wh.tethn,mhus which pr.j..,.,s h.ir way aer..ss the hunen ol the , ,.vu. The ren;,l vein is of eno.inons ad or 12 cm. akm,. the inner border of the tumonr. nv. u no. three branches in its .ourse. All of these veins -h tl..e.vceptn.n or one .ntorin. IVom , he adrenal, ar.: a..tended wuh tluomb,, ..royish-white in.olonr; in the >VM« ve.n the thron.bns is no, adherent to the walls In ...do..app^^ In the braneh.s they are adhei-. Ih^' thunnnis projects from the vein into the interior a.ya, u^, wlaeh ,t pa.s.ses for a distance of H ..„., „.arly o th entrance oi the h<.pa,ie veins. Here, also, it is loo,' ly |idhen.nt, and a space exists along which the blood could mu.sunno M.5 .-m. in c„-cumierence. The thrombus en.ls '•' '^ taper.no- rou^h, bifid extremity, attached to n-hich av some shreds of iibrin. Passing down from the tumoitr distended tube Jdled with soft nnderial ; this, prob;bly t uaids h. bladder was not tra.vd. On the posterior ^ ace ot the mas. there is a hu-,e convoluted vein tilled ti^ a solt, o-reyish thrombus, and several smaller ones 2 to be seen at the left border, in the same condition. At ho upper and anterior part of the tumour is the supra- u.ul capsule, greatly stretched and tlattened, measudng 1; ,^ ?■ .J ' 'r'^y''P^-^^^<^^ its vein is iVee and n p cs into the renal. One retro-peritoneal ghuul in the ;.|.-hbourhood of the aorta is enlarged and so^t, butnon! oi the other al>dominal lymph dands are atlected tumrrr''"?:' examination, the softer portions of the ^^i. F., ict. 44. Admitted November 11th w^ith profuse diarrhcea, and died on the ibllowing day. Atftopst/. — Body that of an average sized, moderalcly well-nourished w^oman. On opening abdomen a conical shaped tumour is seen projecting from, and entirely tillinii', the pelvis, reaching nearly to the navel. The apex of the tumour projects to the left. No adhesions: no lluid in peritoneal sac. Uterus, ovaries, and tumour reniovi'd together, when it is seen that the latter is connected with uterus by a narrow, somewhat twisted sta.' - cm. lon^', representing the Fallopian tube of this mui- wdiile the tumour corresponds to the ovary. It is about the size ol an infant's head, ovoid in shape, smooth externally, and free from adhesions. To the touch it is soft and doughy, but on lirm pressure a harder mass can be felt in the centre. On section a quantity of dirty-looking, sciai- dililuent matter escaped, mixed with long hairs. In the '■^ a BY WILLIAM OSLER, M.I). 77 -vntro thero is a firm mass the si.o of tiie list, .n-eyish- ^vl^te in colour, ol" thr .-onsisteiice of putty, and'consist- ni- oi inspissated sehum, int^-rmin-lod with hairs On reinoval of this nn.l after washino^ out th. .•y.st,th. linino- wall appears roudi and covered with scales, lookiun^ like a bit of K.hthyotic skin. Tlie part near the attachment of he tumour is thicker and more fleshy, and here numerous ong- dark-brown hairs are attached, some 3o cm. in length. Where the lony hairs are absent, there are numerous smal pubescent ones. Correspondinu- to the insertion of the stalk there is a strawberry-like projection of the cyst wall, mdentated with orifices of sebaceous follicles • immediately above this a bicuspid tooth is inserted, with well developed crown, neck, and fany, the latter inserted into the cyst wall for 5 m. Close to it, beneath the linino- membrane there is a flattened piece of bone, irreg-ular in shape notched, and dentated, measurino- about 10 m in j-ach direction. Fallopian tube can be traced up to "the l>ase of the tumour, at which part it is coiled. Uterus and opposite ovary normal. Cfecum and Cohm present innumerable small ulcers. 2.-Canrer of Neck of Ulerm-ConsMclion of Eight Ureter — I i/onej)hrosis. Mary 13., a>t. 40, ill for more than a year with well- marked symptoms of cancer at neck of uterus For more than four years had suffered on and off with hannorrhao-e from the uterus; and this has been a prominent symptom through her illness. No special symptoms referable to kidneys. Autoi>si,.~Y^odj much emaciated. lii abdomen, small quantity of sero-purulent fluid. On clnMvmg- the small intestines aside, the right kidney is seen to be enormously enlarged, extending, from high up beneath the liver to below the crest of the iliuin In 7A ! I ite. lili ir: I I ! I 78 PATIIOLOGK'AL REPORT. pelvis, uterus is in position ; there is thickening about the broad lig-ainent ol' the right side. Right kidney, ixterus, bladder, and rectum removed together. On dissection, rectum is closely adherent to vagina and neck of uterus; mucosa normal. On slittinu- lip vagina, the upper zone is rough and ulcerated, the posterior wall being deficient in one spot. The lips of the litems are gone and the walls of the cervix aic puckered, dense, and roughened. A narrow orilice com- municates with the cavity of the uterus, the mucous membrane of whirh is dark-coloured but intact. Tlie disease is entirely confined to the cervical region and upper part of the vagina, and consists chiefly of filn-oid induration, the softer portions having disappeared in the ulceration. Behind and to the left side of the uterus is a sac filled with pus, about the size of a small apple. It occupies the broad ligament and extends almost to the vagina. The Fallopian tube and ovary of this side cannot be seen, having apparently been involved in the formation of this sac. When laid open the walls are rough, sloughy, and crossed here and there by fibrous trabecukc. There is no communication with the uterus or with the disease at the ne<^k. Right Kidney forms a large fluctuating tumour, irre- gularly sacculated, and when cut into lu^arly 30 oz. oi' thick pus escaped. The whole organ is composed of a number of sacculi, communicating with the pelvis ; some of them are as large as an orange. The walls are thin, 1 to 2 m., and covered internally by a rough, greyish mem- brane. The capsule of the organ is thickened, but strips off easily, leaving a dark surface, whieh still retains some appearance of kidney substance. Pelvis is moderately dilated, in proportion to the kidney ; the ureter communi- cates with it by a Jiarrow orifice, 10 m. in circumference, beyond which the tube is dilated, and in the body was BY WILLIAM OSLER, M.D. 79 as large as the thumb. Walls are thi.'k, mucosa pak- not ulcerated. On tracin- it clown it retains its Iar.>-e size to within 12 m. of the bladder, where it appeal's to terminate in a blind extremity ; but ut the bottom oF this apparent cul-de-sac there is a small oriiice through which a bristle can be passed into the bladder, the narro'w canal being about IG m. in length. The constriction of the ureter at this part has resulted from its involvement in the contraction of the fibroid tissues about the neck of the womb. Left Kidney is normal ; its pelvis and infundibula are slightly enlarged. Ureter is a little narrowed near tlie uterus. ^.—Ruptured Follicle in Rigth Ovary— Peritonitis. E. L., get. 28. Admitted March 11th, with general peritonitis. Illness began on Saturday, the 8th, with a chill and pain in the abdomen. Continued at work, but on Sunday was much worse ; pain very severe, particularly on right side. She? had menstruated three weeks before the commencement of the attack. When sent to Hospital on Tuesday, there were all the symptoms of general peri- tonitis, to which she succumbed early on the morninn- of the 13th. yl«to/?s^.— IJody that of a well-nourished, healthy look- ing woman. Abdomen distended, and when opened intestines found matted together with recent lymph and peritoneum moderately injected. Inflammation most intense about the pelvic organs and specially in region of right ovary. More than a pint of sero-purulent fluid removed. Right Ovary 45 cm. in length, almost entirely covered with a layer of greenish lymph, which can be peeled off as a continuous membrane, exposing a discoloured, in- ilanied-looking surface. Close to the outer end, on the I; ii H , i 80 I'ATlIOl/xnCAL REPORT. anteriov surfiico, is a ruptured follicle with a blood clot hanti'iug- i'rom it. The orilici^ is round, 2 m. across with thin, dark-coloured (red mucosa is e.^posed. This exudation on the surface is composed of innumerable cylindrical epithe- lial cells — cilia, ill-deiined — leucocytes and a moderate number of red corpuscles. AVith these are librin iibi'ils and molecular fat, and occasional shreds of tissue made up of elongated cells, Teased bits of the mucosa show uterine glands, presenting nothing abnormal, and nunier- oils bloc 1 corpuscles. Broad ligament and Fallopian tube on right side, covered with lymph ; not so much on left side. Viscera of thorax present nothing abnormal. Abdominal viscera carefully in.spected with a iew of finding cause for the peritoneal inllammation. Stomach and intestines healthy. i blood clot •TOSS with Lit the sizo i^hat dark- ly yellow s IVoin it, a-iu. The ' is dark- ^uditioii is !)ii section stages of if corpora cured hut ^'O corpora ouvolutcd Peritoneal ith llakos ual thick- ee-fourliis of which elation on al epithe- moderatc >rin iibrils i made up osa show id nunier- e, covered a iew of Stomach BY WILLIAM OSLER, M.D 81 Remarks. — Reference is made in obstetrical works to the possibility of th(> occurrence of peritonitis after rupture of a GraaHan follicle, but I have not be(>n able to find any- thing' definite on the subject. The connection in this case would seem clear— in the a])sence of any of the well recognized causes of peritonitis, and considering the i'act that the intensity of theinilammation was about the right ovary. It appears, moreover, to have been an ordinary ripe follicle which had ruptured, but somewhat prematurely, as she had menstruated three weeks b(>fore the attack. The blood in the uterine cavity was probably not men- strual in the true sense. The history of the beginning of the atta( k and of the antecedent circumstances are imper- fect, and there may have been constitutional or sexual disturbances of which w^e know nothing, but which may have had considerable influence in liringing about the iirllammation. 4. — Exlia Uterine (Abdominal) J'regnamu/. S. A., ivA. 85, patient of Dr. Kennedy's, was admitted under Dr. Ross on November 18th. Had expected her confinement (second child) about the middle of October. On July 24th fd'tal movements \yere distinctly lelt. Early in August she statinl that she thought the child must be dead, as its movements had ceased, and on exami- nation they could not be felt. From the beginning of September she began to fail in health, got thin, and had chills followed by fever. The uterus was examined, and found to be healthy. When admitted, she was ])aJe, emaciated, and febrile. Abdomen is smooth, prominent, and somewhat tense; the lower zone projects, but no definite tumour can be felt. On the right sitle. low down, there is fulness and hardness and great tenderness. iShe has severe rigors, followed by profuse sweating. On the •t i V t !■ i: I "f 82 PATHOLOGICAL REPORT. "2th she had two greyish, very fVotid stools, containing- some macerated fcotal bones, a ti])ia and three ribs. The next day she passed a temporal bone. No aperture could be lelt on digital examination of the rectum. The condition of the woman precluded any idea of operative interference. She rt^mained in this state until the 30th, when death occxured. Aufopsij. — l)ody greatly emaciated. On opening the abdomen, ptn'itoneal layers below the navel closely matted together. After separation a tumour is seen, extendiiis- from the pelvis as high as the transverse colon, to which it is attached ; while lattt-rally it encroaches on the ingui- nal regions. The tumour is about the size of a child's head ; anterior walls ilaccid, and when cut into a large quantity of material, looking like a mixture of ashes and water, escaped. In this are the bones of a foetus, completely denuded of soft parts, and much blackened. All are dis- articulated and those of th(^ head separated. The walls of the sac are from 2 to 4 m. in thickiu'ss ; tin- lining mem- l>rane is dark-grc'y in colour, in some places c[uit 3 black. Behind the uterus the cavity extends as low as the neck, and on the right side are several sinuses passing into the tissues between the sac and the rectum. On the riaht side the sac is firmly adherent to the coils of the ileum; and in one or two places ulceration has almost caused perforation of the thin wall between them. A little to the left of the upper part of the sac is an oval orifice of communication with the sigmoid flexure, about 2 cm. in length ; edges rounded and dark in colour. In broad ligament of right side there is a cyst, the size of an apple, filled with material similar to that in the main sac, with which it is in communication by a valvular orifice. The Fallopian tube on this side terminates in the upper part of the cyst wall in a blind, somewhat dilated, extremity. Ovary of this side was not found. Tissues of brood ligament in both sides thickened and indurated ; and in BY WILLIAM OSLER, AM). 83 the ri-ht, below the smaller sac mentioned abovc^, there are lines of suppuration running towards th.> os' uteri and some ol' the veins in this situation coiitiiin thrombi ' Uterus is enlarged, ] 2 <'m. in length. Mihous membrane soft, not hypertrophied. 5. — Cri/ptorr-h idismus. R. M., rot. 3H; a strongly-built machinisf. Admitted with strangulated inguinal hernia of right side, which was operated upon, death Ibl lowing in a few hours. On openino' abdomen, omentum is injected and attached 111 right miiuinal canal. A lew ounces of dirty semi- feculent iluid in peritoneal cavity. A few flakes of Ivinph are seen on coils of ileum. The ))owel has b(>en nipped just three fret from the valve, and immediately above the constriction there is a tiny perforation. Right inguinal canal is large, admitting two fino-ers, and leads to a large scrotal sac. ° On examination it is ^e,m that the i)atient Inis been the sixbject of und(>sceiided testes ; the riaht oro-an lies ju^t at the internal ring, the left high up on the^postero-lateral wall of the pelvis. Both organs are very small, not laro-er than good-sized almonds. They were removed with the vasa defferentia, prostrate, and bladder. On dissection the epididymis of each organ is small and separated by a con- siderable interval from the bodv oj' the testis, th(^ vasa efierentia being very distinct. On section the substance of the organs is soft, yellowish in colour, and teased pre- parations show that there is an entire absence of secreting structures ; the seminal tubules can be uncoiled, but they are tilled with granular debris and fat. No trace of seminal ve.sicles or epithelium. The vasa defferentia are small and <>ord-like ; the In- mma very fine. Vesiculoe seminales are of a normal size, ' and from some of the tubes a fluid resembling semen can \ > I i m hi 84 PATllOLOGICAli UEPOUT. be squeoz('(I ; ])ut whon examined it is found to be com- posed oi' epithelial cells. No spermatozoa. In some of the laru'er coils there is a firm inspissated matter, like wax. Prostate is normal. Left inu'uinal canal admit.s the index fintrer, and leads down to the upper part of the srrotuin, forming' a short jwritoneal poiich. Nothing- abnorniid aboiit the other organs. LY.MPILVTIC SYSTEM. 1. — Medullar fj Sarcoma of Axillary Glands — Sevondarii Masses in Heart. Lungs, Stomach, Intestines, Liver. Spleen, Kidneys, Supra-Renal Capsules, and Pancreas. P. B., tet. 45 ; for two and a half months had noticed the rapid growth of a tumour in right axillary region. Had lost 30 lbs. in weight. Great ccdema of right ana. Liver enlarged and tender. Left upper ej-elid paralysed and left pupil dilated. All the ocular muscles of this side are paralysed. Optic disc and retina normal. Antopsy. — Body that of a medium-sized, toleral^ly well- nourished man. Right arm and hand much swollen and cedematous, fully double the size of the limb on the loft side. In the right axillary region is a large tumour, involviiia' also the shoulder and all parts aboiit the head of the humerus. The largest mass iills up the axilla, being' moulded upon the chest, convex externally ; above it reaches the clavicle, below the level of the Tth ril). Anteriorly it extends below the clavicle to within two inches of the sternum, while lower down it reaches the mammary line, almost touching the nipple ; posteriorly it iills the subscapular fossa, infiltrating and destroying the muscles in this region. The axillary vessels pass directly through the mass ; the artery is narrowed, but the probe passes freely. The vein pursues a sinuous BY WILLIAM OSLER, M.D. 85 course and in places is almost obliterated by the proiec- at any part The cords of the brachial plexus are com- pressed, but not niiiltrated. The deltoid muscle, whereat passes over the head of the humerus, is much thinned • benel^'th"'' " "-"^^'''"^ ""^ ^^"^'">^«^- Immediately beneah the acromion process, and to the outer and back part 01 the head of the humerus, is a large rounded pro .lc|ct.on, which elevates and involves the terminal portions ot the infra-spinatus and teres minor. The neck of the scapula .s eroded and the articular surface almost separ- ated from the body of the bone. The coracoid process and upper border are involved, the o,.owth passiiu. through the bone and infiltrating the supra-spinatr s. Th^ articuhu^sur ace of the humerus is covered ly peculiai^y d^T, leathery tissue, not unlike the filmnous laminte of an old aneurism. The ligaments are all involved and the On secion of the large mass beneath the pectoral muscles aud m the axilla, it presents an indiltinctly lobulai appearance ; the surface tolerably firm, greyish- white in colour, interspersed with blood-red areas of either extravasation or congestion. Heart presents nothing unusual beyond a secondary mass, the size of a cherry, in the anterior wall of the lei' nodules, ranging in size from a pea to a marble On sec ion, whitish in colour not very vascular th Ztrif -n-^' iT^/"'^'' "^'^ "^ *^^ '''' «id^ - mass tHe sue of a billiard ball exists at the root of the luno- .V... on arged, 320 grams. Four masses, the size^'of large walnuts, project from the convex bord.;. Onrthe Tlo rh^'"''''r'^- -^^ '''''''' '^'y ^^^ reddish-whiie in colour, haimorrhagic in centre. 8 ^'\ I > ! I } J 86 PATllOLOdlCAL UEPOET. Kidneijs onlarg't-d, ]o))iiluted. Subslaiict' thickly stiid- dod with secondavy masses, some us larue as mar])l('s. The majority <>f them have an opaqxie-while appearainc; others are dark-red, or <'veii l)la('lc. Sitpra-reudl bodies eiihiriicii and e\l(Misively inUltratitl. Pancreas presents several si'condary masses. Liver weighs '),!I70 grams., and is unilbnuly eidarged : surlUce smooth, no nodular masses, l»ut on section thnc is seen a dill'use inliltration o( extensive areas, not sharply delined. hut blending with normal looking substance. Sloinarh. — On the mucous membrane of i'undus then^ is a Hat elevated mass, beginning to ulcerate on the surface. Intesfiiifis. — About twtMity small ulci rs are seen through- out jeiunum and ileum, lUMirly half ol" them being in tli(> upper part of the bowel. They range in si/e from a three- penny bit to a sixpence, or a little largt>r; edges much elevated, bases cupped and covered with p greyish-yellow material, beneath which is a firm tr-inslucent malri.x involving the coats of the bowel to the d(^pth of 3-4 m. In the cavum are eight or ten ulcers presenting similar characters. The Brain itself presents nothing abnormal, but the pitiiitary body in the sella turcica is enlarged a.id soft, and a tolerably firm extension from it passes into the left cavernous sinus, stirrounding all the parts in this situa- tion, the whole forming a firm immovable mass. The 3rd nerve runs along the top of the mass and was dis- sected off without mi'ch dilTicnlty, appearing somewhat compressed. The 4th is imbedded in the upper part ; the 5th passes to the outer side, and is not involved ; the 6th is on the under surface, and in part of its extent is surrounded by the tissue of the mass. The artery is not compressed. The histological notes of this case have unfortunately been mislaid. Both primary and secondary masses pre- sented largt; ai cut loc arrange masses : in the organs ; 2.—Sa} J. S. subject ( rapidly ] cmaciati On oj; occu[)y pushed i adherent behind t tresses d of the na join it A cava, per lay a littl tumour if riaht kidi estimated semi-iluct and in fr teriorly ii column ai ■slightly ei a soft cer here and t the poster: hito the ff BY WILLIAAf OSIJiR, m.D. 87 M'nt..d th,. characters ol' .urdullury sarcoma, tlio r.-Ils hein"- hivgi^and round, tho stroma variable iu amount iu dilliM^- ont localitu^s and not prcsi-ntin- a distinctly alveolar arrangement. The oe.urrence of secondary uh-erating masses i. the stomach a)id intestines is a ],oint of interest H. the case, on account of the rarity with which these organs are attacked in secondary disease. 2.-Sarcoma of Re fro- Peritoneal Gfands-Lobstein Cancer. .T.S. Mah' child (patient of J>r. Gardner), .ot. 3 ; the subject of an abdominal tumour, which had been growino- rapidly for al,out three months. Position central. Kapi3 emacnition. Belly greatly distended. Oil op..ning the abdomen a large tumour is seen to cciipy almo.st the entire cavity, the intestines beino- Pii^hed into the pelvis. At the upper end it is closel? adherent to the under surfa.-e of the liver. It lies entirely behind he peritoneum. In front the ascending colon crosses diagonally ; the caecum is pushed up to the level oi the navel and the ileum runs along the lower third to join U A httle to th,' left of the median lin.^ is the inferior cava, Pernous in its whole length, but empty ; the aorta ay a little lurther to the left at the side of the mass. The tumour IS easily turned, having no adhesions except to the viLiht kidney, which is paitially imbedded in it. Weio-ht estimated at about 12 lbs. It is soft, and with an elaslic, .^emi-iluctuating feel. It is enclosed in a thin capsule and in li-ont and at the sides by the peritoneum; pos-' toriorly it is m immediate contact with the vrtebral column and lower ribs, the 11th on the right .side being «ligh ly eroded. A section made through the mass revealed a solt ccrebriform tissue, white in colour, interspersed lore and there with vascular and hcomorrhagic spots. At the posterior part exiensne ha-morrhage has tak.m place mto the growth, and the tissue here is blood-stained and : i ! ! ? r' '^ P 8K PATHOLOdK'AL UEPORT. r n miiiirled with riots. The mass is uniform thronijhoul ; not lobulalt'd, aiul duos not pri'scmt siuiis of dcLicncratioii. The llighl Kidney is murli llattcncd, and tho upper and anterior part is involved in the uTowth. The ureter passed throuffii the mass and was partially compressed, the upper part and thi' pelvis ol' I ho kidney being dilated in consequence. No secondary masses. Microscopii' apix'arancos are those oi' a rapidly grow- ing' lymphoma, composed of small, closely packed lymph corpuscles. 3. — Li/mpho-sarcnma nf Dee// Cervical Glands, involving Hip Tlif/roid and siiiuflaling Goitre. M. D., rot. 1(1 ; an average sized, biit feebly-doveloped girl. Had been under treatment for three weeks for what a])penred to be an ordinary bronchocele. She stated that she had not noticed it before, and it had grown rapidly while u)ider observation. On the evening of the 14th f>f ( )ctober she became restless and had considerable ditliculty in breathing, so much so that a consultation was hdd as to the propriety of i)erforming tracheotomy. She became easier and the operation was deferred Later on in the evi'ning she got up and walked about, and, according to the statements of the attendants, died suddenly. Autopsy, 18 hours after death. Lips a little bluish ; face pale ; no lividity. A large round mass occupies the front of the neck in the situation of the thyroid body, extending to the left and projecting to a level with the chin. Skin over it is tense and the surface has a leaden hue. Heart. — Right chambers moderately full, not distended. Tricnsnid orifice large for the size of the organ. Left chambers contuni small amount of lluid blood and clots ; HY WILLIAM (XSLEK, m.d. g^ n-ntricl. nol (lac-id. Valves normal. Abou, lu o/. of blood and clots ..s.ap,.d Iro.n (h. heart and vess..ls in the im.l.m.nary iiuisiouN. and in th.- ren.ov.d of tlw oro,,n />'/«ir.s crepitant thronnhout, and contain a ooo.l deal ol" l)lood in dependent parts. Ar.-h of aorta, vessels, and nerven of the n.-.-k, with th.. nmonr. larynx, trarh-a, and pharynx rnnoved t()o-,,her The mass tnrns ont easily, but .xteiuls do.ply into the n.ck beneath the muscles on the left sid.. u hi.h are stretched over it. Tonsi/s-and glands at base of tonoue swoll.-n and of an opac, le white .olour. (Esopha^n.s considera}>ly compressed, the little hnovr just passes at the narrowest portion. On sJit nig. It opPii, mucous membrane normal. G/olli, natural looking-. I'rru-nea push.nl to (he right and .onsiderably 1 attened in the antero-posterior direction by the pit^ssure he enlarged l.ft lobe of the thyroid. It admits the little hnovr, so that there is no very o.-, ,osis ; but it may have been greater t,efore the ( .,,1 ou the skin was relieved. On e^tamining. the tumour from the front, the oTowth is seen to involve almost .xchusivelv the ieit lol),> of the thyroid, in the situation of -vhi.li there is a large round mass 20 cm. m circumfercnee, which extends above to the leve ol the thyro-hyoi, .ment, and below passes down beside the trachea to th. bifurcation. In a groove on the outer side of the mass, th<. left carotid artery and piieu- mo,gastrie nerve are deeply imbedded ; both are stretched but not otherwise afle.-ted. From behind, the mass is elongated and of a somewhat oval shape. It lies along the whole length of the left side of the trachea, the lower end resting on the lelt bronchus. Along this surface it mea.sures 12 cm. in length, 5 cm. in breadth. The cosophagus lies between this somewhat flattened i.osterior snriaee .and the spine. The right lobe of the thyroid is of normal size and LftI Ii"#r-' 90 PATHOLOOICAL REPORT. appearance. At the upper and right angle of the mass in front, there is a small thin remnant of the left lobe, capping the tumour in the situation ; the tissues of the two blending together, not separated by a capsule. The mass is of a greyish-white colour externally, and on section the external parts are moderately firm ; centre soft, like softening brain matter. The whole is interspersed with vascular spots. Left pneumogastric nerve is stretched, but not otherwise involved. Teased bits from any portion of the tumour show numerous small lymphoid corpuscles, which, with a small amount of delicate connective tissue, make up the chief histological elements of the growth. In the part corres- ponding to the left lobe of the thyroid there are strands of fibrous tissue, but, except at the extreme upper part of the lobe, there is no trace of the proper gland sub- stance. : mass in )ft lobe, IS of th<' le. The 1 sectioi) soft, lik(^ led with :retched, ir show L a small he chief t corres- strands per part ,nd sub- M i ■ ■) i»f ■ I li '! SY HBOFESSO I Rep) ^1 Xkk J_ ON TPIE I ill I w SYSTOLIC BIUIN MURMUR op CHILDREJ^. BT WILLIAM OSLER. V, U, M. R. C. R Lovn ERSITT, MONTREAL. l/irprfntedfrom the Bo^lon Me,lical and S,n;,ical . Vfal Juuriial] CAMBRIDGE : 1880. i ■! ■ i'l I I : t ^S^^RI n if ■B hE^I 1 f I ■H ni , ! 1 «jl m 1 f 1 K'« 1 i« ■ii If ^B' Hi ifli hBk' M^ I^^H H^Bj ID ', ! HI > ' V I I I' ' '' r • : ON THE SYSTOLIC mim mmmi of ciiildjien. nv n-iLLivM osi.ER, m. d., m. r. c. p. i.ond., Professor of tkt his'ilutes of Medicine, McClill Vniversily, Montrad. I DESiuic ill the followiii!.' communication to call attention to tliis interesting clinical {)lienomeiion, first described by Dr. J. Fisher, of Boston, in the Aled/cf Mtgazim for l«3;i. Like many other observations, this one has suffered from the lapse of time, and has been, to a great extent, forjiolten and ue'«t""s'-''"-'» Scluidelgerausclies der ■ I ^ ■i/l 4 The Systolic Brain Murmur of Children. \yere very anxious. Tlie cliild was a wcll-iiouri.sliod little t;irl, wiili a nidcly comiilexioii, weil-fbnnpd lu ad, fontanclles closed ; no evidences of rickets. On plac- ing the ear upon any part of the head a loud, high- pitched systolic murmur could be heard, variable in intensity, loudest in the temporal regions, also aiidihle in the carotids, and disappearing entirely on compres- sion of these vessels. Tiiere was -no heart disease. Tlie mother had noticed the noise in the head, she llionght. from the time the cliild was a year old, and the child also appeared conscious of its presence, but said she only heard it at intervals. The medical at- tendant had suggested the jiossibility of aneurism, but there did not seem to me to be any evidence in fhvor of such a view. I had a distinct recollection of the fact that a murmur was described as occurring in the brains of children, but I thought it was always audible over an open fontanelle, and partalsing of the nature of a venous lium, originating in the longitudinal sinus. As the child was in good health, and the murmur had persisted for nearly two years, I gave a favorable prognosis. The mother did not appear sati.slicd, but I heaid nothing fiMther of the case for some months, when I recognized it in the description of a Case of Supposed Gunmiy Tumor of the IJrain, in which the murmur was altributed to the possible existence of a syphilitic growth pressing upon the vessels at the base of the brain. About the same time Jurasz's memoir came to hand, and renewed my interest in the case, which has proved to be one of unusual value from the length of time which the nuirmur has continued. The history of the child from the spring of 1877 to the present is as follows: she lias thriven, and is now a bright, intelligent little girl of seven, perfectly healthy, head not enlarged, and no trace of swollen lymphatic glands in the neck. I have examined her on' four oc- casions, and found the murmur persistent, with the same characteristics. On the loth of Jlay of the pres- ent year I examined her again, and found it still verv The Systolic Brain Murmur of Children. 5 .listinct, lo.ulest in tlu, temporal re;rioM,s, nitl.er more vunal.Io .1. n.tensity tlian liitl.ert.., aiul .sometimes .lis- apjH-an..;: entirely tor a fen- monieuts. It was with (lilliciilty lieard m the carotids. I have cxamine.l about sixty diildren for this mur- UHir, and have discovered it in eis,'Iit cases, all un- der three years of ao(" : one, a ease\,f chronic hydro- cephalus; one, chronic intestinal catarrh with rickets- the olliers appeared liealthy. Amonjr the sick chil- dren exanuned in whom no mnrmur existed were sev- eral cases of rickets, tuo of tuberculous merin-itis, and one of chro.Mc hy,ii<,.l.f„utnnl." Aoflv^l, 1«H0. CASES OF [NSFLAR SCLKROSfS. liY WM. OSf.KP. y\.\).. ^]\{('V., l,oNt.. Prof(.f.Rni of fhr liistifiittK of M.'.lirinc, .M,f;m rinivcrsily ; Pliysi, inn to tlic Mniitrtal C'licial Hospifnl. iRfod l,rl'»-e !!,>• Mrrln.i-fhinnfii,',,/ S;, iH„ nf Mnntyinl) TiKNTLEMKN : 1 wish to l)iiiig uii.ler yn.T,^'ctic!iIlv. and iiinro r.'ad.ly controlled ; the shakin- of tlu- i,an.i is w..|| marked and cmsisfs in a series of rapid. sl,„rt, partial, arts „r pronatin,, and supniation. Wl.en tl,e arm is pla.-.d at rest t'le motion ceases, quickly ,f laid naturally in the lap. n.ore shivvlv if laid upon the table or a hook. Whenever a \ohn,tarv 'ellnrr U made with the arms the peculiar niuvenients K.-i,,. ,.;,„i |„,^, ,, 80 active that it is oidy with -reat uiDicnlty and aftrr several attempts that he can pick up his hat. At llie liist part ,.f thr examination the arms showed a sli-ht trcmulousness even when at rest, but this was apparently due to nervousness, as after- wards it completely disappeared. In the upright position therr is a sli-ht to and ['vn oscillation of the head, and when walkii.^ there is a noddin- mutiu,,. which gives him a very o.ld appearaiuv At rr., ,„? ;, , ,ii,„v there is no movement. There is very sli;^ht trembling noticed m the legs when held out ; the act of walkin- is unaffected. The muscles appear well developed, the -rasp of the hand is firm, and motor power gen-rally is retaine.l. Dr. Haviies states that the electrical excitabdity of the mu.scles-faiadic and galvanic — is present. The voice is peculiar, the utterance being slow, and the words brought out with distinctness and with the appearance of Blight effort. He states that he does not experienc ;.v diffi- culty in speaking, but has noticed for some months p.\ , that the voice has altered, and the words do not follow e-dc„ other so smoothly. Muscles of tongue and lips appear healthy ; no fibrillar tremors. SenmtioH is intact ; no abnormal sensations in affected limbs. The tendon reflex well marked, but not excessive. Organs of special sense are normal. Psychical functions intact. No head- ache at any time. No symptoms referable to tlmracic or ab- dominal viscera. Has been short of breath for the past two months. General health is excellent ; appetite good ; sleeiiswell. 8 Hy a hapf)y coincidi'iice I hud Enues^ei ircliiv 15. WII ) r)ii Mltlt 'rt article (in Ziemssen'a i|ili' ftclerosia Ix-fbre rae when the piitk'iit fame ill, and tlio svini.tniu.s presontt-d by 1 so CloS( lim correspondt'd seeinod very ly with til." dcsoriptini, I h;i,i just ivad' that th." d lui^nusia char, roli^ •win;,' is the laiiiily and personal history : Father and mother (lead ; had not 1 t' roin iicrvuMs prostration, and h lail any nervous disease. A sister snlfer,' lis attacks," diirini' which she cannot talk. Other hrothers(;;)aiHl sisters (:.)»-, i.^^i^,,^ i,,^^ '"•''I' cn^rji^ed in mercantile occiPation since I;-. .hvctir. 'boutfive year. a,^o, when in .he employ „i a West Ind an"(lrm in f^ondon, tho trouhlos be;^,,„ ,v,rh dillic.lty in writi,.^. „ n,,„ t . an , .ability t" li"ld the pen properly. From the accuniit wl :., ], -dves the attack socMucl very like writer's cramp. It did not, however prevent hnn from writin- with tl,.. ri^ht hand for manv months l>ut at last he had to .lisconiim.e, and then learnt to write with the lett hand, which at this time shook very slightly, and could l.c stea.l.ed by efVort. Wrote with this hand Corabont eight months, iiiid then had to give up on aecunt of the constant oscillatio,, At this tnne he could still cut up meat and feed himself, but for tiio past year the movements have become so increased on atten>ptmg any action, and ir is only with the greatest ettbrt that t I'' >nnplest .luty can be performe.l. A glass of water lifted to the mouth ,s certain to be spilt, and on attempting to take a spo..nf«l of soup or lift a bit ,.f n.eaton ,, fork to the mouth, the UTOgularity ..i the movetnent is su<-h that the fo„d is much more likely to r..aeh either ear. It is o,dy within the past year that the movements oi' the head have come on. <'ASK fF..--.)a,nes Hennet, n,..^,l [4. an average-sized, dark- co.nplex.oned man, was admitte.l to the Gene.-al Hospital under my care in May of this year, eomplainin , of inability to walk and a t,-embln.g .novement of the anus. He has a somewhat '1>'1I look, but answeivs .piestions intelligently. The follow- J syniptonis a... p.-csented : When sitting at ease the muscles ot the hands a.'e seen to twitch, particularly those of the left and when the arms are extende.i, us in the attempt to perform' any voluntary action, a shaking tremo.' begins, consisting m a J ' •1 ! 1 *i i' m Efii series of to and fro oscillations, the excursions in the right arm heinj!; sli,i;lit, in the left very considerable, sufficient to cause sli>i;lit movement of the tniid<. The tremor is not very rythmic, hut is sufficiently characteristic. In the left hand he can hardly hold a cup, l)ut almost involuntarily assists with the right. If asked to try to restiain the movement it becomes much worse. The tremor ceases when the arms ai'e at rest, and the muscular twitchings diminish greatly when his ntteutiou is withdrawn for some time to othei' matters. The grip with either hand is strong. Karadic excitability of the muscles normal. There is no to iind lio movement of the head. The legs are well nour- islied, and when held out shake irregularly, but the oscillations are neither so tine nor so regular as in the upper extremities. Fatimt can liarely stand alone, but does so readily if assisted, and can then walk across the ward. If encouraged he tries to do .so alone, and can walk several yards. The gait is peculiar: the legs are aliducted and wide apart, the knees slightly fle.xed, the trinik thrown a little forward. The feet keep clo.se to the floor, but the toes are lifted, and the heels appear to touch the tioor first. Does not look at the feet, ("an not stand with eyes shut (Jreat difficulty is experienccil in rising up and sittin"' down, and also in turning round. The legs shake a good deal in making the steps. When tongue is protruded it shakes t'li. /luisse, and also pre- sents libriilar tremors. Slight tremor of lips and muscles of expression when in action — none when at rest. The reflexes are exaggerated, the •• knee tap" phenomenon being well marketl, and the ankle clonus readily obtained. Skin reflexes not exaggerated. No disturbances of tn'tiaat)"/!. The voice is peculiar ; the first words of a sentence are clearlv, though slowly, pronounced, the condusio.. is usually indistinct, at times unnitelli-ilde, from the running together of the words. The speech altogether has a thick, blurred character, reminding one strongly of that of a drunken mar,. The act of swallowing is well performed. Eyes look normal ; there is no nystagmus ; pupils medium sized, active. Sense of smell good — can distinguish auuff from pe[iper. Has no head- ache or pains; sleeps well; cats well. Intelligence appears impaired, but his conversation is (luite rational. Has been im- potent for about a year and a half. Functions of rectum and bladder normally performed. Examination of abdominal and thoracic viscera negative. Temperature 08°. The history, as far as can be ascertained, is as follows : Worked 18 years in the gas-works, latterly as a carter ; has been very industrious, and had amassed a little property, lias been mar- ried 21 years, and has seven children ; has been a very hoalthy man ;^ has taken alcoholic liquors freely, but never " lost a day" by drink. Seven years ago had sores ; no history of any second- ary affections. In Apiil, 1878, his troubles began with business difficulties in a building society, whereby he lost his property. This worried him greatly, and, as his wife says, " he was not the same after." On the _Mth of May he was arrested fur stealing a jacket from a yard which he was cleaning, and -.vas sent to jail for a month. After being discharged ho began to act quecrly, ' carting other people's bricks and dumping them on the road, stealing little things, and making bird-cages, which he could never finish. Was rather dull, moping and despondent. Never ap- pears to have h'ul delusions of grandeur or wealth. In July ho was arrested for taking some boards, and was sent to jail, and from thence to the asylum as insane, whore he remaine,'er ones, there i.-i an infiltration of leucocytes about the atlventitia ^perivascular lymph apace) to an un\isual extent. This hi3tolo,sorption of broken down material and increase of fibrous tissue) ol a spot of infiammatory softening. •Zeitschiift, f. Klin. Mcdicin., M. J., 1879. iw l"^- xun ii ON DELAYED RESOLUTION xj. Has been a healthy man. Is not intem- perate. On April 5th got heated shovelling snow, and lay down on a sofa near an open window. In about an hour he awoke and immediately had a severe chill, lasting about 20 minutes. Became feverish during the night, had severe pain in the right side, got very hoarse and began to cough. Has been in bed ever since suffering with shortness of breath, fever and cough. April i6th, i2lh day of illness. T 103^ P. 102. Pulse- respiration ratio I to 3'5' Face is pale and distressed look- ing. On examination, chest well formed, deficient expansion on right side ; percussion reveals dulness on right side in front as low as the angle of the scapula, in axilla to 4th rib ; blowing breathing and sub-crepitant rales over dull regions, tactile and vocal fremitus increased. Heart action strong, sounds clear. Nothing special in examination of other organs. Cough is very troublesome, short and hacking ; expectoration, viscid and rusty colored ; bowels are relaxed ; urine about 40 ozs, high colored, chlorides present, no albumen. Ordered the Hospital acute pec- toral mixture and linseed poultice to the chest. Reported by Mr. Emdon Fritz. ij " - ' . 1 4 DELAVKD KK.SOI.UTION IN PNEUMONIA. The condition on the 13th, 14th and 15th days remained the same. T. ranged from 102° in the morning to 104° in the evenuig. Respirations about 40; pulse no to 120; bowels moved two or three times in the day; has been taking quinine, 10 grs. per diem. i6th day, seems better. Morning T. 100°, P.84, R 28 cough less troublesome, expectoration viscid but not so rusty' No change m the physical signs in front, behind the dulness appears cleanng a little at angle of scapula and there are some line sibilant rales in this region. 17th day. T, morning 99^; evening ioo<', P. 81, R. 28 ; cough not so worrying ; expectoration muco-purulent, very slight- ly tmged ; urine more abundant, 50 oz.s., not so high colored. 18th day, marked improvement in patient's condition • leels easier than on any day since the attack. T. morning 98^ evenmg loi^ R. 28, P. 84. Dulness is diminishing be- hind, but IS still very marked in the inter and upper-scapular regions. The riiles are coarser and the breathing is less bron- chi.l. In front dulness is scarcely so intense, auscultatory signs persist. 2ist day, patient continues to improve. T. 100^ on previous evening, normal this morning ; pulse 80, R. 26 ; expectoration ess abundant. In front the dulness is much less intense • breathing still bronchial in clKiracter ; lales very numerous at end of inspiration and becoming more liquid in character. Be ,ind the r.ote is much clearer, (he breathing is becoming more natural and the rales not so abundant. 24th day, very little difference in the percussion note at apices behind ; in front a shade o( dulness persists, and on dee,, ■•nspiration a k^v rales. Expiration is considerably prolonaed and hollow. Temperature 99°. Cough has ceased to be trouble- some ; expectoration scanty. 26th day (April 30th), temperature normal, feels much better and was allowed to get up for a short time. Rales have disap- peared. The prolonged and hollow character of expiration very marked. ' Fiom this time patient gained strength steadily and was dis- DliLAYElJ RESOLUTION IN PNEUMONIA. 5 charged on the 14th of Mny. The marked prolongation of the expiratory murmur at right apex persisted. Tiie treatment throughout was restorative ; nourishing food, six ounces of wine and from 5 to 10 grs. of quinine per diem. CASE II* I.OnAR PNEUMONIA OF IHE RIGHT LUNG. RESOLUTION IN 8rH WEEK.. F. S., aged 42, a well built man, was admitted to the General Hospital on May 10th, 1880. Served in the army for 21 years, has been a healthy man, had gciorrlia-a and a bubo. Is not a hard drinker. Initial chill on M(jnday, May 3rd, followed by fever, cough and pain in right side, which have persisted. On admission face suffused, anxious-looking. '!'. 102', P. 117, of fair volume, R. 36, and shallow. Short cougli with rusty sputa ; complains of pain in region of right nipple. On examination, expansion defi- cient on right side. Dulness over whole of this side behind and extending well into axilla. In front dull beneath clavicle and for a finger's breadth below it. Blowing breathing, fine rales and e.xaggerated fremitus over dull areas. lioweis open, urine high colored, chlorides present. On the iith and 12th the tem- perature kept about 103", respirations 35-40, P. 112 to 125. There was considerable distress, and troublesome cough. On the night of the 12th was delirious, and appeared a good deal worse in the morning. At the mid-day visit on 13th the dulness in front was founil to have extended as low as 3rd intercostal space. T. 102°, R. 6.., P. 120, and smaller in volume. Is slightly cyanotic in face and finger tips. Ordered the stimulants to be increased. At 10 p.m I went to the Hospital, as I felt uneasy about patient's condition. Found him dozing. R, 66 P. 130, small and weaker than in the morning. Face more cyanotic ; finger tips blue. Feeling convinced that the patient was gradually dying of suflbcaiion I ordered him to bo bled, and the House Surgeon abstracted xviii ozs. of blood fioin the arm. Fifteen minutes after, patient expressed himself as much relieved. Respirations 52, P. 106, and of much better volume. In the morning (14th) i ' f Kepoileil l)y Mr. J. C. Slumks. I Y- 6 DELAYED RESOLUTION IN PNEUMONIA. P. io6, R. 40, T. loi. Had a better night, not so delirious. Face still suffused, but not cyanotic. May isth (12th day of illness). Feels better. P. 87, R. 30, 101-5°; expectoration abundant; rusty colored; cough T. troublesome. Physical signs persist unchanged with the excep- tion of the rales, which are not so fine as they were. For the next five days the temperature did not rise above 100°, and his general condition improved. Expectoration abundant, less viscid and not so blood-stained ; no essential change in physical signs. On the 20th temperature began to rise, and on the evening of the 2ist reached 102.5°. 'I'he respirations and pulse also in- creased slightly in frequency, but examination of the chest did not reveal any extension of the inflammation. On the morning of the 22nd, T. was normal, rose to 101° in the evening and until the 29th kept between 101° and 103°, there being no regu- larity in the exacerbations ; on the 23 and 24th, evening exacera- tions of 3° took place. During this period the cough has been rather more troublesome, expectoration abundant, less viscid, but still rusty. Note as to condition of lung on the 29th is : — Dulness persists in front to lower border of 3rd rib, and behind from apex to base. In front, inspiration blowing and at the ter- mination there are sub-crepitant rales ; in 2nd space it is distinctly wavy. lixpiration loud, coarse and prolonged. Behind, bron- chial breathing with rales over whole surface, at extreme base the breath sounds are less intense. From the 31st the temperature remained, with the exception of the morning of the 4th of June, below 100°, the morning record being 97°, and the evening between 98° and 99*^. June 5th (34th day of disease). General condition is im- proving, cough less troublesome, expectoration more liquid with small yellowish-brown bits scattered through it. Appetite is good and he sleeps well ; bowels are freely moved about every second day ; amount of urine averaged about 45 ozs ; respirations 20 to 25 per minute; pulse 80. Note of this date on the physical signs is: — Dulness unchanged; subcrepitant riiles in front; wavy in- spiration persists in 2nd space; in quiet inspiration no rSles heard behind, only the bronchial breathing, which is in marked contrast to the normal sounds of the opposite side ; on deep inspiration^ DELAYED RESOLUTION IN PNEUMONIA. 7 very fine small crackles at the end of the act ; vocal and tactile fremitus increased. T3th. The past week has made very little change in the con- dition of the lung, physical signs absolutely the same ; was weighed on the 8th, turned the scale at 120 lbs. ; normal weight over 145 lbs.; expectoration not so abundant, half of a pint in 24 hours, is more tenacious; pulse ranges about 76; respiration about 20. Measurement of chest gave 16^ inches for left side, 15^ for the right. i6th— (4Sth day of the disease)— Dulness not so marked from the angle of scapula down, and the note here is rather tubular in character. The rules are more abundant, particularly in supe- rior axillary region ; at the base the breath sounds are feebler than in other parts, but have the same bronchial character. Patient gets up for a little while each day, but feels very weak. 19th. Was weighed ; has gained sV^ ^^^- since the 8th. 22nd. In front the dull note is not so marked ; breathing still hollow, and expiration is much prolonged , rales not numer- ous. The posterior part is also clearing a little, breathing harsh and bronchial, rales scarcely to be heard, except at outer border of scapula. From this date resolution proceeded rapidly. 25th— (54lh day)— Dulness in front has almost disappeared ; breath sounds coarse, expiration prolonged. Behind there is only a slight difference to be noticed in the percussion note in the scapular and inter-scapular areas. Two fingers breadth below the angle of scapula the note is decidedly tympanitic. The breathing is coarse and rough, compared with the left side ; rales only at outer border of scapula ; tactile and vocal fremitus still a little exaggerated. General condition is very good ; has scarcely any cough, no fever, and has a ravenous appetite. Improvement in condition of lung continued, and on the 28th he was discharged, the dulness having entirely disappeared, ex- cept a shade at the right base ; breath sounds somewhat coarser and expiration prolonged, particularly noticable in front. July 8th, ID days after discharge, reported himself for exam- ination ; weight 137 lbs ; looks much better ; examination of the chest showed expansion to be still a little defective on right side, particularly at the base. Scarcely any uifiference in the charac- l. i ' f.* 1: ti m 8 DELAYED R[':SOI,UTION IN PNEUMONIA. THHi 'iWm- J iJMi • i 3 jflH f fiSs 1 f if ter of the breath sounds on the two sides, except at the extreme right base where the respiration is weaker, and there is still a shade of dulness. The treatment consisted in full stimulation in the early and active stage of the disease, poultices to the chest, moderate doses of (luinine, and tiie iodide and acetate of potasli en the supposition that they might favour resolution. It is difficult to understand how a solid exudation can re- main for weeks in the air ceils without permanently damaging them, but that it may do so is evident from these and other cases. The lung appears to alter but little, maintaining the features ot hepatization, (irisolle gives a case in which death occurred on the 6oth day, and yet the affected part looked not unlike the acute stage of the disease. On July 20th, 1877, I performed a post-mortem on a man who was stated to have been ill with pneumonia for between two and three months. The whole of the left lung was solidified, in a state of grey-hepatizati d^ in II 1 'In 1 1 PWM ■ ^^B i ■I'sJ^^ . ff" "Xxx//* s ft -L ON HEREDITY IN PROGRESSIVE MUSCULAR ATROI'HV Ah ILLUSTATED IN THE FARR FAMILY OF VERMONT. Bv WILLIAM OSI.KR, M. D., M. R. C. P., I.OND. PROFESSOR OF TKK INSTlf U IKS OF MKDICINF. IN MC (,11.1, UNIVKHSITV, MONTREAL. Tlie accoinpanyint; genealogical chart of the Farr family illus- trates well the hereditary nature of progressive muscular atrophy. I will first give a brief account of the member of the family who has been under my care : Erastus Farr, aged 47, a farmer, from hl,f^j Vermont State, admitted to General Hospital September 16, 1880,'^ '^i^ ^ complaining of weakness in the left leg and i)eculiar t"'itchings in the muscles of various jjarts of the body. He is a tall, large- boned man of medium muscular develo|)nient. History. — Has been a hard worker, very temperate, never had any serious illness. Is married, has seven children, all of whom are well. About fourteen months ago began to notice twitchings of the muscles of the left buttock and thigh, which gradually in- creased in frequency, and within six. months after their onset he felt the left leg weaker than the right. Has had no pain, only the uneasy sensations caused by the muscular tremors, which he de- scribes as occasionally accompanied by a feeling of nausea. Dar- ing this year the left leg has got steadily weaker and has dimin- ished considerably in size. The twitchings have also become general and occur irregularly in different muscles. Present condition. — When stripped, the left leg is seen to be smaller than the right, owing to uniform wasting of the muscles. Measurement gives a difference of 2.5 cent, in the circumference of the calves, and 7 cent, in that of the thighs in the middle third. The atrophy is best marked in the hamstring and gluteal muscles, Reprinted from the Archives of Medicine, Vol. iv, No. 3, Decenufcer, 1880. ORIGIN A I. OHSKRVA J JONS. of tl le same side. and extends sliglitly to tliose of the lumbar region I''il)rillar twitchings are of fre([iient occurrence in tlie muscles of tile affected I'.'g, and also in tliose of tlie t runi' and other extremi- ties. 'I'he strength of the left leg is greatly reduced. Sensation is less acute tlian normal in the legs ; the jioints f>f the ?csthesi- \vo impressions are cm eter have lo be separated o\ er 7 cent, betore t perceived, and there is scarcely any difference in this respect be- tween the legs or different parts of them. The electro-contrac- tility of the muscles is preserved. In walking, jjaticnt re(|uires the aid of a stick, and drags tiie left leg very mucii. He remained in hospital about a month, and was treated with the galvanic and faradic currents without evident benefit, though he thought him- self somewliat improved. Family history. — Thirteen individuals in two generations have been affected, nine of whom have died. The following is a brief record of the cases : Saimni Farr, father of patient, died at age of 61 ; ill over two years. Patient cannot say what his ])aternal grandfather died of ; never heard that it existed in that generation. Samuel Farr had ^wii brothers and sisters, t\ wo of whom were affected. One brother, Frasfi/s, who died at the age of 40 lis was the first c. ise heard of in the family. One sister, Afrs. Streeter, who died at the age of 54. It is probable also that another sister, Mrs. Stoddart, had the disease. She died of paralysis, but whether this form or not is doubtful. Ten members of the second generation have been affected. Two of the jAitient's brothers and one sister : Saniiiii, who died at the age of 45 ; ill over two years. Had .six children. Wesley, aged 41, at present affected. Has no evident wasting, but the fibrillar twitchings have begun, and he has rheumatic ()ains. Has two children. FJli'ii, died at the age of 27. Had four children. Six of the patient's cousins, as follows : Alinira (daughter of Mrs. Stoddart), aged 45, still living, has been ill over two years. Has two children, one a cripple with legs undeveloped. Hiram, son of Erastus, died at the age of 45. Two children living, one 30 years old. Four children of Mrs. Streeter ¥'!'! ARCHIVED OF MEDICIXE, 3 Mrs. Alexander, died at age of 55. Four children living. Mrs. Robinson, died at age of 46. T'l .■ cliildren. Mrs. Alexander, aged 48, still living, ai.r..s much affected ; can- not lift them. Hirani, died at age of 24 ; ill several years ; disease began in the legs. Thus, of the 13 members of the family affected, 6 were females and 7 males, a larger pro])ortion of the former than is common in this disease. With the exception of two, all ot the cases occurred, or proved fata], above the age of 40. Of the 10 instances in the second generation, 5 are the offspring of males (Erastus and Samuel), and 5 the offspring of females (Mrs. Streeler and Mrs. Stoddart). Tiie disease has not yet appeared in the third generation, which promises between 40 and 50 individuals, several of whom are over 30 years of age. I append a genealogical table of this family, in order to show its liability to progressive muscular t'trophy, and also repro- duce Prof. Naunyn's table of the Bessel family. {Berliner Med. IVocIienschrift, Nos. 42 and 43, 1873.) f i I 1" : i ■ 1 ; i 1 i ; 1 I' 1 ; 1 ?-; _ \: ti M I • .• ORIGIN A L UHS£A' UA yjUAS. ^ •^ ^ genk.\i.(j(;y (jf ihk iakr family. Rossin l''arr DiL'.! .11 50. Kui-ifll liiir. . . IJii;ii .It fxi. I>riukur. Samuel Farr. . . Diet! al hi. HI two vt;ars. Erastus Farr Dicil at 40. 1-irst case heard uf in 1-aDiily. Mrs. Stoddart. ? Died at 40. Mrs Streeter. Died at 54. I 5 Children 1 N' Children. Ellen. 27. . . .4 Children. Mariu Rossll Wesley. 41 2 Children. Erastus. 47 8 Children. Edwin [ Matilda. > f -i Children died of scarlet -I Hirfiiii. 55- . I { ftlrinii. 35. WiSiiani. died 24 I. Adaline. . . I Aimlra. 55- [ Almond. 60. . f Joil. .... Hiram. .^4 Mrs. Alexander. 55 Mrs. Robinson. 4(i Mrs. Alexander. 48 Mrs. Smith. 38 Mrs. Cleveland. 60. . a ( lilldren. 3 ( hildien. I Child. 2 Children, i child legs undeveloped. 3 Children. 4 Children. 3 Children. All well. All well. 3 Children. All well The individuals whose n.irnes are printed in heavy face type were the sub- jects of the disease — the others escaped. ARCHIVES OF MHDICIA'E. I child loped. uell. well. well sub- GENEAI.OiiV OF'I'HE HK.SSKl. IWMll.V (N.AUNYN *• r_. 1 1> 01 » ..ai O^, %.%. IMAGE EVAlUATrON TEST TARGET (MT-3) V* /. ^ M / i^°i%' \ (/. 1= 1.25 •^ Itt mil 2.2 u 1^ ■UulI |ia. JA lliil 1.6 PhntnoranViif' Sdences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 145B0 (7)6) 872-4503 4: iP iV <> ^ ^ ^^ ^ b SP MP I IP- Ua z '^ ^ \ \ ^ :$> \ 1 ■ J^i IB ■ Hw ^■^M ^^B' it ■Hh V HKJ xxxv/ / CASK OF MEDULLARY NKUROMA OF THE BRAIX. By William Osler, M.D., :\LH.C.P. Loud., Profissor of the L.Mtutes of Medicine, JlfGill Unicersity, Munhcal, (I'late XVITL) Josephine X , age 16, adniitted to the Montreal General HosiMtal, under Dr Ross, 2nd Dt ->. 1879. Histori/. — Ha.s been bliml .since third year ; lo.s.s of sight is said to have followed scarlatina. Had mea,sles at eiglith year, and shortly after an account is given of what appears to have been a temporary hemiplegic attack, lasting only one day. It is difficult to ol)tain satisfactory details, as she is in the care of people who know but little of her early history. In July 1878, she began to have headaches, which persisted 'through the mouths of August and Sept'jniber, and there appear to have been attacks of spasms of the muscles of one side, lasting for a quarter of an hour each day. She was better in October, and on the 11th of Noveml)er returned to her studies at the Blind Asylum, She remained well until about two weeks ago, when the headaches returned, and on the 29th of Xovember she had a spasm during the night. Sinee then the headaches have come on every day. There is no history of syphilis or of any injury Prcnnt Condition.— VaiiGwt is a dark-complexioned, well- nourished French Canadian girl, bright and intelligent, answers ([uestions freely, spefks English, and has made good progress in her musical education at the Asylum for the Blind. The liead is not unusually large, decidedly not hydrocephalic, forehead not prominent, the left side is fuller behind than the right. Tliere is complete atrophy of the optic nerves. Has had iio vomiting, no fever. Walks well, and has complete command of all the limbs. When first brought to the hospital the gait was irregular and unsteady, and the possibility of cerebellar disease was suggested by the admitting physician. Tliere is nothing of the kind now. Abdominal and thoracic organs healthy. Patient was put upon bromide of potassium, grs. v. every five hours. The headaches were relieved, and she left the hos])ita] 't ■| ?' i ! I 1 MU 218 I'liOFEHSOli OSLKli. i i.. on the 9tli, no " spfisms " liaving occurred during her stay. On the 15tli she was readmitted. I'ains in the liead had recurred after leaving the hosi-ital, and on. the 10th tlie head became drawn down l)y contraction of the muscles of the right side of the neck, and they are now (16th) in a state of firm contraction. There is much pain in the head, chielly occipital, and there are also pains in the neck and chest. At 10.30 p.m. a hypodermic injection of morphia (gr. j) was given; at 11 o'clock she was asleep, at 12.;:)(* n.m. was awake, and said she felt easy. At 1.30 a.m. she was found dead. The mode of death was not observed. AtUo2)sij. — Body well nourished ; nothing of note in external inspection. Signs of puberty marked. Calvaria, at line of section, of average thickness, slightly expanded in parietal regions ; left half is decidedly larger than , the right. Bwa mater is so firmly adherent that the brain had to be removed with the skull-cap ; membrane is thin ; sinuses contain small quantity of blood. When the brain was turned out of the skull a large quantity of clear fluid escaped; the organ is remarkably soft and fluctuating, and when laid on the table the heniis})heres collapse as the fluid escapes. The vessels of the pia mater contain blood ; arachnoid not opaque. Vessels and membranes at the base lock healthy. Convolutions are flattened, and the sulci are almost obliterated. On separating the hemis])heres the corpus callosum looks thin, particularly in its posterior half. Projecting from behind it is a large clear cyst, which lies upon the upper surface of the cerebellum. The lateral ventricles were then exposed and found to be enormously distended. So much fluid escaped in the manipulation of the organ that the total quantity could not be estimated, but it nuist have amounted to nearly a pint. The left ventricle is the largest ; the distension is tolerably uniform, but does not afiect the anterior conma so much as the others ; the hippocampi are fully exposed. The lining membrane is cleai', nowhere granular, and numerous vessels course beneath it. The brain substa ice of tlie hemispheres is nnich reduced. Over the central part, in the region of the parietal convolutions, it is not more than 5 or () mm. in thickness. The grey niatter is everywliere thicker tlian the white layer ; in tlie neighbourhood of the fissure of i "I' I V:.(;l CASK OK MEDULLARY NKUKOMA OF Till', liliAlN. 219 Kokndo the '^vey layer measured 3 una., tlie white only 2 mm. Over the anterior and i)osterior parts of the distended cavities the brain substance is not so expanded ; this is particularly the case with the frontal lobes, the distance from the anterior cornua to the pia mater is here nearly normal. Tlie structures forming the floor of the lateral ventricles are greatly ilattenod, the corpora striata and thalami appear superficially of large size, especially on the left side. The fornix is very thin; the velum Interpositum is closely adherent on the left side to the tumour to be described, and its vessels are full. Th.o choroid plexuses look natural, though flattened. The clear cyst, projecting beyond the corpus callosum, is directly continuous with the ventricles. It has flattened the upper surface of the cerebellum and the cori)ora quadrigemina, the nates and testes being scarcely distinguish- able. The membrane enclosing the cyst above is thin and clear. Lying upon the left thalamus opticus is a brownish yellow elevated mass, about 3 cm. in length, 2'5 cm. in breadth, extend- ing over the choroid plexus towards the descending cornu. At the inner side it is attached to the fornix, beneath which it extends, and is continuous with a rounded greyish-white body in the third ventricle. The part on the thalamus is firm, and several yellowish-brown bands pass from it over the corpus striatum. The choroid plexus lies beneath its hinder part, and is closely adherent. Chi the surface are several small calcareous particles. The growth in the third ventricle, when fully exposed, is found to project from the upper part of the side of the thalanms, and to be continuous with the nuass in the lateral ventricle. It occupies the anterior half of the third ventricle, touching the thalamus of the other side, and in front is closely united to the pillars of the fornix. It has a greyish colour, is soft, surface smooth, and altogether it has the appearance of a young, rapidly-growing neoplasm. On making an incision through the anterior part of the tumour, it is found to extend to the depth of about 8 mm., has a greyish brown translucent aspect, and though it appears to grow directly from the thalamus, yet the difference in the two is evident. At tliis section also the growth in the third ventricle is cut, and is seen to be lighter in colour, and is of softer consistence tluui the main mass. The ,1 '1 i 22U I'lIui'KSSoi; (tsi.KK. tumour gets tliiuncx' as it passes backward, but maintains tliu same structure tlir.ni-liout. The substance of the thalamus h.oks normal, an.l is the same on both sides. Corpora striata and lenticular ganglia much flattened, normal-looking on section. The a(]ucduct of Sylvius is almost closed. Corpora (piadrigemina, crura, pons, and medulla present when sliced a normal appear- ance. Cerebellum presents a flattened depression on its upi)er sni'face ; substance is healthy. Optic nerves and tracts tirm, small, and atrophic. The examination of the thoracic and abdominal organs revealed notliing of note in this connection. Histological Rvarni nation. Timour on Thalamus qjtims. — The matrix or ground substance is granular in character, resembling closely That of the cere])ral grey matter (fig. 1). The granules are small and dark, and in places little spherules are nn'ngled with them. Towards the surface, where the mn ' firm, there are numerous fine interlacing fibrils passing through the matrix, and they are also abundant at the inner part of the mass, where it is con- tinuous with the growth in the third ventricle. In the matrix are — (1.) Small corpuscles, about the size of white blood corpuscles, of various shapes, some round or ovoid (figs. 2 and 3), with large vesicular nuclei ; others stellate, with three or more fine processes {figs. 4 and 5). (2.) Large cells, looking like ganglion cells (figs. 1, 6 and 7), having processes, darkly granular protoplasm and large muclei.' They are elongated or flattened, with one, two or more processes, which can sometimes be traced for a considerable distance in the matrix. The muclei are large, usually single, and about some of them an aggregation of brown granules was observed. They are toleral)ly abundant throughout the sub- stance. The measurement of these cells ranges from -0300 to •0550 mm. In addition, there are rounded granular ' ells with- out processes, which are occasionally seen in groups of six or eight. (3.) MeduUated nerve fibres (fig. 8) ; seen best in teased preparations taken from the central and inner portions of the CASE OF MEDULLARY NEUROALV OF THE BRAIN. 221 les, mass. They liave a distinctly double contour line, the inner one often irregular, and in many iibres the coagulation of the medulla could be seen, while small rounded masses of it (myelin drops) occur here and there in the field. These nerve fibres were abundant in some bits, scanty in others. (4.) Delicate translucent fibres, with peculiar bead-like swell- ings at different parts (fig. 9). They are tolerably uniform in size, and the swelling occurs irregularly in their course; fre- quently a fibre appears to end or begin in one. The substance of the enlargement is uniform with, and continuous into, that of the fibre. In places these are numerous, particularly towards the mass in the third ventricle. (5.) Giant cells, few in number, with 8-12 nuclei, and dark granular proto[)lasm. Tumour in Third Ventricle.— Teased bits show a structure differing in many respects from the one above described. It is composed of — (1.) Large spindle-shaped cells, which, with their greatly elongaied processes, make up the chief part of the mass. They look like enormous connective-tissue corpuscles (fig. 10), and vary in size and general appearance. Some are very slender, and taper gradually; others are more distinctly spindle-shaped, and the processes can be traced for a considerable distance before assuming the delicacy of a fibril ; in others, again, the processes are broad and flat, not tapering, but keep the same diameter, or even increase a little in width. In several cells such a broad process was observed to leave one end, while a fine delicate one was given off from the opposite side (fig. 11). So elongated and attenuated do these processes become, that a small teased bit looks as if it were composed almost entirely of somewhat coarse areolar fibres, among which corpuscles were scattered ; but a careful examination shows that the fibres are only the prolonged extensions of large cells. Isolated cells were measured as much as -4130 of a millimetre in length. The majority of the cells present elongated nuclei occupying a large portion of the centre of the cells ; in some it is distinctly vesicular in character ; in others, granular, with indefinite outlines. The protoplasm of the cell body is either homogeneous or very finely granular, and a VOL. XV. y I u ' ill ^ Ill m\ 222 I'JJOFKSSOU OSLEIi. Similar appfamnce is presented by tlie processes. The fibrils measure from -00166 to -0025 m. in diameter. (2.) Scattered amongst the preceding are a few cells like them in general outline and in the prolongation into fibres, but difler- ing in the extraordinary translucency of the protoplasm and the absence of a nucleus (fig. 12). The term "vitreous" best ex- presses the appearance of these structures. Some of them were quite as long as the ordinary forms; one was observed which ex- tended through two and a half Helds of the No. 9 in. (Hartnack) In several a few fine granules were noticed about the broader parts, but as a rule the body and processes maintained a uniform and remarkable translucency. (3.) Large granular coipuscles, interspersed among the fibre cells, and of very varied sizes and shapes; some are flask-shaped with a single clear process (fig. 14) ; others are large, broad, flattened, bipolar cells (fig. 13). The nuclei are large, sometimes granular ; in some no nucleus could be seen. The protoplasm is in most granular, in a few clear. The processes are flattened not long, and resemble strongly the broader variety of proces.s seen in the cells described under (1). These cells often occurred in groups, accompanied by smaller rounded ones, very granular with distinct nuclei, but without processes. Jiemarks.~The so-called medullary or ganglionic neuroma is perhaps the most uncommon form of tumour met with So far as I can ascertain, no case has been reported in the British journals. The literature of the subject is fully given in Virchovv' uork on Tumours.i In most of the instances there referred to the new growth was in the lateral ventricles, and, as in the present case, in connection with hydrocephalus. In a few the m-owth was situated in the white substance of the centrum ovale trom the description above given, there can be no doubt that tlie tumour on the left thalamus is composed of a tissue similar to bram matter, and from the situation and the continuity with this ganglion, it may probably (with others of the same kind) be regarded, as Laucereaux suggests, as an heterotop^j of the Lv substance rather than a true neoplasm. Indeed, tlii.. writer^' ' French crlition, vol. « Tvy/fe D'Anul HI. p. 4.57. "«u> I'alhfih ixjique, toiiir i. l(J7 CASE OF MEDULLARY NEUROMA OF THE BRAIX. 22; holds that if all the cases which can be regarded as malformation of the brain substance be ruled out, the existence of a true neuroma of the brain is doubtful. The histological interest of this cas centres in the growth which occupies the anterior half of the third ventricle, and which is continuous with, though differing fn ui, the tumour on tlie thalamus. What is the nature of the enormous spindle cells of which it is in great part com - posed ? Do they correspond to connective-tissue corpuscles, or are they modified nerve cells with greatly extended fibrillar pro- cesses ? The only form of tumour which has such enormous fibre cells is the large spindle-celled sarcoma; but such a growth lias never been found in the brain, and, moreover, the processes of its cells do not, I think, ever become prolonged into such delicate fibrils as in this case,— at any rate, with retention of the character of the cell itself. The only instance I can find of a brain tumour containing somewhat similar elements is one referred to by Lancereaux,i occurring in the white substance of the left hemisphere. It was composed of large cells, many of them fusiform, with ribbon-like processes. In the figure which he gives, certain of the cells bear a resemblance to the ones above described, and he regards them as probably nervous in character. I am inclined to take the same view in the present instance. The majority of the cells are greatly elongated, with flattened or attenuated processes, and look like large connective tissue cor- puscles; among them, however, are corpuscles which resemble ganglion cells, and possess also similar ribbon-like processes (figs. 13, 14). I believe that a careful study of the growth war- rants the supposition that the elongated fibre cells are trans- formations of structures closely resembling nerve elements. The pecuUar fibre cells above described, with extraordinarily translu- cent protoplasm and no discernible nuclei, are structures which, though unlike nerve fibres in general appearance, remind one strongly of the gelatinous fibres of Remak. On the view that these elongated cells are transformed nerve corpuscles, what are the fibre-like extensions in connection with them which cannot be distinguished microscopically from areolar fibres ? Though a somewhat heterndnx view, it appears probable, from the rest orchcs ' Luc. lit ill \ r i • ti % j/V \9 224 PROFESSOR OSLER. i 1 of S ricker and Ungor.i that nerve cells may give off processes winch pass into connective-tissue fibres, and these authors regard the protoplasmic processes (with their fibrillar extensions) oUhe cells of the central nervous system as of this nature. If such is the case, we can look upon the fibrillar extensions of the cells in this instance as constituting in reality, what they so much resemble, connective-tissue fibres, or we can suppose a trans- formation or degeneration of tlie nerve cells into fibre cells. Doubtless, as Virchow supposes, the malformation forming the tumour m the thalamus, was congenital. The early blindness at the third year, and the hemiplegic attack at the eighth, favour this supposition. The hydrocephalus can scarcely have begun in early childhood before the closing of the sutures, else the head would have become enlarged. It was only in July 1878 that she began to snft'er from headaches and to have unilateral "spasms," and it may be that the distension of the ventricles dates from about this time The tumour m the third ventricle looks recent, and it may have been its growth and the increasing induration about the mass on the thalamus (to which the velum interpositum was firndy adherent) which caused pressure on the venee Galeni sufficient to induce the ventricular dropsy. Clinically also the case is of interest, chiefly from the ne<^ative character of the symptoms. Headache was the only prom°ineiit one during her first stay in hospital. On the second admission the muscles of the right side of tlie neck were strongly con- tracted, and the pain in the head was severe. The cause of the sudden death could not be ascertained. The mental condition of the girl was remarkable, considering the degree of hydrocephalus and the extent of atrophy of brain substance. In the majority of such cases there has beqn more or less impairment of the mental powers, but this girl appears to have had quite the ordinary intelligence, and for her station, and considerino- also her blindness, was well educated. ° J V(yrlem,v,cn iiber aUgemeinc und cvpcrimcntelh Patholocjie, von Dr S htncker, III. Ahtheihmg, 11. Lief., 1880. CASE OF MEDULLARY NEUROMA OF THE liliAIN. 225 Exp^ANATlo^f op Plate XVIII. 1 -9. From mass on left tlmlamus. 10-14. From tumour in M ventricle. (1), CJcnoral appcaviin((i of the matrix, with a ganglion cell im- bedded in it; (2, 3, 4, and 5), small colls, some looking like corpuscles of the neuroglia ; (6 and 7), large gangliun cells ; (8), double contoured nerve fibre ; (9), libres, i)robably nervous, with curious bead like swellings ; (10 and 11), elong- ated iibre-cells from mass in 3d ventricle ; (12), very translucent fibre without nucleus; (13 and 14), cells resembling nerve corpuscles, with ribbon-like processes. ; 'V I" . /. V//7/ . c '/ ; huii it- Pli r.v. , I II II ■' /X\/ * A i;-/.ir/Y v/-.// V' V/s' ^n \.. ..>: (■'•.■■ ■#? / y v\ t .'^. ^_ --^^ \ • 1 J.; 1 V- /^. /^ // /o r" I / m^ t. IS. \ A'^ y*. !' Hiift.Lift'EJin' III ; r * f; ' «| 1 1 f.ttj HHHbI 'Is 1 ii ^^^m"** l|l kLH^HI ;B|H till^^^^^^H'' ^ rUI^^H! ^n^H '■^■l ill 1 ^^^^^^^B'l 1 4-. jC^LXTT "S^ INFECTIOUS (SO-CALLED ULCERATIVE) ENDOCARDITIS DV WILLIAM OSLER, M. C, M.R.C.P., Lond. PROFESSOR OK THE INSTITUTES OK MEOICXE, MCGU,. UMVKRS.TV ; PHYSICIAN AND PATHOLOGIST TO THE GENERAL HOSPITAL, MONTREAL [Reprinted from the Archivf- of Medicine, February. i8Si] *t- NEW YOKK ('. P. PUTNAM'S SONS 182 Fifth Avenue 1881 "4* i C( ar INFECTIOUS (SO-CALLED ULCERATIVE) ENDOCARDITIS. By WILLIAM OSLER, M. D., M. R. C. P.. Lond.. PROFESSOR OF THE INSTITUTES OF MEDICINE, MCG.LL UNIVERSITY ; PHYSICIAN AND PATHOLOGIST TO THE GENERAL HOSPITAL, MONTREAL. UNDER the terms diphtheritic, ulcerative, malig- nant, septic, or infectious endocarditis, arterial py- ismia, mycosis endocardii, physicians now recognize one of the most formidable of cardiac affections, characterized by a peculiar morbid process on the valves, blood con- taminations, constitutional symptoms of the typhoid or pyaemic types, and usually associated with multiple em boli. It is only within the past few years that the sub- ject has received due attention in the text-books ; indeed, in some it is barely touched upon, and even in recent manuals on heart disease the account is not very satisfac- tory. From the number of reported cases in French and German journals, and from the interest which the disease has excited in these countries, we might suppose it to be more common there than in England or America. A considerable number of reports, however, occur in the "Transactions of the Pathological Society of London" and in the British journals. In the leading American periodicals there are yery few r eferences, but cases have Reprinted fr,.in the Archives of Medicine, Vol. v, ■:i^~C,'J€^^^:^^i^~^, -^ , m i' H 2 INFECTIOUS ENDOCARDITIS. been repoited by Ellis,* Lomax.f Pepper,:}: Keating,§ and Peabody.ll With regard to the nomenclature, I think the terms in- fectious and septic, as given by Jaccoud.T better than the others. Against the name ulcerative is the fact that there may be no actual ulceration on the valves, and there may be, on the other hand, endocardial losses of substance with- out the specid constitutional disturbances by which the disease is characterized. The term diphtheritic is good, in so far as it expresses a resemblance in the histological feat- ures of the valvular disease to that of true diphtheritic ex- udation, but this is scarcely sufificient ground for its use; and it is, in a way, misleading, indicating a relation be- tween diphtheria and the disease, which is not known to exist. The ns.me mycosis emiocardii CQr\.3i\\\\y ^.x^resses Si striking feature of the local process, but with our present imperfect knowledge of the relation of the micrococci colo- nies to the disease, such a designation is, to say the least, premature. On the other hand, the term infectious presup- poses no special view as to the nature o"" the local process, and at the same time indicates, as Jaccoud says, a constant and exclusive character of the disease. It would appear that, clinically, three classes of cases are included in the disease known as ulcerative endocarditis, and' I think it important that a distinction should be made between them. We have : I. Those cases in which the disease appears without any obvious cause, either spontaneously or in connection with rheumatism or some other affection. The term infectious * Boston Med. and Surg. Joiiniii/, Nov. 15, 1S77. t P/iittidc/p/da Medico I and .Surgieot t\\for/ei: 1S74. X American Jonrnal of Medical Sciences, n^yr. § " Transaciions of ihe College of riiysiciaiis of riiilaclclphia," 1879. I :Vcii' York Med. I\ccoi-ii, iSSo. TT rathologie Interne, tome i, and Nouveau Dictionnairo, toine iii. WILLIAM OSLEH. might be applied to this class. It is the arterial pyamia of VVilks, the primary ulcerative endocarditis of some au- thors. 2. Those in which the endocardial disease is secondary to some inflammatory focus— acute necrosis, puerperal en- dometritis, etc. To these the term septic might be applied. 3. In certain cases of chronic valvular disease an acute en- docardial process may be engrafted (recurrent endocarditis), presenting anatomical features similar to the infectious form, but not characterized by the same clinical picture, the patients dying with the symptomc of chronic heart disease. The following paper embodies my experience of this dis- ease. The chief points to which I wish to call attention, and which are illustrated by the cases, are: 1. That the majority of cases of infectious endocarditis occur independently of rheumatism. 2. To the frequency with which infectious endocarditis is associated with pneumonia. 3. The production of acute multiple aneurisms of the aorta in the disease. 4. To certain histological features in the endocardial vegetations, and particularly to a remarkable fungoid growth met with in one of the cases. rf * Case i.— In January, 1878, I received from Mr. McEacliran, of the Montreal Veterinary College, the heart and part of the aorta of a cow which had died with symptoms of urgent dysp- noea. He saw it only a short time b-fore death, and no satisfac- tory history of the case could be obtained. The weather was very cold, and the heart was frozen immediately after its removal, and in this state I received it. The organ was large, particularly the ventricular portion ; the chambers had been cut open, and the blood had escaped. On ex- posing the tricuspid orifice, from the auricle it appeared to be al- most closed with irregular vegetations attached to the valves. From fmrr ml ; '^ INFECTIOUS ENDOCARDITIS. the ventricle the following condition was presented : The seg- ment next the septum was completely covered on its under surface with a gray.sh-wh.te outgrowth, which was prolonged at the apex and extended about half way over the auncular surface The tended down the septum, forming irregular warty projections some of wluch were the size of large cherries. 'iL other seJ-' ments were not so much involved, but in both the growth was most extens.ve on the ventricular surface, and irregular ma ss projected from the tips of the cusps, which resembled some vh the comb of a cock. The chord., tendine.. were uninvolved Pulmonary semilunar valves healthy ; mitral valves unaffected Aort.c orifice blocked with vegetations similar ^o those in the tncusp.d. On slitting up the vessel the segments of the valve were found much crumpled and covered on the ventricular sur- faces with warty outgrowths, some or which were ove- a centi metre m length. In the ascending portion of the arch there were several small outgrowths on the endocardium, and near the terminal portion of the arch there was a much larger, irregular mass. All of these structures presented a similar appearance-grayish-white in color of moderate consistence, but on firm pressure somewhat friable' They were very closely adherent to the parts from which they grew. An outer cortical and an inner parenchymatous part could be d.sfngu,shed It appeared a typical example of a verrucosa endocarditis. I he other organs were examined, but I could get no information as to the presence of infarcts. Case 2.— Infectious endocarditis; pneumonia; menin- gitis. Mary D., aged 29, admitted to hospital October 22, 1878 in an unconscious state. She is a married woman, and has L chil- dren. Has been a hard drinker for several years. History of the onset of the attack could not be satisfactorily obtained. On the 23d, when examined, she was still unconscious ; pupils moderately dilated ; no twitchings or paralysis ; slight dulness at right apex with blowing breathing and rales ; systolic murmur at apex t' 104 ; P. no; R. 40. ' ■ ■ , On the 24t;i, she was partially conscious for a short time and complained of great pain in the head and back of the neck Morning, T. ico° ; Evening, 104° c i t n d ii \^ e h WILLIAM OSLEA: 5 Throughout the 25th she lay in an unconscious state ; passed liEces and urine in bed. Evening, T. 104°. On 26th, temperature rose to 107° at 4 a.m ; was 105° at 2 p m There was a shght divergent strabismus of left eye. and commenc- ing superficial ulceration of left cornea. Right pupil dilated widely. Death took place at 4 i-.m. Jufopsy.~In the /lear^, ventricular surface of anterior segment of mural valve was covered with grayish vegetations ; toward the right side of the valve they were larger, and extended to the chordae tendineaj, passing down the entire length of several of them. On the auricular surface of the valve there was a soft grayish.white patch, , by 1.2 cm., covered in part by a thin mem- brane but in the rest of its extent rough and divided into a num- ber of irregular projections, which were friable and readily de- tached. '1 he other valves were healthy In the right /u»g the upper lobe was in a state of red hepatization ; toward the anterior border the process was more advanced, and a sero-purulent fluid bathed the surface. The upper third of the lower lobe was also mflamed. In the i>ram, meninges at the base were matted and oedematous, but there was no exudation. On the hemispheres there were numerous patches of lymph beneath the arachnoid situated chiefly in the anterior regions. The posterior margin of corpus callosum and contiguous surface of cerebellum were cov- ered with a thick, creamy exudation. Sp/een presented a single infarct. Organ a good deal en- larged. A'ldneys healthy. xNothing special in other organs. ^i^^^ l-— Infections endocarditis ; pnctimojiia. J. B., aged 38, admitted January 7, ,880. Has been a healthv man. ^ Ten years ago had a severe attack of pneumonia. On the niglit of the 4th he felt uneasy, and did not rest well ; got feverish, and in the morning had pain in the side, with cough. These symp- toms continued, and he came to the hospital jn the 7th On ad- mission, T. 103.8° ; P. 128 ; R. 40. Signs of pneumonic consoli- dation in right lung ; dulness from second rib in front, and extend- ing into the lower axillary region and the base posteriorly There were blowing breathing, rales, and increased tactile fremitus The expectoration was viscid and rusty. During the first week in hospital neyous symptoms appeared ; he became delirious rest- ! t I i \ , -i lUFECTIQUS ENDOCARDITIS. less at night, and passed urine and fajces in bed. Tongue dry and on the 9th and loth there was troublesome vomiting The temperature was irregular, ranging from 100° to 104° • the even- ing record was usually a little higher, but twice it was lower than in the monnng. Pulse range 120 to 148 ; respiration 32 to 50 Durmg the second week the intensity of the symptoms abated somewhat; the temperature kept lower, not once reaching 101° Respiration diminished in frequency, and the pulse range was from 112 to 120. The nervous prostration continued, with tremor of the whole body ; the muscles of the face and hands twitched constantly. Delirium persisted, and discharges were passed in- voluntarily. A very disgusting fetor emanated from his body rhe cough improved, and the dulness diminished somewhat in front. Tongue dry ; took food and stimulants freely. On the 19th, a painful swelling appeared in left parotid region In the third week he began to have chill.s, and sweated a great deal each day. The swelling in left parotid diminished, and the lung cleared. The prostration continued and the delirium per- sisted, but the twitching moderated. The temperature w is very irregular, usually below 100°, but on two occasions it went up to 103 after chills. Pulse range from 116 to 130. During the fourth week the swelling of iWt parotid increased and on February ist an abscess was opened in this region Severe chills on the 30th, blueness of face and finger-tips. T 102° Still sweats. Became somewhat brighter after the abscess was opened. Tongue dry; nervous symptoms less marked. No cough. Pulse feeble, range 108 to 120. Temperature 98° to 100° • on three days after chills it rose about 102°. In the fifth week he remained in this typhoid condition with very little change ; an occasional chill and profuse sweats. During the sixth week the prostration increased, and he lay in a heavy, unconscious state. Tongue dry and cracked ; no chills but profuse sweats. ' On the 13th and 14th, T. began to rise, and reached 104°. Mus- cular tremors again set in, and death took place on the 15th, after an illness of 42 days. Autopsy.— ^oAy wasted ■ in preliminary incision thoracic and abdominal muscles pale. Heart of average size ; noi apparently hypertrophied. Coagula m all the chambers. Valves on right side normal. In left ven- tricle a large mass filled the outer angle of the mitral orifice look- ing like a fibrinous clot between the valves, but on closer inspec- WILLIAM OSLER. tion it proved to be a large endocardial vegetation. Viewed from the ventricle, tlie outer half of the aortic or anterior segment was involved, and the disease had penetrated the entire thickness of tile valve, projecting in grayish-white, flattened masses between the points of attachment of the chordai tendinea;. On this surface it extendetl to within 1.5 cm. of tlie semilunar valve. The poste- rior mitral segment was not so much involved on this surface, but at the outer angle between the two flaps, the mass was very thick, and extensions from it passed along the chordai tcndineai to the top of the posterior papillary muscle. The full extent of the dis- ease was seen when the mitral ring was laid open— a thick grayish mass encrusted the auricular surfaces of the outer halves of both segments, filled the angle between them, and extended up the wall of the auricle. On this aspect it measured 3 by 2 cm. The sur- face of the mass was nodular, in great part of its extent unbroken, and covered with a thin membrane, which could be lifted up. In ])Iaces there was extravasated blood beneath this thin coating. The portions upon the wail of the auricle and on the contiguous part of the valves were roughened and granular. The anterior curtain was most affected, but the vegetations on the posterior I)rojected much more. Section through the mass on this segment gave a thickness of 12 mm. ; no proper tissue of the valve could be seen, but only a uniform, finely-granular, grayish-white tissue. Aortic semilunar valves healthy. Aorta not atheromatous. Lungs crepitant in upper and anterior parts, heavy and oedem- atous posteriorly ; the tissue of the right lung at the base was firmer than that of the left, but the section was not granular. Spleen large, weighed nearly 400 grammes ; pulp very soft ; one wedge-shaped infarct of grayish-yellow color. Kidneys pale ; no infarcts. Liver soft, and of a muddy-brown color, of special note in the stomach or intestines. swollen. The brain presented nothing abnormal. In the left parotid the abscess had nearly healed. There was nothing Peyer's patches not ■ 'I ^'^ \ it; |. »: ;l. Case 4. — Infectious endocarditis ; ptieumonia ; meningitis. M. W., aged 43, a tall, well-built man, was admitted to hospi- tal under Dr. Ross, Feb, 36, 1880. Served his time (21 years) in the British Army. Has had syphilis, and only a month ago was under treatment m ward 11, for syphilitic ulcers in right ir |:iM rfir- t \ il SI. I 8 INFECTIO us EA'DOCARDl 77 S. gluteal region. On Oct -.-j tS-,^ i.^ . • • h.al2T7 1 ''''; ''' ''^'^ ' -•-- ^'«- followed by fever Phys.cal signs. Temperature has fallen an b ':;;; ^ for the past three n.ornings. Is free from delirium ' '' 4tli. Patient had a chill at one o'clock P \f n.. • ^ ^ vomiting, and the temperature rose to xo^ '-^"-"P^-d by dise t in te r'"' "''''' ''^''■'■""^ ''^^"'■"' "° -^--on of the disease in the lung; at two o'clock P. M had i chill .nH i temperature went up to 1035° P ^o/r 7 S '/ . ' stools ^^ ' 4, R. 40. Has had five «th. Morning T 100° F rr,. ,° t-, 1 basera,.more^i,.,-,Lc^--,^^:j:^-^^^^^^ T went !^TJ-?-' Ir '"'■"' ''""''^ '°"^'"^ '^-^^^ -d dry. 'lotl Prof,, 'r 7 '''"'"^' ^- ^'' ^- '''' '-'"d f<--eble. loth. Profuse diarrhoea, nine stools ; is very prostrate. P 134 K- 36, 1. mornmg 101°, evening io-° ^' From this time until his death on the 14th he gradu.llv sank remaining unconsrimis tu^ ,. b''iuuaiiy sank, to io^° tirr ^'''^ '^■^P^'-'-^ture range was from loi'' degreel ' o„ th'^^f r"'^"'-'^^''°" '^-"S --ally about three degrees. On the 12th there were signs of cedema at right base The amount of unne passed ranged from 40 to 50 o acid in reaction ; there was albumen on the first three days afte'r admi smn ( hlorirlpc u-oro ^,\ • • 1 1 ""/a tiller aanns- absent. duninished ; on the 2d of March they were k*'- WILLIAM OSLEN. Autopsy. Nothing special on sui)crficial inspection. Brain ; at base membranes a little oedematoiis, no lymph. An aneurism UK- size of a pea projected from the centra! part of the basilar artery and has formed a bed for itself in the pons. There was consider- able meningeal inflammation on the left hemisphere ; the posterior part of the ist frontal and the ascending frontal convolutions were covered with a thick creamy lymph, and a similar condition existed along the outer part of the Sylvian fissure and over part of the ascending parietal convolution and the superior i)arietal lobule. On the right side there were a few patches of lymph along cenain of the vessels, but none on the convolutions. Nothing special noticed in the substance of the organ. Heart. All the chambers contained blood and partially decolorized clots. I,eft ventricle looked a little large. Mitral orifice not enlarged, valves thin and healthy-looking; on auricular surface of the edges numerous small bead-like vegetations. Aortic orifice obstructed with large irregular vegetations, which, on slitting up the vessel, were seen to spring from the right posterior segment. ']"he ventricular sur- face of this valve was almost covered with a grayish-yellow out- growth irregularly divided into two portions, the pointed ends of which were covered with closely adherent blood-clot. The sur- face of these masses was smooth, though nodular ; it was only in the cleft between them that the granular substance of the vegeta- tion was exposed. From the arterial side it was seen that one- half of the valve was completely destroyed and the gray-green tint of the substance of the growth was here very marked. There was one small patch on the ventricular face of the anterior seg- ment. Lungs. Lower three-fourths of the left lung heavy, airless, reddish in color, except at anterior border where it is more an?emic. Granular condition of section not very distinct. Pleura of this part covered with a thin exudation. Other parts of the lungs crepitant. Spleen is large and very soft ; no infarc- tions. Kidneys. Left presented one small infarct the size of a pea. Organs are soft and cortices a little swollen. Liver pale and soft. Lntestines pale, no ulceration. 1 < Cases 3 and 4 offer typical examples of this disease; —the chills, irregular temperature, sweats, and diarrhoea were very characteristic. Case 3. conformed more to the typhoid form, Case 4 to the pyemic variety. .'fl*?r.'^ ^ ' r I i 10 /A'^£C7jc US thDOCAJiDlT/S ^Um^.icn4a.trruns; vnUUpL .unrisn.s of aorta ; rupture tnio pith ardiHin. ' . i!°lrl ' ' '^"■' "'• '''°'^^'"''' "'■'^''■■'y- ^^''^'" ^^--^ y--^'" old had Z^^^\r ',"'" '""'' -^Jf'ontof chest, which has left a U r^. tl '. , T^ '"f ^'' "'■"' ''^•''^''•^""" --'-• ^^ '^'d, and c io H^ " y^^V'"''" '"■""'-• —. particularly on for ■•,■ "'" ' '"''"■• ^" '^76 was treated in the hospital attack of qu.nsy .n K-bruary. ,879. and in the clinical report it was l,en noted "that the heart was son>ewhat hypertn .lied double nn.rnu,r at base, and a distinct systolic thrill could i dt' n the aort,c area " Unfortunately the notes of his final illnes a^e \ZTTu "'•■ '""■" '"■"•■■^'"'^^ ^^''^'^ "- ^'^"--"g by Dr. mne. the House Surgeon: Patient was readmitted on June 4 880, w,th a history of diarrhoea of several days' standing chills h^ache, dyspnea, cougi, and fever. On exan.ining L lungj i^ were signs of pneumonic consolidation at left base, dulness bV.ng breath.ng. rales and exaggerated fremitus; temperature a :/"^,'.^V''''T' ,^'"'''°"' "''-' '""'''^ ^^^"'"^'- "'^art embar- rassed ; distmct double aortic murmur, and basic thrill The .n ammanon of the lung extended and involved nearly the entire dktin . T '""" ^'""' ""''""^ prostration, a low delirium, and du,t,nct dulls at intervals. The temperature ranged from 99° to 105 ; death took place on July ist. ^/^./.:;..-I!ody somewhat emaciated. In thorax there was a rounded tumor beneath the first piece of the sternum, and which passed to the nght beneath the first two ribs and the clavicle It was quue soft and had no superficial adhesions. Pericardial sac looked large and when opened. 18 ounces of blood and clots were removed. The source of the hemorrhage was discovered to be a laceration m an aneurismal pouch which projo .cd into the pencardmm from the ascending aorta. //,,,;-/._Auricles contained 'blood and thick clots ; there were numerous small ecchymoses beneath endocardium of the right side. R.ght ventricle small in comparison with the left ; tricuspid and puln.onary sem.' -.ar valves healthy. Left ventricle d!la- ted and hypertrophies, ■,..„.,]3 unusually thick. Mitral orifice Z? T> Y '"• '""""" '"'^"'^^^ ^^^'^'- opaque ; chorda, ten cuT^ t nek : aortic v.iv.. :.u..mpe.ent : segments thick and cuiled at the edges ; th> a.te ■o.^ and left posterior segments have ^--Hi WILLI AM OSLEA' If fused together, and from the ventricle, presented the appearance of a sinj^le curtain, but on the arterial side, a median raphii passed iialf way uj) the segment and divided the sinus, s incom- pletely. Attached to the thickened border were four grayish veg- etations, the size of small peas ; and on the right posterior seg- ment, a large flat one covered nearly one half of the ventricular face of the val^'c On the endocardium of the ventricle, just be- low the anitic ring, there was an elevated flattened mass the size of a five-cnt pii^ce. Immediately above the rigiit posterior seg- ment, two large grayish-yellow vegetations i)rojected from a slight d< I r-ion in the wall of the aorta and were in contact with the edge of the valve. A sort of cleft separated the two masses, and when probed, was found to lead into a saccular pouch the size of a large marble, from the edges of which the outgrowths arose. The walls of the small aneurism were thin, com])osed chiefly of the adventitia, and had lost the appearance of an arterial coat. The interior of the arch was smooth, witli the exception of two small patches of .superficial atheroma. Two and a half centime- tres above the valves the arch measured 8.5 cm. in circumference. At the junction of tlie ascending and transverse jjortions, about 1.5 cm. from orifice of innominate, there was a circular opening the size of a fifty-cent piece, leading into a saccular aneurism, the size of a small apple, which projected to the right side and was partially enclosed in the pericardium. The edges of the opening presented large fungoid vegetations, attached to the margin of the intima, and projecting in some places as much as i cm. The sac contained blood and recent clots, but no laminated fibrin ; the walls were exceedingly thin, in places (piite translucent. The veg- etations at the edge of the orifice extended upon the inner sur- face of the sac, covering it in at least half its extent, and in places infiltrated the entire thickness of the wall, so that the i)eculiar g)j':fri-,h-yellow color of the growth could be observed from the outside. In the wall of the aneurism, just within the line of at- tachment of the pericardium, there was an irregular laceration 1.3 cm. in length. On the intima of the ascending portion, just be- low the margin of the aneurism, were two small warty outgrowths which, when carefully examined, were found to spring from the edges of small lacerations or losses of substance, behind which were two aneurismal ])(juchcs, about the size of large pCas, the walls thin and formed chietiy of the adventitia, which appeared dissected away for a short distance around the narrow break in the internal and middle coats. In one the vegetation extended il I \ III '^ 4 ill ii !-i 12 INFECTIOUS ENDOCAKDJTIS. V < ' congested ,L!,e ' ""^ "'"' '""' '""""""-^d ^y deeply «.^ti^:::' ^"'"°^-' ^ "■= "«"• -S- ™"'a,-„ed one s,„a„ ye,- "ire c,f Rolnndo ■ it >>^as thi^l ^ """^ ""'^ "'""S 'l« fa- over (he second and IZV, .1 ] '"' •■■ """ "'ravasation ,."i-.i conv^Lt's ""^t: tTi;":i;r '"' r "^ "'«"^'"« substance healthy.. '''^ '"'^'''^'^ '^^'^ found ; --a. aged .,, iu^ni; d fr T he^Tj. ''^^'r'^^"' ' ^°""^ ^'-ing a fire, and sustained a doub ott 7' T'"'°" '' "" '"'^'• of lu„.bar vertebr.-e. She seenied in h H ■ '' '"^ ^'"^^'"'•^ a week, when the temne Iture rn . .'"^ ^""^ '''" ^°' "'^°"* al-t the heart and X:: 1;;". 'Trfr' °^ ^^^'" tl'C mitral area was detected She h. ^' °''' '""™"'" ''" prostrated, blood appeared in tif ^''!'"'' r'^^^^^Sh weak and after admission '' """'' '^"^^ ^''^^ ^ied sixteen days 'n'^i:;;:r^X:::itr.rr^"""-^^°"^ ^'-^— part of right upper lobe .rd Posteriorly, and the lower lobes were hep i'dThe ;;",'"" '' '' '' "'^^'^ ^^^ '"-r <-'"-.ain of the mit al va v 7" "'' '"'"^^^^ = °" ^'^^ '^"^erior v".ving the a.^; r 'of X : j^f ::^^--^''^'^' °-^-vth. in- '•'■ the clK.rda.tcndine" hood ;"^' ^r""^^ "^ '° -- ^''-----ee.b;.e:°^^::;^,-^---^:^^ "*^-.l. WILLIAM OSLER. 13 in kidneys. There was purulent infiltration in the sulci, beneath the arachnoid on the cortex of the brain, chiefly on the parietal and frontal lobes ; none at the base. In the ccecum and ascending colon, were eight or ten superficial patches of membranous colitis, the exudation grayish-yellow, thin, and situated upon injected mucosa. This case comes, doubtless, under the second class, in which the endocarditis appears to follow some injury or wound. In go- ing over the literature of the subject, I noticed the reports of a considerable number of cases of this kind. Dr. Pcabody's case, the autopsy of which I witnessed, resembled this in all its essen- tial features. I should like to remark here that the endocarditis in many cases of this class is a secondary and subsidiary phe- nomenon in septic infection. Thus, in acute necrosis and in puerperal septicaemia, it is sometimes present, sometimes absent, and the fatal effect and malignancy of the affection does not ap- pear dependent upon it. Case -j.—Sdcrotic aidocarditis of aortic valves, tvith incompetency ; recent vegetations {ulcerative endocarditis). Annie M. L., aged 40, admitted Nov. 23d under Dr. Ross. No history of acute rheumatism. For five or six years has suf- fered with shortness of breath on exertion. For tiie past year health has been failing, and she has had a troublesome cough. For three months has been confined to bed ; dropsy has gradually come on, and for three weeks past spitting of blood. Her condi- tion on admission was that of a patient in tiie advanced stage of obstructive heart disease,— great dropsy of legs, right hydrothorax, dyspnoea, lividity, cough, and bloody expectoration. A double aortic murmur was determined. She only lived for a little over two days after entering the hospital. The temperature was normal. At autopsy heart was large, chambers full of dark clots. ' Mitral valves healthy. Left ventricle dilated and hypertrophied.' The aortic orifice was blocked with vegetations, and when slit open tlie valves were found much diseased ; all the curtains were thickened, curled at the edges and foreshortened. On the ventric- ular faces were large grayish-yellow vegetations, closely adherent, but friable and roughened on the surface. In one mass the de- position of salts of lime had taken place on the outer part. I.ar-e patches of apoplexy in the linigs. No infarcts in spleen or kid- neys, which were large and indurated. i '\ • ■;i ill i I' ^"^ ^^^^CTIOUS ENDOCARDITIS. This is an illustration of the tlnVH ,>!. j • i. , tnird class, and perhan<; dnrh -stances urnish the large proportion of ,„e case XHo "ndcr the heading of ulcerative endocarditis ^ ^, Genera, and microscopical characters of .he vegeta- With the exception of the specimens from' Case , the ou grow hs on the valves presented the well.known appe a ceo, the so-called diphtheritic endocarditis. Th=rare to wlict?"'? '■" ^°""^"'°" '"'■'" "-'' «"""' char c lo winch 1 wish to refpr Tl,« *. , , , rcrer, ijie term uccrative t^ T .-<. marked before, is in certain instances a misnome The" vegetations on the valves in Case 6 presented a 1 'th I face, nether granular nor broken, and there were no signs of separa„on at the attached border. One or two write We ren^arked upon this, especial,, Cray, of ^ f 1: ened ii' ""' T '""'" °' "'= ^=S«»'-"' - ™"gl.- course f the entire mass were removed there would be -.n .Iccrat,on or even perforation of the valve. We do no that the ulceration comes firs,, and the thick vegetations represent subsequent formations in the exposed surfad About the vegetations in Cases 2 q nnrl . fl, !• v^"ov-o ^, j ana 4. tliere wac ^ peculiar greenish-gray color, especial,, marked when . ey were broken. It was common to meet with a blood ,„t adherent to the masses, and frequently a thin superfi 1 , in Case , the vegetations were firmer, not so friable and had rather the characters described as verrucose In Case 5 the outgrowths on the aorta and at the margin CI an?:: T":"; ''"^ '°"- -^ ^ "■^'" S.ayish-ye„!„ color, and the term "fungoid " best expresses their general W^^^-ce^Thevalvular outgrowths in Case 7 pre'e" ted */!/£■a ■^ .n^ H:;.; '•r- Ml ■.r^'.y. 7i ^/ J- ■"■^•. r^^ <"^-^^ lii'J-j' // A -, r WILLIAM OSLER. 15 the same general characters as in the other specimens, ex- cept in the slight calcification at one part. The microscopical characters of the vegetations in Case i offer many interesting features. In the study of this speci- • men we will begin with the description of small outgrowths. Fig. I represents the section of a small wart-like excres- cence on the wall of the ri-ht ventricle. It is mushroom- shaped, measures 3 mm. across, and springs from the endo- cardium by a small pedicle. There is no special change in the heart muscle immediately below it {a). At the site of attachment the subendothelial tissue is thickened, and con- tains in the deeper part many nucleated corpuscles imbed- ded in an indifferent matrix, while in the more superficial part it is distinctly fibrillated, and large elongated corpuscles occur. The vegetation is attached directly upon the fibril- lar layer, with the intervention of a thin stratum of round and elongated cells. At /; in the figure there appears to be an additional base or stalk, and here the proliferation of the subendothelial elements was very marked. The pedicle itself is composed of closely aggregated corpuscles of the size and general appearance of white blood corpuscles. The material in which they are imbedded is granular; fibrils ran- not be detected. An irregular break, probably the result of manipulation, occurs about halfway across the mass. At the edges of this {c) the colorless cells are thickly set and are stained deeply. The stroma of the mass is made up of a dense fibrin meshwork, only seen with a high power and in a thin section. It is variously interspersed with 'ells ; from some places they are entirely absent. Toward the surface the fibrin assumes a stratified disposition, and the corpuscles are less numerous (Fig. 2). A short distance from the pedicle, ball-like masses are scon imbedded in the fibrinous stroma, and at the super- ficial part of the mass similar bodies are very numerous and J \ , 1^ 1 Vi It !; ' I INFECTIOUS ENDOCARDITIS. constitute the most remarkable feature in the entire tex- ture, Fig. \, d ; Fig. 2. Many of the tendinous chords passing from the tricuspid curtains were thickly encrusted, and sections afforded a good view of the general arrangement of the parts. In a section of such an encrusted tendon, 6 mm. across, there can be seen the tendon in the centre, 1.5 mm. in diameter Under the microscope :t does not appear much altered, and 't IS only at the periphery that there is any nuclear in- crease; outside of this is a layer devoid of cell elements finely granular, and in places laminated. In logwood this part does not stain so deeply. In it are remarkable micro- coccus balls, some of large size and isolated, others smaller and closely aggregated together (Figs. 4 and 5). External to ^h.s layer and separated from it by a small amount of granular matter is a narrow zone of fibrinous tissue in which elongated corpuscles are very abundant. It looks as 'f this was the outer part of the tendinous chord, and as if the layer just described had developed beneath the suben- docardial tissue. The external part, comprising the greater portion of the section, is made up of a fibrinous matrix con- taining leucocytes scattered through it ; most abundant in certain areas. The outermost part of the encrusting mass IS distinctly laminated, and contains very few corpuscles but is thickly set with micrococcus balls, and the tissue has a darkly granular appearance. Fig. 3 shows the stratified appearance and the 'splierical bodies which here form a nipple-like projection, and appear as if passing toward the surface. This appearance is by no means infrequent. In the larger outgrowths the chief mass is composed of a nucleated fibrillar tissue, while in the superficial parts there are fibrinous lamination and numerous micrococci colonies ^apillary blood-vessels penetrate the deeper parts of the arge masses, and along many there is a deposition of WILLIAM OSLER. jy brown-red pio,n,cnt. In some sections Iar<,e micrococcus balls were met uitl. 4 or 5 mm. from the surface. The most remarkable structures in this specimen are the rounded bodies represented in Figs i to 6, and which have been spoken of above as micrococcus balls. They vary very greatly in size ; the majority of those in the specimen from which Fig. i was taken measured from 0..5 to o ■'7c; mm. Many are not more than .0075 mm., while at Fi<. 6 one ,s shown which measured .,500 by .1 ,35 mm. In pierces they occur in hundreds, closely set together, and often very small, as at Fig. 4. The outlines are sharply defined, but it .s not certain whether they possess a definite membranous .nvestment. They contain minute refractile granular spher- ules, uh.ch behave with reagents like micrococci. In some of the larger balls, as shown in Fig. 6, secondary ones can I am not prepared at present to discuss the nature and affin.t.es of these structures, but hope to do so on another occasion, when I shall enter n,ore fully into the histology of the prmiary and secondary lesions of this disease The vegetations in the other cases may be finally spoken of together, as, histologically, they presented the same features, with a few slight variations. A section throu^^h the grayish-yellow material composing the outgrowth L an appearance as represented at Fig. 7.-groups of granular bodies separated by an indifferent tissue. '■ ',ese colonies are usually closely compressed, and form rounded or tubu- lar structures. In the specimen from which Fig. 7 was taken, the groups measured from .050 to .125 mm. in diameter. In the out growths from the aorta in Case 5 this arrangement in colo- nies was particularly marked, and there were sharplv-defined bod.es. which bore a close resemblance to the micrococcus balls of Case ., even to the occurrence of secondary spheres i 'J i i !■!:! .jjl ; r- : i8 INFEC no us EN DOC A R DI T/S. \- within them. In a section througli the entire thickness of an outgrowth from the mitral valve, 7 mm. in diameter, the following appearances were presented: At the site of at- tachment there was moderate proliferation of the endocar- dial tissue, as shown by numerous round and elor.gated cor- puscles, which stained deeply in logwood. The greater part of the thickness of the mass is made up of irregular groups of dark granules, separated by indistinct fibrinous bands. The arrangement is not so uniform as that repre- sented at Fig. 7. In the superficial parts the texture is lower, the fibrinous laminse more distinct, and the corpuscles much more abundant. A collection of red blood corpuscles exists just beneath the outermost layer of this fibrin. I do not propose to make any further reinarks upon the special clinical features of these cases, none of which came under my care. My attention, however, has been directed to several circumstances in connection with the disease, which have not, so far as I know, received attention at the hands of writers on the subject. First. — The fact that primary infectious endocarditis in the majority of cases does not occur in connection with acute rheumatism, as is almost universally stated to be the case. I have gone over the reports of 57 cases of this kind, and in only 15 is there any mention either of acute rhciivia- tisni or of previous rheumatic attacks, i, e,, in 26.3 per cent. I have not been able to make an exhaustive review of the literature of the subject, but have gathered the cases from the British and American journals, transactions, hospital re- ports, and from some of the recent French and German journals. I have excluded those due apparently to septic infection, as from whitlow, urethral laceration, acute necro- sis, and the puerperal condition. Nor have I included those instances described as ulcerative endocarditis in chronic valvular affections (with dropsy, etc.), class ^ of above WflJ.lAAf OSLKR. 19 division, often accompanied with aneurisms of tiie valves ; but it may be mentioned in this connection that Dr. Ogle', in the ninth volume of the " Transactions of the Pat'lio- logical Society of London." gives 21 cases of aneurism of the valves from ulcerative endocarditis, and of 18 of these cases in which a history is given, 15 are distinctly stated not to have had rheumatism. Kirkes,^^ the pioneer in tins depart- ment of pathology, noticed the fact of its independent oc- currence. I confess to having been considerably surprised at the result of this investigation, as I was previously of the opinion, expressed so strongly by Rosenstein f and others, that the great majority of the cases were met with in con- nection Willi acute rheumatism. The second point to which I wish to direct attention is the frequency with which this disease occurs with pneu- monia. Naturally, I regarded it as not a little remarkable that ii! five cases in succession I should meet with this com- bination. Cases 2, 3, 4 and 5 appear to have set in with the symptoms of ordinary pneumonia. In Case 6 it did not de- velop until after the patient had been in hospital for some days. In all, the disease appeared to be of the primary lobar form. In Cases 3. 4 and 5, at the time of the autopsy, the stage of hepatization had passed and resolution had be' gun. Of 21 cases of primary infectious endocarditis re corded in the " Transactions of the Pathological Society of London," hepatization of the lung is mentioned in 10 as a concomitant pathological condition. Of the 57 cases which I have analyzed, 22 were complicated with or occurred in pneumonia, i.e., 38.5 per cent. What is the nature of this connection? Is the inflammation of the lung a complica- tion of the endocarditis, or vice versa ? In most of the cases it is dist inctly stated that the lung was hepatized. and in * Brids/i Medical Journal, 1863. ~~ f Zieinssen's Cyclopedia, vol. vi. 20 INFEC no US EN DOC A RDI TIS. \ I the majority of "^hc instances the disease appears to have begun, as in Cases 3, 4 and 5, with the symptoms of ordinary pneumonia, so that the conchision naturally suggests itself tliat the endocarditis was cither secondary to the pneu- monia or excited by the same cause, whicli kxtter I think tile more probable supposition. Endocarditis is scarcely mentioned as a complication of inflammation of the lungs. In Huss' statistics* there arc only 4 cases mentioned out of 959. Still, I was not altogether unprepared for the occurrence of the so-called diphtheritic inflammation in other organs in pneumonia. Bristowe f was, I believe, the first to point out that diphtheritic colitis was by no means infrequent in this disease, having met with it in 2 out of 30 cases of secondary and 4 out of 16 cases of primary inflam- mation of the lungs. I have also had my attention directed to this complication, though I have not met with it so fre- quently as Dr. Bristowe; still of some 40 autopsies in lobar pneumonia, of which I have notes, diphtheritic colitis occurred in 4, usually in the form of thin grayish-white patches, but in one case;}: there were large, thick, rupia-like masses involving the entire thickness of the mucosa It is exceedingly interesting to note that in Case 6 this condi- tion of the colon occurred with the pneumonia and endocar- ditis. Litten § gives a case of ulcerative endocarditis accompanying diphtheritic colitis. The condition of the inflamed part of the lung in these cases did not present any coarse or microscopical differences from ordinary cases There were no micrococci in the air-cells, nor any appear- ances resembling the remarkable bacteritic pneumonia de- scribed by Delafield.il It is not very evident wherein the * Quoted by Wilson Fox in Reynolds' System of Medicine. f Path. Society Transactions, Vol. viii. \ P.-ithological Reports, Montreal General Hospital, No.i, 1878. § Quoted in Brit. Med. Journal, Sept. 7, 1878. I Studies in Pathological Anatomy, Page 65, PI. XXXV. WILLIAM OSLER. 21 ■connection lies between these affections, hut the very c(mv sidcrablo number of instances in wliich tiiey occur to-nluT as against a simple accidental complication. A third point of clinical interest is the occurrence of mcnin-itis in these Cases as in 3, 3, and 6. In the ;; cases which I have analysed this is mentioned as present in 13; /.''., 22.8 percent. In 7 it occurred with pneum.Miia. Meningeal hemorrhage, as in Case 5, is mentioned several times. It is probable that the meningitis is embolic, though I have not found micrococci in the exudation. Meningitis is a very rare complication of pneumonia and may occur apart from endocarditis; but in a case of inHammation of the lungs, particularly if the apex is involved (in 3 out of 4 such instances I found the upper part of the lung affected), the development of an irregular temperature with cerebral symptoms should suggest the possibility of end.Kardial mischief, with secondary meningeal inflammation. The exudation in the meninges in these cases is lympho-puru- Icnt, not very extensive, and generally on the surface of the hemispheres, not basic. The presence of multiple aneurisms of the aorta in Case 5 is deserving of comment, as I have not been able to find any similar observation in the literature of either ulcerative endocarditis or of aneurism. The man had evidently been the subject of that peculiar congenital malformation of the aortic semilunar valves which results in the fusion of two segment.s. In this condi- tion they are very liable to be the seat of a sclerotic endo- carditis which terminates in incompetency ; and I have met with two other cases in which the united curtains, when in this state, were the seat of extensive ulcerative endocarditis.* The ca rdiac affection was evidently of old standing, and in potSVoft" 1880'° "''^™'"" "^ "'" •''"'^"'^ calves. Mont. Gen, YK^^^:^. 4| , 1 i w fVi 11 :. 23 /A'//%CT/OUS hNDOCAKDl I IS. \\ February, 1879, a year aiul four motiths before his dcatli, hypcrtropliv. a double iiuirmur and a tlirill were noted. Tile interest oi tin; ease centres in the four aneurisms of the arch, their a^e, and method of production. There can be no question of the recent character of the three small dila- tations, but in the case of the larire one there is room for doubt. 'ould it have been formed durinir the five weeks of his last illness, or was it of old stanilin^r. and was the thrill heard in I'ebruary iiulieative of its presence? I incline to the belief that it was of recent 'oriLjin for the followinj^ reasons: — 1st. The character of tin,' sacwall, which was thin, in places translucent, lookint; like the stretched adven- titi, li )f n a very considerable iuiini)er of aortic aneurisms o all sizes which have come under my observation, I have never seen one of this size with such a thin sac-wall and without any attemi)t at coiulensation. The internal and mitldle coats were not prolonged into the aneurism. 2d. The absence of laminated fibrin in the sac. Such a narrow- necked aneurism, if it liad lasted for many months, would certainl)' ha\'e showed signs of the deposition of fibrin, which takes [)Iace in aneurisms quite as small and less saccu- lated. 3d. The condition of the intima of the arch. Apart from these aneurismal dilatations the lining membrane was remarkably free from degeneration, particularly when wc consider the h}-pertrophy of the left ventricle which must have existed for some time. There was an entire absence of that cndartcriitis deformans which has, in my experience, been invariably associated with multiple aneurisms of the arch. 4th. A study of the four aneurisms shows that they have essentially the same characters and differ only in size. There is loss of substance involving the intima and media, the edges are covered with fungoid vegetations, and there is saccular distension of the adventitia, the only difference being that in the smaller aneurisms the breach of continuity lV//././.tM OS/./-: A- 23 is sli^rht, and tlu' v.-ctati-.tis so luxuriant that they com- pic-tcly cover it. Whatever tie essential nature of the so- calletl ulcerative cmiocarditis may be, I think there can [.e no doubt that in this instance wc have to deal u-itii an identical process in the arterial tube, which has caused loss of substance and subseciuent dilatation, just as it does on the mitral or aortic valve with the production of valvular aneurism. If this be -ranted, Case 5 adds an intere.stin^r section to the etiology of aortic aneurism. With regard to the intimate pathology of this disease, it is assumed by most recent writers to be a mycosis. /,r..'to be dependent upon the growth and propagation of lowly fungi on the valves with a consequent blood contamina- tion. Certainly the minute bodies found in the endocar- dial vegetations correspond in their chemical and micro- scopical relations to micrococci. They are motionless, highly refractile spherules, less than a micro-millimetre in diameter, arranged in groups or colonies without any per- ceptible stroma. Acids, alkalies, ether and chloroform have no effect upon them. These characters are supposed to afford satisfactory means for distingui.shing them from granular detritus of an albuminous or fatty nature. Most writers have accepted the view that these bodies arc fun- goid in nature. Heller.* however, criticizes strongly the prevailing conceptions with regard to micrococci, and thinks that there are scarcely any micro-chemical agents or physical signs by which they can be distinguished from fatty detritus. He recommends soaking the tissue in 10 per-cent. potash solution and then in iodine solution, i in ,0 of spirit, which tints monads yellowish-brown, but is inert on fat granules. Sections of the vegetations in these cases, treated in this way, show the colonies stained of a brownish-yellow color. * Vinhow's Archiv. Ixii, 1875. , ~ ~ ^ " 11 '« 11 t ! ti I" 24 INFECTIO US ENDOCARDITIS. \ i Apart from any micro-chemical tests there arc peculiari-^ ties about these masses which we do not see in any form of fatty degeneration, as the uniformit}' in size of the gran- ules and their collection into large groups. The cjucstion of the relation of the micrococci to the dis- ease presents many dfficulties, and we are probably not yet in a position to give a final answer to the problem- Klebs, and most German writers on the subject, give an uniiesitating assent to the ]>arasitic theory and suppose the micrococci to gain access either through the gastro-intesti- nal or respiratory systems, and the}' believe them to con- stitute the actual niaterics iiiorbi. According to Kostcr* and Klebsf not only are these fungi present in the so- called idcerative form, but they also exist in, and cause the development of, the ordinary warty or bead-like vegeta- tions so frequently met with in the valves. Within the past few months I have examined four specimens of this variety of endocardial vegetation, and have been able to tletermine in each instance the jiresence of micrococci, not, it is true, in the same luxuriance, or arranged in defi- nite colonies, but still sufficiently distinctive. In one case of mitral stenosis a fresh vegetation, when teased, showed many closely-packed spherules, some of which were, a* Klebs has remarked with reference to the micrococci in this variety, larger than those met with in the ulcerative form. I was greatly struck with the resemblance which certain of these bodies, in this instance, bore to the indi- vidual elements of Schultze's granule-masses — those pe- culiar granular clumps common in blood of some anim-- s and of impoverished persons. These structures are usi, ally regarded as the debris of colorless blood corpuscles, but I have shown;}: that they are aggregations of discoid bodies^ * Virchow's Archiv., Ikl. Ixxii. \ Archiv filr Exper. Pathol, u. Pharmacol., IJd., ix, % Proceedings of the Royal Society, 1873. WILL/AM OSLER. 25 probably living organisms of the nature of which we are still ignorant. They do not exist in the form of masses in the blood, but as isolated particles which might readily be- come adherent to the fresh endocardial outgrowths. I merely mention this as a point worthy of future investi-a. tion. ** It matters little how the micrococci get to the valves, whether by embolism of the small vessels, as Koster sup- poses, or by deposition on the surface, as Klebs thinks; the question is : Are they responsible by their growth for the peculiar course and malignancy of cases of infectious endocarditis, primary or secondary? The facts of their oc- currence in the ven-ucose form, which may not be accom- panied by any symptoms, and of their abundance in the recurrent endocarditis, which attacks old sclerotic valves are, I think, opposed to this view, for if they act as a septic poison in the one case, why should they not do so in the other? The micrococci do not appear to infest the blood in any numbers, so that they must be supposed to distil some subtle poison, " such soon-speeding gear as will dis- perse itself through all the veins " and profoundly disturb nutrition. The occurrence, however, of fatal septic cases closely allied to, or identical with those in which a bacteric endocarditis is found, but in which no micrococci can be detected, either in the local process or in the blood, teaches us that the same poison may exist without the interven tion of bacteria, the presence of which in any case may be only a partial phenomenon in a general infective process is 1 ,0 ■ > H , rJ Bi '^ ^ I I ^ y "a / -I / .^. .^2^ ^ ^ii>*^ ^. ^ <.*~ t ) ^^ ^-*-tol^ 4 /^^^*^^ >*....,*.>^^*.^-..^_ ^^^-^2^^ --«aw«*«sx- ^It^i^i-*-^^ I II II ifc >%^ _ ^ ■r ^'.^---^j i- «; yZ-*^-^ .^-< • < -<.-^< .S^ i^ 1 4A^j/:aiJ^ y^^ ^^iy-^^ ^-<^ f^i4.C^C(. y<:^^,4„<.^ ^fcTs*^ 4;;4e- >^L^ ^^ //iU'^^ (^l^U.^^^/^ XX X i/ii CASES OF PIODGKIN'S DISEASE. Bv WM. OSLEH, M.D, M.R.C.F, Lond. Professor of the Institutes of Mo.licine in MeGill University, an.I Pin-sidan to the Montreal General llospitiil. !| itt.-,.rinf.,lfn,m //,. - Ca,,,,,!,, M„,i,.„, ,(■ S,n;n,:,l .l..,n;,.,l . M.„„n;,l. F>hn,a>-y, IW.) OASES OF HODGKrN'S DISEASE, By Wm. OSLEU, M.D., M. H.C.I'., L.,nd. Professor of the Institutes of Mwlicine in M.Gill University, a.ul Pi,ysiri,m to the Montreal (it'iiLrul Hospital. There is at present a tendency amon^' certain writers to the belief that the various diseaserl conditions of the lymphatic glands are so related as to form a pathological series, the menihers of which may ])ass the .me into the other. 'J"lnis Dr. Goodhart, of Guy's Hospital, says : " We find the following conditions of the lymphatic glands all closely related to each other : First there IS a local chronic inflammation (the so-called scrofulous gland); next a local simple tumour, called l.y some hypertrophy ^ lastly a local malignant tumour, some varieties of which are called l)"y some lymphatic cancer. These are all local. But there is also a parallel series of generalized aifections, a diffused chronic in- flammation or scrofulous state, a diffused or general simple tumour, a generalized malignant tumour, and with the exception of the scrofulous or caseous group .... and perhaps of the generalized malignant tumour these various conditions can bo shown upon very good clinical, if not pathological evidence to lead the one into the other." However this may be, the cases characterized by a certain set of clinical features have been con- veniently grouped together, and are described under the various names of Hodjkm\ Disease, Amemia lijmplmtwa, Adenie Pseudo-leukcemia, / and Thoracic Glaiuh—Larije Medinstimd T amour— lUjht Hijdrothurax—ProgreMive Ancenda. James K., ict. 20, a patient of Dr. Sherman's of Morrisburg. Ont., who brought him to Montreal i'or examination on June :50th, 1880. Family histori/~Vixrents alive ; has brothers and sisters ; he is himself a twin ; no history of scrofula or other hereditary disease in the family, the members of which a|)pear healthy and well nourished. Father and sons are very hard-working farmers. Previous histor//—Uiis been a healthy lad ; never any special llness. Has been a very haid worker. Present illness— In November, 1879, he caught cold, had a severe chill, and pain in the right side. Did not lay up or have a doctor, but felt unwell for several weeks. About Christmas he noticed the glands on the left side of the neck to be enlarged. Tliere was at the same time swelling of the thyroid. A slight prominence of the upper part of the sternum was noticed in January, and shortly after the glands in the right a.xilla began to enlarge. About a montli ago the left axillary glands became swollen. Under treatment (iron and cod liver oil) the cervical glands diminished in size, and the enlargement of the thyroid disappeared. He has lost flesh, not much since March, and has become [lale and short of breath. Present condition. — Patient is an average-sized young man, fairly well nourished ; eyes blue ; complexion ! I i; *i ', iddy, particularly ii t HI lU If! if i ■■ i III |- 8 on lower part of tho laco ; is amvimic, and complains of muscular wiMkiK'ss. Appotito is good; bowels ro-ular ; tongue moist, nuU'i.tcMl witli tl,o tooth. I'ulso 12S ; irspirations ojj. Oil ii.speotioii, loft cervical glands greatly enlarged, forming a continiiniis tuiM.nir lV..m heliind the ear to tho chivicle, occu^ pyiiiglmth anterior and posterior triangles. Tho individual glands iM tho collection can he felt, are moveable beneath tho skin, of elastic feel, and not paiidul. On the right side there is no evi- dent enhirgement, but the glands can bo felt with unusual ais- tmctness. and just above the clavicle they are decidedly enlarged. In right axilla, just within the a.xillary fold, there is a tiunour the size of a couple oi' billiard bails, and in the left axilla a smaller one ; both are freely moveable, of moderate consistence, and not painful. The inguinal glands are not enlarged. in front of the ehe.st there i.s marked bulging of"' the upper two-thirds of the sternum and correspomliug co.stal cartilages, f-rming a .somewhat Ihitteu-d tumo„r, extending from roo't of neck to level with the nipples, and about six inches in breadth. Its point of greatest prominence is opposite the I'nd rib. The skin t)ver it is natiu'al looking ; there are a few dilated venules. There is no pulsation ; it is painful on pressure, and pits slightly. The glands are enlarged in the epi-sternal pit, and just over the right steruo-ehivicular j.)int are two glands, to which the skin is firmly adherent. In respiration the left .side of chest moves more freely than the right, and the intercostal spaces are obliter- ate,! in the latter. On mensuration, right, 18 inches ; left, 17^ niches. Apex beat visible If inches below and 1 inch to the outer sid,> of the left nipple. On percussion, absolute diilness over swelling in front of the chest, exten.ling on the left side as lar as the nipple line. Outer part of left infra-clavicular and mammary regions piesents a clear note ; same on posterior regions of this side, lli-ht .side is unif .rmly dull, except a finger's- hreadth beneath the clavicle and in the supra-.sj)inous and upper part of outer scapular regions beliind. Tactile fremitus absent over dull areas. On auscultation, breath sounds exaggerated and harsh on left side ; tubular at upper part of righUung iu front and l»ehind, abolished c-t b:i?e on this side. 9 Heart is depressed, dulness mer-os with that of the sternal tumour ; impulse forcilde ; sounds clour. Abdomen looks full ; superficial veins distended : when he stands up they become very marked, are coiled, and in places varicose, ^ense of increased resistance in re-ion of navel, hut no definite tumour can he felt. Liver o.Ktends two fni-ers-hreadth hehnv costal border and in sternal hue reaches to the navel. It is depressed, not enlarged. iSpleen jiot increased in size. ^m/. is amber-coloured ; sp. gr. 1023. No albumen. There IS no tenderness over any of the bones. _ ^/. Z>%««.v/.,_I [odgkin's disease (lymphadenoma ) .with pleuritic ethision on right side. The young man returned home, and th, .,., ther history of the case as gathero.l from Dr. Sherman, ,s as follows :-About the middle of July the fluid was drawn off from the right side U pints, straw coloured. This relieved him consider.-^jly, and he was able to breathe .piite freely. The sternal tumour had in- creased m size and became infbnued. On July 2C>th Dr. Sherman opened it at the lower part, i, , ..i.uut half a i.int of ill-conditioned bloody, pus escaped. Appetite keeps good. On Aug. 9th the' lad s father reported that the breathing had again become diffi- cult and droi,sy was beginning in the legs. Death took place on Aug. :>Oth, rather suddenly, as he had been walking about the barn-yard the same day. Avtopsi/, about 40 hours after death, in the presence of, and assisted by, Drs. Sherman and C. E. Hickey of Morrisburg, Dr Wagner of Dickinson's Landing, Dr. S. Hickev of Anltsville and Dr. Blackstock of Chestcrville.-Decomposition had set I !| ' i { ■ H vJl i I 10 In ; face swollen, skin discoloured and crepitant to the touch. Swelling in front of the chest had increased in size, and at the lower part, the incision above referred tu was seen. Cervical and axillary tumours about the same size. On making the jireliiniuary incision, a (luantity of soit .greyish material escaped from the tumour over the sternum. Wiien out into, substance soft and pulpy, with harder masses scattered through it. To a level with the 4th rib the stermira was destroyed, only a small bit uniting the clavicles above, The cartilages of the 2nd and -ird ribs were also eaten away, and on the i-ight side there was erosion of the l)ony parts as well. There was slight iniiltration beneath the pectoral muscles, b>it the growth was not continuous with that in the axilhe. On fully exposing the cavity of the thorax, the entire anterior mediastinum was filled u]) with soft greyish white masses, lying upon the aorta and pericardium, and extending into the neck. A large rounded mass, firmer than the rest, occupied the position of the right auricle and pushed the heart to the left. Several isolated tumours were attached to the diaphragm. The anterolateral part of right lung was closely united to the tumour ; on the lei't side the hnii: was free, but the growth projected in nodular masses into the pleural cavity beyond the costal cartilages. About four pints of blood-stained serum in right pleura. Entire mass removed with lungs and heart. On dissection from l)i'hind, aorta not compressed, though the arch was surrounded by irregular nuisses. (Esophagus ])resented one or two enlarged glands attached to its lower third. On slittiny; up the trachea and bronchi, former not compressed, right bronchus free, left somewhat narrowed, a conglomerate mass of enlarged glands surrounded the trachea from the root of the neck to the bifurcation, and passed out the bronchi, ]iarticularlv the left, and were imbedded in the lung substance. Immediately below the fork of the bronchi was a group of large glands, some- what firmer than the others. Heart transversely placed and pushed down ; chambers and valves noi'inal ; arch of aorta crossed at level of ih-d intercostal space. Lungs — Right collapsed, only the extreme apex crepitated. 11 . Throughout the lower and mirldle lobes were numerous greyish- white masses, varying in size from a cherry to a Avalnut. They were very al)undant in the fissure between the lower and middle lobes. The left lung was oedematous, otherwise healtliy. The enlarged glands at the root i)enetrated into the substance, but not to the same extent as in the other lung. Spleen. 1") cm. in length, pulp soft, uniform ; no nodular masses. liidnei/s presented nothing alnu)rmal. Livn- pale, not enlarged. Nothing sperial was noticed in stomach or intestines. Poyer's glands not urged. LinnphaCic Glands.— -The ee.rvical, on tiie left side, formed a large tumour made up of a cliain of glands extending from the stermnn to the back of the ear. They occupied both triangles ot the neck, and tlie sterno-mastoid muscle was stretched over them. Tiie enlarged glands were closely adherent, about tlie size of walimts, and tolei'al)]y firm. Many ot tlie smaller ones could be enucleated. On the right side, otdy tlie lower cervical glands, just above the clavicle, were atlected. Tiie axillarij glands were much enlarged, forming large bunches, composed of closely packed glandular mas>e.^ the individual eleimmts of which were with difficulty separated. Mesenfer/'e glands of normal size. Jiefro-peritonral glands enlarged to the size of horse beans, and firm. One or two in the hilus of liver, also enlarged. Inguinal glands not aifected. Owing to decomposition, the glands were doubtless softer thai, during life. On section, they iiad a greyish colour and a soft cerebriform appearance ; a con- siderable (piantity of juict; was obtained on scraping the cut sur face. Some of the glands were firmer, and had strands (,f firmer tissue i)assing through the substance. One or two of the masses m anterior mediastinum i)resentcd in sjiots a caseous appearance. The decomiiosed state of the glands did not allow of a very satisfactory microsco])icaI examination of theiritissue,when recent, but hardened .specimens showed, on section, closely packed lymphoid cells with a varialde amount of fibrous stroma. In several portions of the mediastinal mass the crowded elements had undergone caseous degeneration. 1 I 1 '■1 II ry am 12 Case III. — LijmplMdcnoma of the Cervical, Axilla Mediastinal Glands — Proyressiue Anwrnia. T. B., agod 20, a machinist, was admitted to Hospital Nov. 20tli, 1880. Parents living and liealtliy. Has four brothers and sisters. He is a twin. There is no consumption in the family, nor have any of the members suffered fr(»m glandular enlargements. Had ty|)lioid fever tln-ee years ago ; does not think he has ever been so strong since. About the middle of last Febiuarv the glands on the left side of tli(> neck became enlarged, and shortly after those of the left axilla ; the latter increased rapidly iii size, and got painful. lie has lost Hesli, and has become pale and weak. Has liad a cough for some time. Oct. '■I'yth. — .Vt this date the patient Avas sent for examina- tion by Dr. Rodger, (,f I'oint St. Charles, under whose care he has been. Appearance that of a pale, thin young man ; long face, eyes blue ; head elongated in anterior and postei'ior dia- meter ; forehead narrow, but very prominent. In left cervical region glands in anterior and posterior triangles enlarged, the size of large almonds, and forming a conspicuous swelling. There is an enlarged glaml placed directly over middle of left sterno-mastoid muscle. On the right side there is a single large gland in subclavian triangle ; the others are scai'cely perceptible. In left axilla there is a bunch the size of a small fist, situated anteriorly, beneath the pectoral fold. The separate glands can be distinctly felt, and they are elastic, moveable, and not painful. Right a.xiilary glands were sore at one time, and a little swollen, but are now of normal size. Inguinal glands not enlarged. On inspection of chest, a decided prominence is noticed on left side, over cardiac area, extending beneath third, fourth and fifth ribs, as far out as the nipple line to the left, and to the middle of sterimm on the other side. The sw«dlin"- occupies an area about the size of the palm of the hand. Per- cussion gives a dull note over the swelling, as high as the second space above, and merging below with die cardiac and hepatic dulncss. To the right its limit is about the mid-sternal line ; to the left, the nipple line. Over the rest of the chest the per- cussion is normal. No special alterations in breath sounds. and 13 S'/>/mic (lulness not apfiarently increased. Liver normal. Appetite -00(1. Blood not loukicnic ; proportion of colourless corpuscles not ascertained. Weight, l;;i lbs. ; in May was 141. Mv. 21.9^— Present condition. Has been at homo since last note, in much the same condition, hut is now somewhat weaker, ami has lost five pounds in weight, (ijamls in left cervical region have diminished much in size, the enlargement being now luirdly visible on cursory examination. On palpation however, they can he felt, slightly enlarged, hard, and freely moveable. There is one the size of a small wahuit, lying (hreetly upon the centre of tlie sterno-mastoid nniscle ; on the right side, tliere is one in the anterior cervical region, and a couple of small glands orer the mastoid process of the temporal bone. The right lobe of the thyroid seems a little larger than the left. In left axilla f'.. 'much of glands formerly described maintains about the • dze. He thinks they have been larger, and tliey have oeen painful (since last examination.) The individual glands are noi distinctly perceptible. The skin over them is not adherent, the whole buncli being freely move- able. Inguinal glands just perceptible. T/ior,ix and Ahdomen.—lnspectwn.—Thevti is a promi- nence, as formerly noted, in the left mammary region, extending from al)out the second to the sixth rib, and laterally from the left border of the sternum to the left border of the nipple, and is most prominent in the transverse nipple line. Pn-cuHsion.— On the left side there is dulness, from the second rib in the para-sternal line, which is contimious with that of the heart. To the left, the dulness extends for half an inch outside the nipple line. To the right, it extends nearly to tlie right border of the sternum. Over the upper none of the sternum, the note, though not absolutely dull, is deficient in clearness. A clear note is obtained over the clavicle, the infra-clavicular, axillary, and posterior regions of the left side, and over the entire right clust. Apex beat can neither be seen nor felt. Au^mI(afion.—At apices, in front breath sounds appear somewhat weaker on the left side ; behind, scarcely any notice- 11 I -It: I 14 No special diiiercnce in breath sounds else- able difference, where behind. Z/ye'r.— Dulness fro . lower border of sixth rib, and does not extend below costa' niurgin. Splseii.— Cannot he felt on palpation. Vertical line of splenic dulness is about three inches. Notliin^ special on palpation of abdomen. Heart sounds clear. Region of greatest intensity, Just below and a little to the left of the nipple. Appetite very tair. Bowels regular. Urine, no albumen, no sugar. About three weeks ago his voice suddenly became harsh and husky. JSfov. 25th. — Blood ex.vmined to-day. Drop of a good colour, not hydroemic. Red corpuscles run together into irregular clumps, and do not form natural rouleaux. They appear of tolerably uniform size, no very small ones arc seen. One or two have an irregular outline. Colourless corpuscles are in- creased to a moderate degree, and many appear smaller than usual, otherwise they have a natural appearance. Schultze's granule masses very abundant. Fibrin filjrids form an unusually dense and clearly defined network. lI;i;inogl(.I)iii (with Gower's apparatus), 48 per cent. Nov. 27. !| !i . m Bi II I KXXVt\) T- < Ih-vrii,t,,l f,;„n th, " (\,„wl,i Mr,U,„l .(■■ Smilnil .l,.iir,vd" „/ M„n-/,, 1880. ©Mtimnf. CHAS. F. A. LOCKE, M.D., CM. Many will have ueanl with deep regret of the death of this Sentlemau on the 24tli, at the earij age of 80. lie appears to liave been attacked with unTemic convulsions, and died after a few days illness ; the kidney disease having been latent, and causing no definite symptoms until the sudden and fatal seizure. He was a strong powerfully-built man, of unusual vigor, and when last seen by the writer in September, looked a picture of physical health. He was born in Barrie in 18r>0, and entered upon the study of medicine in 1807, at Toronto, proceeding in the following year to McGill College, where he graduated with honors in 1871. Shortly after, he went to Hamilton and entered into partnership with the late Dr. Hamilton, succeeding to the practice on the death of that gentleman. His skill and°attention gamed the confidence of the public to an unusual degree, and lie was in the enjoyment of a large and increasing practice. He was a member of the stafl^ of the General Hospital, and A^ice-President of the Hamilton Medical k Surgical Society. In the struggle of professional life as at present carried on, some- thing more than ability is necessary to ensure success ; there "Hist be tact, amiability and judgment, and these had been alloted in an unusual degree to Dr. Locke. From his parents he had received some of the finest call your I, which is well murk.-d in thin ca.., and luts been so i., all of the cases whu . I have seen in this city. It ,,s not blanched fron. sin.ple bloodlessness us n, tlu' pallor of fear .„■ I.emorrhage ; but there iH a peculiar sallow, .lirty yellow „r le.non tint/not the hue o| lannd.ce. .nd, n.oreovor, the cnjunctivu. are not stained It IS also quae .iistinct f.un. the wieeiu.h yellow tinge of the •skm ni chlorosis. The patient st.ll has a fair an.ouat of sub- cutaneous fat, though he has lost a good deal of flesh in the past tluee years. He is weak, easily tired, and it has been as much .18 he conhi do .o get frou, the v.anl to the lecture room His breath is short on exertion, and he feels faint and dizzy, when l.e stands for any tin.e. The appetite is poor and the .ligestion weak, but he has never luul vomiting. The bowels are re-ular no diarrh.ea. Pul.se is 84 per minute, soft and weak. On istening to heart sounds, which are very distinct, there is a blowing systolic murmur at the ba.se, evidently ha.u.ic in character, aiul the venous hum is loud in the neck. There is no evidence of any p.dmonary trouble. The examination of abdomen is negative ; liver .lulness, normal. .Spleen dulness Hbout, tour niches in vrtical diameter, edge cannot be felt under the ribs. Urine clear, reaction acid, sp. gr. lOlf. There are no cerebral symptoms ; he has sufl'ered Irom headaches, but not latterly. On examinatio.i of the eyes, retinal hiemorrh'ages are seen, and also pigmented spots, the result of old extm- vasations. •> The examination of the blood yields the following n suits • With Gower's Ha-macytometer, red corpuscles per cubic milli- metre, 'J70,000, Vj-i per htemic unit, instead of about 5,O00,0UO in the c. m. 'J'he luemoglobin, as estimated by Gower's Htemu- chromon.eier, is only :i07 of the n.nnial, .nd about the same percentage is obtained by Quincke's apparatus. The blood drop when expressed, has not the full rich colo.ir and consistency of normal blood, but is paiei-, thinner and watery. Under the micro.sco))e, the corf.u.seh s show a great inequality in size, some are krger than normal, others very much smaller. xMany are very irregnlai- in outline. The colour of individual cor- puscles is j.retby good, a few nucleatcal led corpuscles exist. The white corpuscles are not materially increased, the proi.ortion when counted, 1 to L'30 red. There is an entire absence of ■ H m Bolmltzo'H (^iRtiule ninRBen, bo common in the bloorf of debilitated indivi(i\ialH. I have put, for jmrpoHes of comiiariHon, tiif blood of an Mnn'iuic girl nndcu- another niieroHOOpn and you will be able to percc'vo a marked dill'erci if. Humniing up I he chief Hynll)tolu^^, we have, — 1. Profound anaemia without any obvious cause. 2. CanHac and vascular nmriinirs. 3. Repeated attackn of ej^istaxiH, which began originally after the anttiniia waa e8taV)liKhed. 4. Retinal haiuiorrhage. G. Peculiar alteiatious in the histological character of the blood. The clinical picture wliich Addison lias left of the disease is unequalled, as you may gather from the following extract : — " It makes its approach in so slow and insidious a manner, that the patient can hardly fix a date to his earliest feeling of that languoi' which is so'>n to become so extreme. The countenance gets pale, the whites of the eyes become pearly, the general frame flabby rather thau wasted ; the pulse, perhaps, large but remarkalily soft and comi)ressible . . ; there is an increiising indisposition to oxcirtion with an uncomfortable feeling of faintness, or breathlcssnesn on attempting it ; the heart is readily made to iialpitato ; the whole surface of the body presents a blanched, smooth, and waxy appearance ; the lips, gums and tongue, seeui bloodless ; the flabbiness of the solids increases ; the appetite fails ; extreme languor and faintness supervene, breathlessness and paljntations being jiroduced by the most trifling exertion or emotion ; some slight ludema is probably perceived about the ankles ; the debility becomes extvf^'-ie."* He says that these were "cases in which the. , d been no previous loss of blood, no exhaiisting diarrhoea, ■> lilorosis, no purpura, no renal, splenic, miasmatic, glandidar, strumous, or malignant disease." Of the individual symptoms of the affection, I shall not speak fully, as most of them are common to all forms of aniemia, but one or two demand special attention. I have already told you of the state of the blood in this ])atient, and of the remarkable diminution in the red cori)usclcs. Instead of 5,000,000 to the ♦ Aililis.m'.s Works. New Sydoiiliaiii Society, p. '21*2. 5 cubic niillimrtif), th- minilx-r in iciliucl (o ;»7(),()(t(). |,, ovor fifty ciiHdH of (liKOiiMfH, acL'oiii|ijiiii(M| with wiiHting, in wliicli I Imvo carefully ooiintcl tlio coipiiwIcH, |M.ini( ioim amoniiu is.tlin only ono in which I liavo inrt with a mluction jii tho red corpubclfH hflow 1,00(»,()(I() to th<" cubio niillinictm Even in an instance of stmtro hiunioirhagu -hiunioptyHiH (;xtentlin^ over a week— and during' which tiino tlut man loHt ncaily ton jiounds (by nioaHur(Mncnt) of blood, tho number of corpusclcH waH l,3!)n,0()0 per cubic niiiliuiotro. Tho reduction may bo much nioro marked tliaji in this cii.se ; th(! most striking instances which I have found rocoidod are ^^iven by O ,,;Kiv ,* in one 330,000 [ler c. m. ; and in auoMi. r, 1 t.'J.OOO ; .'r <■. ui. i Strange to say, this jjatient lecovered after transfusi» n, nd the tuinber of corpuscles rose from 113,000 on the 22nd of S\..\ io 1 34,000 per t: m. on the r)lh of Auey develop in the anaemia * 9roix/Aor. variously foiuiod. t Berliner KHn. fVwkcnschrift, 1877. of naiicor, and after Hovorn Iosh of I)1()<)(1. Tn sovoral of tlie cases which havo ouourml in this city, tiinrc were small culaneous extravasations. The etiology of tho disease is, in many cases, oliscurc; but in otherH, well recognized iiredisposins causes n)ay he traced. Of the recorded cases, the large i)i-oi)()rtion appear to have been in women, particularly in Switzerland, where the disease appears to prevail extensively, owing, doubtless, to local con- ditions. Thus, of ninety-three cases reported from the clinics of Berne and Zurich,* sixty-seven were females and twenty-.six males. In Kn!,land, the majority of caseu have been males. Of eleven cases which I know of as occurring in this city, eight wen? uuiles. Among the more important causes which have been assigned, are: 1. Pregnancy and Parturition. Many of tho cases on record have developed during pregnancy or shortly after delivery. It may be doul)ted whether such cases can be classed under the heading Idiopathic or Essential. 2. Defective food. A considerable propoi'tion of the Berne and Zurich cases resulted from this cause, and were more correctly examples of inanition anaemia. It is quite striking, in reading over the records of continental cases, to note how frequently this circumstance is mentioned, and the majority of rhe i)atients appear to have been derived from the lower classes; while here, and in England, many of the cases have been am.jng the well-to-do. 3. Gastro- intestinal troubles, atonic dyspepsia or diarrhoja, have preceded the onset of the aniemia in a large group of cases. 4. 0rief, mental shock or worry, have been mentioned by writers as probable causes. In one of the cases whi'^-b occurred here (Dr. Gardner) the failure in health btigan after the death of two sons. In the present case none of these causes can be assigned. The diagnosis is arrived" at only by the exclusion of all possible affections which might cause, or be accompanied by, great poverty of blood. You must carefully inquire into the history and mode of onset, interrogate the various systems * Miiller Die pro. p,r. Aniimii; /Zurich, 1877; Quincke, Volkmann's Saimilung, «•). 100; and Ziammt's Archiv. Bde. xx. and xxv. I k '■'n ! 8 and orgims in a searching and nietliodical manner, when, it' nc definite disease can be deteotod tlio diagnosis of idiopatliic or pernicious anieniia will probably be correct. Tiie affections with which it would be most liable to l)ii confounded, aro : 1. Cancer of the stomach, some instanci's of which run a voi'v latent course. Jn th^^ case you have here, the gastric .symptoms have not been marked, tliere is no tumour, nor tenderness, nor nuirked < niaciation, and the disease has hi.stcd a mucli longer time than cajicer would. 2. The api)earance of the patient and the retinal haiuiorrhages suggest llright's disease — and would still n)oro if tli(" ankles w(>re swollen, as formerly — but examiiuition of the urin*; is n( gative. No casts, no albumen. 3. From certain other blood diseases the diagnosis udght be difficult, but scarcely in this instanc(>. In leiikiumia there might be the same palloi,' the poverty of red blood corpu.scles, the va.scidar murunirs, and tlie irregular, slight pyrexia, but we wuidd have in addition, s])lenic enlargemei.t, ami a great increa.se in the colourless elements. Hodgkin's disease and sj.lenic anav.nia, while i)resenting a blood condition, closely resembling that of pernicious auiemia, woidd be dis tinguishable by the glandular enlargemetits. It is not im- l)robable, however, that there is a reiatioushii) between these affectio' s, which resemble each other so closely in certain clinical features. Litten* gives a remarkable instance of ameuiia follow- ing ])arturition, in which three days before^ death leukiumia of a high grade develo[)ed. lu the mwbid amitomij of this affection there are three points of interest, the extreme bloodlessness of the organs and the small cpiantity of blood in the he;irt any some writers .., « idiopathic fatty degeneration.' T a erat.on ,n the hone n.arrow has attracted considerate tte„t,on and ,s believe,! l.y certain pathologists to lav ^ ^.r^n conneetK. with the disuse. The long hones L: cen fotmd to contan. a r.oh re,l n.arrow, which has replaced U>enor.^l,,tty tissue of the n.ednlh.ry canals of hon^ :^ adults. 1 his consists of granular marrow cells, su.all lyniphoi,! corpuscles, ■nyelopla.ues, red blood corpuscles, an,l hu^ Z^ atec .,d corpuscles. The latter have been spoken of by Jn, wvxters as .f the, were not a usual constituent' of adult LrZ'- .-.cconhng to r.y observations they can always be foun,l in L' nun be, T am surprise,! that so goc' an observer as Prof Kutlierforc^ of Edinburgh, should state, in the little work i Practical Histology, which many of you use, that he has nev" been able to see these bodies in the marrow ] This change in the medulla of th. bones, in pernicious anaemia was hrst studied by Pepper, Cohnheim and myself, and ITZi inchned to attribute to it a son ewhat in.portant rAle in the patboiogy o the ,lisea.se. The position wliich 1 took n the matter may be gathered from the following remarks in a pape before the Canada Medic3al Association in 1877 • "Clinically, these cases present certain similarities to those of leukemia and Hodgkin's .li.ease. or pseudo-leukaxni... C these atter diseases differ chiefly in this, viz., that in leuk.omia he colourless blood corpuscles are in excess ; in pseudo-leukaan.; they ai-e not. Both present three varieties: 1st, the splenic m winch the chief lesion is the groat enlargement of the .spleen 2nd, the lymphatic, in which the lymph glands throughout thJ body are mainly affected; an.l 3rd, the researches of Neumann Mosler, an,! others have made us ac,,uain.e,! with a varietJ known as the myelogenous or medullai^,' in which .'he marrow of the bones is the seat of disease. This ti.ssue is no.v .enerallv regar„e,l as sluiring, in the young animal at a,n r:,e with the .spleen and lymph glands, in the formRt.io,. „V .,,J., ..^ h 3 1: , 10 puscles. In the long l)ones of the adult it is in a Htate of iitio|)liy, and its placo, in great part, supplied liy fat. In many caises of leukamiia and pseudo-leukteniia, it incieaHcSj becomes more vascular, its cellular elements multiply, nucleated red blood corpuscles, such as occur in the embryo, are formed, and the whole tissue passes into a condition of hyperplasia, strictly analogous to th",t affecting the spleen and lymphatic glands. This may be, as in a case recently repoited by Hosier, the primary lesion in leuka;mia, and the development of the manow may produce definite symptoms, such as swelling and tenderness of certain parts of the bones ; so that the myelogenous forms of these affections are now well recognized. Clinically, the myelo- genous form of pseudo-leukiemia, though laiely uncomplicated, presents such a similarity to j)erniciou8 aniemia that Jaocoud and Immeiuian suggested the identity of the two affections, while Prof. Pepper, declared distinctly that pernicious aniemia was ' merely the simple meilullary form of pseudo-leuktemia.' " In the present state of our knowledge it may, I think be reasonably afliiiued that certain cases of idiopathic amemia may be })lac.d in the category of myelogenous affections. To many it may ap|)ear far-fetched to seek, in the altered condition of the bone marrow, an explanation of the extreme ana;mia of tliis disease, but the reports of numerous cases leave no room for doubt that a serious alteration in its structure, and a return in adult lifi^ to its embryonic state, may i)rofoundly influence the composition of the blood, producing auicmia and death. It must be borne in mind that the red marrow in the short bones of an adult probably equals in bulk the constituents of the spleen, and structurally is very similar to that organ and to tlu; lymphatic glands. In tlie long bones it is largely replaced by lat, but traces of it still remain. Now, granting that the marrow is a tissue which .shares in the blood-niakiug functions, it is quite as re;isonable to suppo.se that, if hyperplasia of the elements of the spleen can lead to serious disturbance in the composition of the blood, producing the splenic form of leukieuiia or pseudo-leukiemia, according as the colourless corpuscles of the blood iiu'! increased or not, so a general increase of the consti- tuents of the nuirrow may induce similar conditions. For it io to be remembered that, in a general hypsrplasia of the 11 i marrow, the actual amount of lymphoid tissue in the osseous system equals or perha,,s exceeds, that of an enlarged spleen. Why a simple hyperplasia of this tissue should interfere with the elaboration of the blood, Jtering in the one case the mutual proportion of the corpuscles, and in the other simply reducing the total number, we do not know; but we are just as Ignorant why an enlarged spleen and lymphatic glands should produce in the one case leukemia, and in the other not " When the paper was published, from which I have read you these extracts, a systematic investigation into the condition of the bone marrow, in various diseases, had not been niade • but since then a number of observers have found this hyper- p asm of the medulla in many chronic diseases, particularly in phthisis and cancer. In a considerable number of examinations, 1 have also n.et instances of red marrow in the Ion- bones m chronic wasting disease, but not so frequently as Litten and Orth,* or Blechmann.t In only two instances have I found such intense and univerrd hyperplasia of this tissue as in the three instances of pernicious anemia, which I have had an opportunity of examining. On the other hand, in eight cases ot phthisis, and in two of cancer, (oesophageal and pyloric) i have found the marrow of the long bones fatty. I think that we have still a good deal to learn with reference to the bone marrow. I am not quite disposed to give up the view that 8ome instHnces of pernicious ananuia may be of myelo i i! I 12 te forms, determined by the condition., under which they occur, may occasionally t,ake on progreBsive and pernicious characters." And this is the view tak.n by Q.nncke. Dr Howard further maintains that, there is not a distinct variety of anaemia having an aiology and pathology peculi..r to itself, and it is upon this poi.it, particularly, tluvt n.ore hght is wanted. The cases re.piire sifting ; and, for .ny own part, would insist, with Immerman, " that no c.s^ should b. ..oc.pted as beloi^c-ing to this disease, unless, beBide« being .r instance of extreme and fatal an.^raia, it is also impossible to r.ccour either rationally or empirically, for the progressive coa-se ot the anwmic Bvmptomp."* The prognc^h is movl unfavourable ; all of our Montreal cases have died. Of the si:.-,v.fcn Zurich evses, given in Mullera monograph, only sever, recov.v.d. Oi Quincke's thirty-one cases, eleven are stated . bave recovered; but you must remember, with referenc. w many of these Switzerland cases, that they come mor. properly under the head of inanition anieraia. The duration of the disease is from three months to a year. This case is remarkable as lasting for over three years. One ot Biermer's imtients lived for tive years after the first onset of tb. symptoms. The most rapid course in his c»,8es was seven weeks. The- treatment is not very satisfactory. Special attention musr be given to the weak digestion which almost invariably accompanies the disease. Iron, in some form, sho.ild be em- ployed ; this patient has been taking Blaud's pills for some weeks, but without any apparent benefit. Arsenic should be given, as several successful cases hate been reported under its use • it may be given in combination with the iron. Our patient has 'not been taking it long enough for us to say whether it is doinc^ any good. Transfusion of blood has been employed in many cases, but without very encouraging results. Quincke, however, has had several successful cases. He transfuses into the radial artery. The transfusion of milk, as first employed by my old preceptors, the late Drs. Hodder and Bovell, of Toronto, is stated to h«ve cured, even after blood transfusion had failed. • Quoted by Hartshorne in his article on "Prog. Pernicious Anemia,- in the American edition of Keynf-.;.- ^ System, Vol. III. xu CLINICAL LECTURE ON A CASE OF FIBROID PHTHISIS. By WM. OSLER, M D, M.R.C.P, Lond. Professor of the Institutes of Medicine in McGill University, and Physi to the Montreal General Hospital. cian D^UVKRED AT THE MoNTRKA,, GkNKRAL HOSPITAL m THE SuMMER SksSION CuuRSK. May 10, 1881.; "i^ksk, :\ H ^ \ f r Re-printed from the "Canada Medical & Surgical Journal," Montreal, June, 1881. 1 ; CLINICAL LECTURE ON A CASE OF FIBROID PHTHISIS. By WM. OSLER, M.D., M.ll.C.P., Lond. Professor of the Institutes of Medicine in McGill University, and Physician to the Montreal General llospitul. (Dclivmd at the Montreal General Hospital in the Summer Setsion Course, May 10, 1881.) Reportku Stenookai'Hically by S. a. Abbott, Esvi.,OF thk Hansard Stafi\ GentlemExV : There is no disease that you will have greater difficulty in thoroughly understanding than phthisis. I have no doubt that to many of you the difficulties which this subject presents have already become apparent. It is, in fact, at present, the bugbear of medical students, particularly in their last year. This is owing in great part to the inherent complex- ity of the subject, and in part, I am sorry to say, to the exceedingly diverse theories and views which at present prevail upon the pathology of the disease. The simplest classification of phthisis is into pneumonic, tuber- culous and fibroid varieties. It is of the last that I wish to speak to you to-day, and to show you this interesting example of the disease which many of you have already studied in the ward. This form of phthisis is characterized by certain peculiar features. In the first place, it runs an unusually long course. Patients may live for twenty-five or thirty years ; in many instances, indeed, it does not diminish to any great extent their term of existence. I will refer, in a few minutes, to a case of a gentleman who has been under Dr. Howard's observation for the last twenty or twenty-five years, and who only died last week of the affection. Then, in the next place, it lacks certain of those characteristic features which we recognise in ordinary phthisis. The patients have not night sweats ; they rarely have diarrhoea, and the loss of flesh is not very mark :', They may have attacks of i;i; m !« i - 1 m f; haemoptysis, occurring usually at long intervals. On examina- tion they [iroseut certain peculiarit'oa, Sv auich so, that super- ficial inspection alone may 1k> -i-.tticic ' ' ■ give ynu a good idea of the nature of the disease frojn which the patient is suft'ering. There is generally some contraction of one side the chest, accompanied by deficient expansion and some de- gree of immobility. There is not much fever throughout the disease except towards the close. Most of '! ,\t8 are able to engage in the ordinary occupations of life and are only troubled with a cough and more or less expectoration. As a rule they enjoy ;i tolerably quiet existence for a long period of time. They are F"l;ject to recurring attacks of bronchitis, par- ticularly in the wii t'-r season. The history of this patient is as follows : J. VV., aged 44, a native of Sheffield, a saw-maker by trade, admitted April 18tii with cough and shortness of breath. Family history is good ; none of his relations have died of ^'onsumption. Has worked at his trade from his youth ; the pecial work which he does is beating the saw blaiK'S and is not accompanied by much dust. lias been a i fetty steady drinker, though not a drunkard. Was strong and healthy up to about five years ago, when, in the winter of 1875, he sjtat a small amount of blood and had a cough, but did not leave oft' work Had no pain in the side ; does not think that he was fevei '.-^h. The next spring ho returned to Canada and remained well until the a tumn, when he entered hospital for bronchi tc. Ho has had cough ever since, and has been laid up part oi each winter, getting better in the summer. He has spat blood on several occasions, but never much at i time. Has not h.ia uight sweats o>- diarrhoea. Has lost flesh, particularly in the last four months. Coughing is chiefly in spells, which are violent and very often acoorapanied by vomiting. Has never brought up very lart" quantities at a time ; never noticed the phlegm to be stinkli. H:us not had palpitation of the henrt ; feet have never swn' a. he fingers are clubbed and the nails incurvated. Thisnii.ii has sutt'ered for the past five or six years from these i '1 iiood symptomn, tlio cough coming cliielly in the winter, during wliich time ho lias had to lay up for a longer or shorter [jcriod. (The patient disrobes to the hips and is examined.) Nof-iee in the first place that the left shonldcr h a little lower than the right. There is decided flattening of the left half of the oliest, and when ho draws a full hreath tlx-ro is deficient expansion. The heart is drawn a little to the left and is heating a little outside the nipple line, but it is not disftlacod nearly to the extent we sometimes find it. Sometimes you may find it beating I.igh up in the mammary region, owing to the drawing up of the heart by the contract! ni of the lung. On measure- menr of the chest the left side is smaller than the right ; tlie left measures loj inches and the right side !■ inches, not so great a difference as one might have expected. On percussion you will notice that there is uniform didness. a hard, flat note, over the wliole posterior region of tlie chest, and a similar note in front. The note is nowhere tubnlnr, as is soinetimes found. There is a little resonance high up in the axillary region. The tactile fren,. us is not markedly increased, but the vocal reson- ance is grca.; exaggerated, ajiproaching to bronchophonic over the greater [x.i tion of the dull regions. On auscultati. -, you hear very peculiar and characteristic sounds. The breathing in front is hollow, and of tlie character known as cavernous. ■ accompanied by rales, some of which are whistling and piping, ..iid others, just below the clavicle are more gurgling m character and suggest bubbles passing through a liipiid. Thest' cavernous sounds are heard all over the front and in the lateral regions. The breathing at the upper part of the lung behind and in the left inter-scapulat region is weak, as those of you who have examined this man will remember. At the outer angle of the scapula the breathing is intensely hollow, approaching to ani[)horic, and is also accompanied by rilles. The voice sounds are he>ud with much greater intensity — pectoriloquy. These are the chief features on a physical examination of this patient. Yon find flattening of the left side of the chest, deficient expansion, dulness, increased vocal resonance, and f: I H I :l 6 numerous cavorni)us si|^ii8 over the greater portion of the dull region. At the apex bihiud and in the leit inter-scapular region, the breath sounds are somewhat diminished, being weaker than in the other regions. Over the ri^'' lung the breath sounds are clear except at the extreme apex of the lung. At this part you hear coarse breathing, a prolonged expiratory murmur and rales. These are heard in the right infra-clavicular region and at the apex behind. In tlio rest of the lung the breathing is loud, distinct and unacoompanied by rales. Now the ali'ections which could produce such a condition as this are verv limited. There are only three or four which cause contraction and immobility of one side of the chest, with a dull percussion note. These are fil)roid phthisis, or cirrhosis of the lung ; chronic pleurisy with retraction, and malignant disease of the lung, and you have to distinguish between thewi. The immo bility of the side of the chest and the dull note might be produced by a general collapse of the lung, or by a chronic pneumonia, but you would scarcely have the flattening and retraction. Now, between fibroid phthisis and a cancer of the lung there can rarely be any ditliculty in the diagnosis. In the case of this patient the phthisis has lasted for five years, cancer of the lung seldom lasts over a year. Cancer of the lung almost invariably invades it from the mediastinum, and you have other symptoms of intra-thoracic pressnre which we have not in this patient. More- over the cachectic appearance of a patient with cancer is marked. There can be no doubt in such a case as this. The diagnosis between chronic pleurisy with retraction and this condition of fibroid ])hthisis, presents greater diSiculty. In both you have dullness, deficient exj)ansion and retraction of one side of the chest. The shoulder is usually depressed much more on the affected side in chronic pleurisy with retraction than in fibroid phthisis. The chief differences to be met with on auscultation of the chest are these : in chronic pleurisy with re- traction you do not find the cavernous signs, which ai e so com- monly heard in fibroid phthisis. The breathing is weak and feeble. Some of you may remember the patient with chronic pleurisy, with retraction, that was in No. 11 Ward two summers ; I ago. That man had lowering of the shoulder, retraction of the side, and dnllness over the ;;ieator part of his lung. Tlic diagnosis between collapsed lung and chronic pneumonia 1 need not go into. Now with reference to the morbid anatomy of this disease, the alfection is known as fibroid phthisis or cirrhosis of the lung, both terms indicating an increase in the fibrous elements of the organ. The latter terra was given by Sir D. Corrigan, and I pass around the riutn illustrating his paper. It is, in fact, a fibroid substitution : the normal, histoloifical elements of the lun"; are replaced by a fibrous tissue which in time undergoes contrac- tion, as all new growths of fibrous tissue do. On examination of one of these patients after death you will have such a condition as you so•hich I referred was under his obsei'vatiou for over twenty-iivo years. Indeed, chronicity is one of the remarkable features in connection with the disease. The patients sutler from attacks of bronchitis, which come on during cold weather. The cough is apt to be spas- modic, the expectoration is usually profuse, very often half a cupful or a cupful is brought up at a time. The phlegm is frequently stinking, having remained lodged for sometime in a cavity or in a dilated bronchial tube. There is not much fever except when the patient takes a fresh cold. Several symptoms come on towards the close when the hypertrophy of the right ventricle of the right side of the heart begins to fail. When there is dilatation of the right ventricle and incom[)etency of the tricuspid valves, they then begin to have dropsy of the legs, sometimes dropsy of the belly. These symptoms usually pre- cede a fatal issue of the case. That is a very common train of symptoms, audit occurred in the case of a woman who was under my care in Ward 23, in 1879. Other cases die of asthenia or gradual failure of strength. Expectoration becomes more pro- fuse, and they die of gradual wasting. The man who died under my care this time last year of miners' phtliisis, and whose lung I now exhibit to you, died of asthenia. He had been under my care for two years, and gradually coughed himself away. Then, again, other cases die of waxy degeneration of the organs. The chronic loss of pus from the cavities in this disease, tends to produce the peculiar degeneration known as waxy or amyloid. The woman I spoke of as dying in Ward 23, had extensive amyloid degeneration. Lastly, some cases die of haemorrhage from the lungs, which is not an uncommon symptom. The bleeding is caused either by rupture of a small aneurism on the walls of one of the cavities, at ulcox'ation of the branch of an ai'tcry. 11 to The prognosis depends entirely on the condition of your patient. In this man's case tlic outlook is bad. He has lost a good deal of flesh in the past year, disease is evidently com- mencing in the other lung, in which there is a cavity at the apex, and he very probably has tuberculous disease. Where the one lung is healthy and uninvnlvod the patient may live for a con- siderable period of time ai'.d enjoy comparatively good health. Nothing special need be said with reference to treatment. It is entirely a treatment of symptoms. This man came in with severe cough ; lie was put to bed and given a sedative cough mixture, and soon felt improved. The shortness of breath diminished, and he is now feeling pretty comfortable and is ready to go out. During the summer months these patients always improve ; during the \vinter months their bronchitis is aggravated aad they are always more troubled with a cough. One point with reference to the treatment, and it also bears upon the cause df the disease, and that is, the use of alcohol in phthisis. It is believed by many, that the use of alcohol in large quantities in eertain forms of phthisis tends to produce a fibroid degenuration of the affected lung, and of course tends to a cure, because this fibroid substitution in a lung is in a measure a healing process. Now it is a peculiar fact in connection with many of these cases of fibroid phthisis, tliat they occur in persons who have been habitual drinkers. Such has been the experience of Dr. Andrew Clark, who was one of the first to call attention to this affection. It has also been the experience of the physicians at Guy's Hospital, and of many other English j)hysicians. The man we have just examined seems to have been a pretty hard drinker. I merely mention this as an uiteresting fact in con- nection with this disease. This patient will remain in until to-morrow afternoon, and I would recommend those of you who have not already done so, to examine him thoroughly and try to get the main features of the case impressed ujion your minds, as he affords an exception- ally good illustration of the disease. */ 1 \. !„,j™.«_, ,» SI «,»'■:<■ ■ J ^ 1 ■ i)e^ii Im I I ■iM XL ON SOME OF TJIE EFFECTS OF THE CHEONIC IMPACTION OF (ULL-STONES rs "*. IN THE BILE-PASSAGES, AND ON THE "FIfiVRE IXTERMITTENTE HfiPATIQUE' or CHARCOT. -^'^.^ Delivered in the Demonstration Course on Morbid Anatonvj, January 15, 1881 BY WILLIAM OSLER, M.D., M.RC.P. LonJ. fBOFESSOa Ob- TUK IM8TITUTES OF MEDICINE, SKQILL UXIVEUSITV, SIONTUKAL ^Reprinted from "t/LBvicki. Times axd Gazette," JulyZO, 1881.) 1 at-' LONDON PAHDON & SONS, PMNTEUS, PATERNOSTER ROW mm Gentlemen,— I proposo to ciill ynm- attention this mr.ming to some of the otteL'ts of the impaction of gall-stones in the liiliai-y passages. The specimen before you, obtained from an old woman who died this wei'k of septicemia. (Case 5) after a fraotnre, illustrates the distension of the gall-bladder and ducts which follows the lodgment of calculi, and it has served to remind mo of other cases which have come under my observation. I shall therefore occupy the hour with this subject, and shall, moreover, depart somewhat from my usual custom in this course, and speak of certain clinical features in these cases which have not received much notice at the hands of English writers. I will first speak of the effects of impaction of a gall-stone in the cystic duct. This tube is narrower than the common duct, and its mucous membrane is not nnifornjly smooth, but presents numerous transverse and oblicpie folds, so that it is almost impossible to jiass a probe up or down its course. These valvular folds (valvula Heisteri) often form definite pockets, and the entire arrangement is certainly not the most favourable for the easy passage of a calculus. The following eflects may result from the plugging of this duct :—l. Dilatation of the gall-bladder. 2. InfiatJima- tion of its coats— catarrhal, diphthi'ritic, sujipurative, or phlegmonous. 3. Obliteration. 4. The formation of fistula; with contiguous organs. -i ^». OX SOME OF THE EFFECTS OF THE CIIKOXIC IMPACTION OF GALL-STOXES IX TJIE B [IE-PASSAGES, AND ON THE " FIICVKE INTEK3I1TTENTE HKPATIQUK" OF CHARCOT. I- M.mi .i*l It!: if The dilatation may attain a very hi<,'h oracle, and the organ contain several pints of fluid. The foUowincr instance IS reinarka,ble, as the tlistended gall-bladder reached to the pelvis, and was diagnosed as an ovarian tumour ;— Case 1. -On March 23, 1877, I performed an autopsv on a patient of the late Dr. Bell, a woman aged fifty-eidit. In August, 187(5, she consulted Dr. Bell for pains in the back and loins. Ho made a vaginal examination, and determined the presence of a tumour, apparently connected with the rijht sidej. On account of the obesity a satisfactory examinatTon (.f the ab.lomen i-ould not be made. Many of the symptoms were thoseof obstruction of the bowels. No previous histcay of gall-sti lUes. At the autopsy, localised purulent peritonitis al)out anterior border of liver, and between it . and the trans- verse colon Gall-bladder moderately distended ; walls tense. and of a dark livid aspect; when slit open, a dirty, brownish- red, ill-smellins>' tiuid escapeil, and six or ei^-ht liji;ht coloured j^-all-stoues. A calculus was found in the orifice of the cystic duct. The mncDiW membrane was not ulcerated, but was dark, and the cuts Icoked sphacelated, particularly towards tiie fundus, 'l iie .'nuuion and hepatic ducts were free, and there were rj>- ''.b-jr tijiecial morbid features. Between :. ih',.;:>i( and inflamed . //^^^.^ The very large calculi, which are sometimes passed per rectum, and which may induce symptoms of obstruction, most probably idcerate into the bowel, and do not pass the common duct. Wo will turn now, ^■ontlemen, to the consideration of soma of the etl'ects of impaction of gall-stones in the common dxvU The usual site for the lodgment of the calculus is in th>' ter- minal portion of the duct, the pars intestiualis, as here he calibre is considerably narrower than elsewhere. You see in this specimen taken from Case 5, above mentioned, how small a stone may find ditficulty in getting through. It is impos.«)blo to say exactlj liow larye a concretion may pass. i IMAGE EVALUATION TEST TARGET (MT-S) V // 4r 1.0 1.25 |50 '""^^ I" 1^ ^ 1^ 2.5 IIM 1.8 .'A ill 1.6 1 iiuiugi a[jiiiL Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 iV ^o M,^ :\ \ #^v rv ^;n % 0" v^t," Is I m ; r : =•■ ill! 1 ift ■f^>^' 12 hours gave place to a high f.ver, which was followed by a copious sweating, that stained the sheets of a deep yellow colour. Til ■ liver was found to be slightly enlarged. The intense pain gradually abated, but the tenderness per- sisted for several days. All of the essential phenomena of jaundice were present. She remained under my care until January, and during this period she suffered every two or three weeks from a paroxysm, varying somewhat iu intensity and duration, such as I have described, except tliat the acute pain became less and less on each occasion, until at last there was scarcely any ; but the chill, fever, and per- spiration were invariably present, constituting, with an increase of the jaundice, the entire paroxysm. Itching of the skin was a most distressing symptom throughout, often preventing sleep and rendering life almost unendurable. The stools were repeatedly strained for days together, but no gall-stones were found. The slight enlargement of the liver disappeared." I ascertained from her that during the early part of last year the attacks continued, but during the summer (under homoeopathic treatment) the jaundice almost disappeared, and she had not a paroxysm for several weeks. Latterly they have recurred every week or ten days. On the occa- sion of my first visit, she was intensely jaundiced, and suffering from the most terrible itching of the skin which I have ever witnessed, and for this she specially sought relief. Finding that most of the usual remedies had been tried, I ordered ;i '-mi alkaline bath, which had a very beneficial effect. IJuring the night she became quite incoherent, and greatly alarmed her friends, who of course blamed the bath. In the morning the itching had almost disappeared and she was rational, but complained of a deep throbbing pain in the heart. I examined her care- fully, and made the following notes :— Body well nourished ; thick layer of panniculus on abdomen. She says, however, that she has lost flesh in the past year. Skin of a deep greenish-yellow tint. In examining the abdomen, the edge of the liver cannot be felt; no tumour is evident below right costal border. She winces on firm pressure midway between navel and eusiform cartilage. Area of liver-dulness some- what diminished j no tenderness over it. Splenic dulness a little increased j seven inches in vertical diameter. Heart and lungs normal. Tongue red, and indented with the teeth. Bowels regular ; stools clay-coloured and offensive. Urine very dark-coloured, and contains much bile-pigment. Pul.se 80 J temperature 08-4\ Appetite is poor and she can only take soft food. During the next three days she improved. 18 and the itching disappeared, except from the palms of tlio hands and soles of the feet. These she stated liad been most troublesome throughout the attack, and the pads of tho palms, at the bases of the Angers, were swollen and tendi-r. liy the 15th she was feeling much bettor, and the jaumlico had begun to disappear. About noon on the 10th she had a severe paroxysm, the chill lasting nearly two hours, and at 5 p.m. I found her sweatin-- pro- fusely and much prostrated. During the cold stage she had constant relays of hot flannels wrapped round her, and hot bottles applied to the feet. The shaking was some- times violent enough to move the bed and cause the room to vibrate. There was no vomiting with the attack, nor any special abdominal pain. On examination of the hepatic region no change wns noticed. The following day the jaundice had become intensified and the urine much darker. From this time until Christmas-day she had seven attacks of varying intensity, five of which followed each other on the Fridays, coming on at noon. The temperature in one of the paroxysms reached 10t°. The itchin^.¥^,,/j ii, it! ml B- ■■ •^iii 1 hi ^f^.. ■M Id The tonipcraturo throughout the illness hiis heon from 00° to OS'ii", rising in the paroxysms as high as 101". Tiie inilso has ranged from GO to !tO per minute. During last summer there was an interval of nearly six weeks during which she had no paroxysm and the jaundice disappeared. The daily amount of urea was estimated for me by Dr. Henderson during a period of three weeks, but there did not appear to lie any special diminution dui'ing the p.iroxysms. Acting on the suggestion of Dr. Kennedy, of Bath, Ontario, I gave her huge doses of oil, in the hopes of inducing the passage of the calculus. She took three Florence flasks of it without any effect. Latt-erly she has been taking potassium bicarbonate and Bethesda water. The similarity of the clinical liistorics of these two cases is very striking ; the chronic jaundice, varying in mtensity, and the febrile paroxysms are, with trifling deviations, the exact counterparts, and let us hope that the parallelism will be still further carried out by the passages of a gall-stone in the second case. Considering how rich is the literature of gall-stones, I have been sin-prised to find very few references to this symp- tom. Occasionally in the reports of cases of chronic obstruc- tion by English writers, shivering fits are mentioned. Thus, Budd,* in the history of a case of impaction of a large gall- stone in the common duct, which lasted many months, says : " Has lately had many fits of shivering, and sweats much at night. Never had ague, and the spleen is not enlarged." In the second edition of his work on the Liver, Dr. Murchison speaks briefly of periodic paroxysms of intermittent fever occurring in connexion with the lodgment of gall-stones in the ducts. The only full account which I know of is in Charcot's work. He ha§ lieen able to collect twenty eases for analysis, and his conclusions, briefly put, are as follows: — 1. The paroxysm begins suddenly with a chill, often severe enough to shake the bed ; the temperature rises to 102' or 105'8', and jirofuse sweating succeeds. 2. The jjeriods of apyrexia are clearly defined. The fever comes on with the regularity of a quotidian, tertian, or quartan ague ; but to this rule there are many exceptions. 3. In one instance Eeynaud determined that the amount of urea was diminished during the paroxysm, whereas in true intermittent fever it is increased. 4. The paroxysms usually come on in the even- ing, while in gi'nuiiie ague they most frequently occur in the mcruing. 5 The lic])atic fever is chronic, and may la.st •' On Diseases of tlie Liver," second American ti-iucin, pn^e 219. 15 two or three months, with intervals of eight, ton, or fifteen duys Ijetween tlie paroxysms. Aa many as thirty-one attacks have been known to occur. C. A favourable termination is possible, as shown Ijy a case of Henoch's ; but a fatal issue is the rule. Death may take place suddenly, with symptoms like a per-ncious malarial fever, or as a remittent fever with typhoid cl„.uacters. Dr. Charcot states that the condition of the bile passages which accompmies this fever is dilatation with inflamma- tion of the mucous moiabrane, and the presence of pus or muco-pus. He suggests, in explanation, that a septic principle or pyrogenic material is developed by changes in the bile, and getting into the blood induces the chills and fever. Though the cases which I have detailed to you conform in all essentials with OViarcot's description, there are a few additional points of luct.'rest. In both the course of the disease seems to have been, com- pared with other cases, greatly prolonged ; nine months in the one, eighteen in the other. The recurrence of the i)yrexial attacks did not follow any definite order like true ague, but came on irregularly at intervals of from two to sixteen days. In Case 2,the " shakes " recurred on Friday, at noon, for five weeks. One very remarkable feature in these eases I do not see mentioned, and tliat is the deepening of the jaundice after the attacks. No symptom was more constant, as some of you doubtless remember, in Case 1. It was rarely necessary to ask whether there had been a paroxysm, the colour of the face was a sutHcient index. In the case of Mrs. S. the jaundice intensified very rajndly, often within eight or ten hours after the onset of the chill. The cause of these repeated paroxysms must bo confessed to be very obscure. Char. < it supposes, as I told you, that a septic principle is developed in the dilated bile passages. Murchison suggests that " they are due to the simple irrita- tion of the stone, and are analogous to the febrile paroxysms resulting from the passage of a catheter along the urethra." Certainly, in Case 12, the deepening of the jaundice and the absence of bile in the stools after the paroxysm favour the idea that a calculus, pi'rmanently lodged in the common duct, had shifted its position and had become for a time more closely wedged. '-^ t*. I if W* Pardon aiid Sons, Pnntrrn, I'aiKriiOSter How, Lotit'un. K XUI ^^ t*. /tVT H RENAL CIRRHOSIS. w S( /It-printed from the "Canada Lanctt," AMgutt, 1S81. RENAL CIRRHOSIS. WITH SPECIAL REFERENCE TO ITS LATENCY AND TO SUDDEN, FATAL MANIFESTATIONS OCCURRING IN ITS COURSE. Being a Clinical Lecture delivered May 28th, 1881, in the Summer Session Course, by Wili.iam Osi.er, M.D., M.K.C.P. Lend., Professor of the Institutes of Medicine, McGill University; Physician and Pathologist to the Gen. Hospital, Montreal. (Steiwsra^hUal Report by S. A. Abbott, Esuperlicial lesions are shown in braiiKS preserved by Ciaeomini's method (kee N. Y. A/i-a. AWcni, .April, i8So). No. 4. Apoplexy of pons. No. 5. Cicatrix of apoplectic dot in cerebellum. Hoth of these specimens are fiora the same case, a woman .ny^.d , 40j dissipated. The lesion in cerebellum dates from a year before _ patient's dcalh, and is a good ex,ample of a healed injury to br»iii subst.ance. She remained dull and stupid after the .iti.ick, an;oid di>ea>e. 'I'liere wa.s no paralysis ; headache, chdinrss and occasional inability to e.^press hiiu.self freely were the rliief brain syniptoms. Xo. 7. ]'!ml)o]i.'im of left micUllc corcbra! artery. Tiic einbol(jn i- seen in sifii. Case of younii' girl with mitral stenosis and numerous vegetations on the valves. Sudden ri_L;bt-sided heininle- _i,'ia with aphasia. Red softening of third left frontal convoluliou and neighboring imrts .^^lpplied by middle cerebral. No. S. Anciiri.sni of left middle cerebral artery. Aneuiisnis on branches of the cerebral arteries are more eor.iinon ihan is Mippo>ed. I have met uilli si.\ cases in four years, two on the basilar, three on branches of ilie left middle cerebral and one on the anterior comnnniicating. In four of these death was caused by biH'^ling of the >ae. Xo. 9. Miliary aneurisms on small cerebral arteries. T'he .-triictures, de-->eribed by Charcot 1!^ Bouchard, are suiiposed to play an imjiortant rt'ilc in the causation of cerebral ha.nnurrhagc, particularly in _,lvi,ui fissures. Nu. II. Section of coarse tubercle of biain. Tln' pail >hown is ju.-.t at the border of a mass the si/e of a pea; There are numerou - .small tubercle cells embedded in a granular rnatri.x, tivo giant cells aie also seen. Internally there is a granular degene- ration of the cells (caseation) and an obliterated vessel can be seen, Xo. I J. Miliary tubercles on small arteries. From case of acute hydrocephalu.-,. The tidjcrcle cells are seen in outer coat (ad\t.ntitia) of the small arteries. The increase of these cau.ses a bulging which can be, in small arteries, seen with the naked eye, and the calibre of the vessel may be greatly deduced oreven obliterated. In the ca-,e from which this specimen was taken, there was no iri.uofthei.eri;.,ni..i simc.„ ,h. l,t;le tuhoivle. were ^I'tn nil ilio small aituries. ■N''.'. (;,. Syi-hilitic artcriiis. Kn.m n man as;e,I 36 ; syphilid ,S ,non,l„ Ivm„, ,|,,„,, ,,,„c1, U^Ilowed n-pture of an aneuri.mal dilatation of the basilar .ause,! l,v the arteri- »'s. In tins spennu.n, tlu- altcalion consists in a verv ^.a.nt thicken- .MR of tl,e >.n.n,, which in places is of greater diameter Ihan the other con s together ; the eellnlar elen,ents are feu in number, the chief part "I '■ ne^.v orowlh consisJng in a lou f „m of rd.rillated t,,sue, Kv. i.(. (JlioiiKi of (.orinis .striatum. Ti.mor consists of , mall ro,md celb. bhe tluKe of a sm.dl-ccUed ^•ircnma. enibedded in the mc^h.-s of a ivli.uluin of Uuc liincs. Nn. 15. I'achNnioiiiiigiti.-,. A localised spot upon the frontal h.b. in the case ,>f a voun.. nun (Me subject of severe cpilepisv. ' " ' There is tlnckeniny of the dtira mater and adhesion to the ararh- """■ ••""' I":'- Ther. has been extravasation in the thickened num,- branes as evidenced b.v numem,,- h,. nialoi.hn nrain-,. No. 16. Insular sclerosis. Localised areas of libroid tran-tbrmation, i^uallv in the white "'.'Her. the result, it is s„pp„.,,l. of a chrome innamniatorv process. ' I he sHb.st,luiioii 01 ihe wliite siilotanee by a fibrillar .rrowt'h is well seen m tins specimen. Many of the fil.res are in connection with elon.^ate.! corpuscles. I he development of those patches in the brain nnd spinal cord causes a welbrecym.ed lonn of disease, characterised by a reiini-kabie tremor, .f-v. No. 17. .Medullary neiiroiiu. ..^•w growth (heterotopia, of ,.,ey matter on ih.ilamu, oiui-us v.Hi eMension into thud ventricle : chronic hvdrocephalus front' jnewne on ven.e ( lalem . Intellectual ficultie, retained, (iirl ,.-ed •16, ^ •n.e section shows the (n.ely -ranular ^n-y matter, a ^rnHi.m cell nn-, numerous smaller vlierve) corpuscle--. ' ' No. i.S. I'igincntarydegeiicraliun of eerelu-al vessels. Incase of apoplexy of the pons, cerebral vessels were much .hseased, whereas tne seneral arteries of the body were but sli.lulv involved ■ Many 01 the smaller arteries present the peculiar piumemarvchan«e in flie adveniuia, seen in the specimen, the deposition h,mg chietly in spiiler like connective tissue c^dls. M mm}\' 4 CORD. No. 19. Locomotor ataxia, jiostcrior spinal sclerosis. Thickeniny of tlif neuroglia with compre'^sion ami atrophy of tlie- lUM've cylinders constiiiites the es>ence of the (li>ea';c termeil se)erosi> or giey degeneration. No. 20. Descending ilegenerali' n of crossed i<\ramidal column. This spiviiutn ilhi-trates the >eeoiidary degi:iu;ir,tion uliii'h takes jilace in tlie cord after a destructive lesion in the l)rain, which has involvcil the motor y.alh. In this case there is no degeneration as there often is in the situation of the direct pyramidal fasiceulus, /. r, in the pail of the ar.tcrior C'llumn next the median fi'-sine on the same side as the lesion. No. 21. Antero-Iateral sclerosis. Degcn;rati(ni of anterior horns of grey matter with sckro.-is ol antero- lateral columns. Jt is characio s\niplom is known to lie connected \\iliilliis process. No. 24. Annular myelitis. Sclerosis chiefly cfirlical, deepest in posterior parts of ialer.il columns. Section from level of 6th dorsal nerve, in case of sjia^tic spinal |aralysis. No. 24. Lateral sclerosis. In case from which prece''''-'' is less frequent than the other. I have notes of only three (jr four such. In one a protrusion the size of a walnut existed in the duodenum just below the papilla. It com- municated with the bowel by a wide orifice, and appeared to consist chiefly of the mucous coat, though no rent was evi- dent in the muscular coat, which appeared rather thinned and wasted. I met with a most remarkable instance a few weeks ago in tlie person of a man aged 65, who died of an acute enteric attack with meLxna.^ The jejunum presented fifty-three diverticula on the mesenteric border — all of hemi- spherical shape and attached by broad bases. They ranged in size from a cherry to a large apple. One measured 8 by 6 cm. Six of them were larger than billiard balls. The walls were somewhat thinner than those of the intestine, but the larger ones presented a distinct though thin muscular invest- ment. All contained fluid faeces ; two of the larger ones were fully distended. The mucous membrane looked nor- mal, but was, perhaps, a little thinner than in the bowel. The valvuLne conniventes were absent. When distended with air and dried, and openings madtJ in the bowel opposite the di- verticula, it was seen that some of them had imperfect valv- ular folds at the margins of the orifices. They lay between the peritoneal surfaces of the mesentery, and numerous blood vessels coursed over them. There were not any in the ileum or colon. They were not connected with the acute enteric trouble which caused death, and which was situated in the lower part of the ileum. So far as could be ascer- tained, the patient had not been a very constipated man, but had for years been subject to colicky pains in the abdomen, which may have been associated with these diverticula. ' 1 am told by Dr. Trcnliolmc tli.it for years the p.iiiunt had suffered much IroLii loud nitnbling noises in the belly, jiarticularly alter each meal. So loud were iluy that it was his habit, shortly alter eating, to go out to take a walk and keep away iroin people, as the noises could be heard at some distance. >■ WILLIAM OSl^ER. ,,r ( J. In the large intestine I have met with two instances of curious diverticula forming globular sacculi the size of large pea? or cherries; very numerous in one case along the whole colon, in the other, confined to the lower part, and consisting of thin pouches of the gut filled with firm f;ecal concretions. The number and .irrangement gave a very pe- culiar appearance to the bowel when distended. They were not coiuiected in any special way with the appendices epi- ploiccX'. In one case the faecal masses were of almost stony hardness, owing to the presence of lime salts. Many cases of this sort are reported — one by Mr. Sidney Jones ' termi- nated by the ulceration of a sacculus into the bladder. The false diverticula are caused, in tlie majority of cases, by distension of the bowel either by ffeces or gas, and are rarely more than hernial protrusions of the mucosa. The occurrence in such numbers as in the above reported case is uncommon. Dr. Gross, in his " Pathological Anatomy," 2d ed., p. 601, figures a somewhat similar specimen, and refers to other cases seen by Monro, Cruveilhier and Sir Astley Cooper. 1 Lond. Path. Soc. Transactions, vol. viii.