■,'iu V>^--...T. ^. 1^. IMAGE EVALUATION TEST TARGET (MT-S) // § %^ <'>>? < ^/^ A 1.0 I.I 14^ IIIIIM M 2.2 lis i 10 11:25 i 1.4 1.6 V <^ /a %V iiutugiapliiu Sciences Corporation ^ 4^ «v ■4 .v \\ 4^\ A. '#?<\ ^1? 23 WEST MAIN STREET WEBSTER, NY. 14580 (716) 872-4503 #»t Wb'^ -^^Ij^ >^ A 6 CIHM Microfiche Series (l\/lonographs) ICIVIH Collection de microfiches (monographies) Canadian Institute for Historical Microreproductions / Institut Canadian de microreproductions historiq ues -inn I Technical and Bibliographic Notei / Notes techniques et bibliographiques The Institute has attempted v^^7 L^.. COLLECTED REPRINTS SECOND SERIES. (January 1st, 1882-January 1st. 1892.) n V: -l;:. « •^ WILLIAM OSLKR, M.I). F R (^ p r 'ospital, liallimore. 'he John- nr n ''■'''■''' ""'^ Av^^ctan-m-CT^/ /o 'I J Ml >^' X ■i TITLES OF PAPERS. ( Cimtinued from Series I. ) m^^ iWc XLIV. Kti..Io,iryan.l Pathology of Ulcerative En.locanlitis. VT^r rp, ,, . '^^''"'O'- J^"f(^rnaf.3ft',l. Congress, 1881. aL\. Iho Brains of Criniiiials. Can. Medical and Surgical Journal, 1882. Al.\ 1. Obliteration of Portal Vein. vr XMr .T •^"'"■""^ 'f/' ^l""'o'«i/ «"f^ P/n/sioloqy, London, 1882. AL\ 11. I eber der d.itten Formbestandthoil des Bhites. vr A-rrr GeniralbluH f. d. Med. Wissenschaften, Berlin, 1882. vr I f;'"""^^'-«^'^-^i<'»C'linics-four articles. Montreal, 1882. • ALiX. Lestode Tuboroulo.sis. Am. Vet. Review, New York, 1882, L. file Antiseptic Treatment of Empyema. ,-. ^^ Medical Neivs, 1882. \A. Uraemic Delirium and Coma. ^,^ ^ Archives of Medicine, 1882. LI I. Parasites of the Blood of the Fro of the Heart. Pc/tjier^K Sj/.ite)ii of Medicine, 1885. LXVII. Difsease.s of the Mamatopoietic System. I'ljiper.'i SijKtem of Medicine, 1885. LXVIir. On the Growth of a I'rofe.^sion. Presidential addres.s, Canada i\[ediea I A.'isociat ion. Medical Xcnv, October, 1885. LXIX. Retro-peritoneal Sarcoma. Med. Nen:^, Mar. Oth, 188(). Trdn.^. Path. Soc, Phila. LXX. Atrophy of the Stomach (primarv). American Journdl «/' Medical Sciences, 188(>. LXXI. Cartwright Lectures on the Blood. Delivered at the College of Physicians and Surgeons, New York. Med. Xetvs, and Med. Record, 1880. LXXIL Bicuspid ('ondition of the Aortic Valves. Tran>^. Axxo. American Pliysician,% 1880. LXXIIL Use of Arsenic in certain forms of Anaemia. Therapeutic Gazette, 1886. LXXIV. On Duodenal Fleer. Can. Med. nnd Sur(j. JournnI, 1880. LXXV. On Cerebral Aneurisms. Can. Med. and Sure/. J I., 1880. TrauK Path. Soc, Phila. LXXVr. The Hamatozoa of Malaiia. Ilritixh Medical Jourudl, 1887. LXXVII. On Antifebrin. Therape.tic Cazclfe, 1887. LX.N LN v..*»- L] LX Lx: LXX LXX li^ •^'■,\ Lx: LXX . Lxx: 1 LXXX LXX X X X X( xc^ X LXXVIIl. LXXIX. I A' XX. I.XXXI. lAXXII. I. XXXIII. LXXXIV. |vv*i»\\ LXXXV. LXXXVI. LXXXVII. LXXXVIII. The ( iirdiMc Relations of Choreii. Amerinin JoiirtutI of Mfdlraf Srlence.y, 1887. Nott« oil Hut'iiioiilui^Mc Iiifart'tif)!!. TmnK. Amo. Amer'mitt P/n/.nri(nis, 1887. Oil Cliorfa; two Lt-ctiirey. McdirAtl Newn, 1887. Case of Chole.steaoiiia. 'f Joiini'i/ of N,'rr<>u.'< and Mciila/ I)imti^e,'<, 1887. Ilereditarv A ii^io- Neurotic Oedema. American Joiirnn/ of Medico/ Srifiicri*, I8«8. Nitni-Olvceriiic in lOpilcp.^iy. ■ loiiniol of Xrrroux and Menial Dixeases, I8^<(S, On (lie Diasxiiosis of Sniall-pox. Medical Staitdord, ("liicajro, 1888. (ilioiiiii of Mediill;!. Jonriiid (,f AV/-(v»(/.s oitd Menial iJineaxex, 1888. The Cerebral Palsie^i of Children. Three Lectures. Medical News, 188s. Pnhl itched also in London, as a Mono(jntj)li, Issit. Ca.-ase o( the Caeciiiii and .Vppendi.x. Medical and Snccfieal Heporter, 1888, l*ost-rarluni Aii:ii mia. Ildstoii Mediral and Snr(/icai Jonrnal. 1888. Tiic l)iaj,'no.-*i.s of Duodenal I'lcer. Xen< York Medical Record, 1888. LXXXIX. ., ' XC. On racliynK'iiini:i!is IlaenKirrhii^rica. Medical Xeivs, 1888. XCI. Lesions of the Caiila-('(|uiiia. .}fedical Nnr.'i, 1888. XCII. On a Form of i'urpnra. Xew York Medical Joan tl, 1888. XCin. On the Mortality of I'neiiiuonia. University Medical Magazine, 188i). XCIV. On IMiagocytes. A Lc-ture. Medical News, 1880. XCV. Filsating Pleurisy. American Journal of Medical Sciencen, 1889. XCV I. The Lio-nse to Practice. (An Address), 1889. XCVir. Kquanimitas. A Valedictory Address at the University of Pennsylvania, Phila., May, 1889. XC'VIII. Aberrant Thyroid Tninoiv. Mediral News, 1889. X(TX. Idiopathic Mii.sciilar .Atrophy. American Journal of Medical Sciences, 1889. )|t| I'f I!' if 7'\ ,} If < '. Syphildma »t' ( unl mikI ( 'itii(lii-c<|iiiiia. •I'X'l'IKll oj Xn-VOHs ,1)1(1 Mflitill /»i.^>;i.^,.i, \SH[i. CI. |)iii. 1, |,H0. <'IIf, I'ost-Kthrile Irisaiiity. /A/-/, 1,S!M», ('I\. liarv Korriis oJ'Caidiac 'I'liroiiilii. J/jiil.\S>tH ('\'. i;iu|,,canliiis in I'litliisi,-. //^/,/ |,sj(,) <'\'l. 'ruhcrciilar I'tTitmiids. Ti(,' Johns Hojik-ins llo.tpH,,! lU/,„rf-<. \\>\ || No. -1, I «!»(). CyjJ. Aciitt' i\e|ilinti!< in 'JVpluiid Fever. /,'wV/., |,S!)(j. CV'IJI. On Anidlta Coli in Dyseiiterv. The Johm Jlopkina Hospital Bnlleli,,, N'ol. 1, N,,. r,, |«(„, ' ^^^ ()ii Convulsive Tic. Medlml News, \m). ex. Sen.sorj- Aplia.sia. •■'•"^''I'inni 'h'"'"'-'*^- (An A,idre.ss.) Baltimore, 1891 tAI\ . Hereditary Cliurea. ^'/"' -/'Vt/;,>> //oy>/.-//,.s. y/o,s;/;//a/ JJu/letin. 1891 <- A\ . (.eneral Bronchiectasis of Left Lung. Ibid 1891 rK^vM ^ l'''^'"^'-'"" «^' ^^'^ Si'porior Vena Cava. /6,W.'| I89l" *- A \ II. C ase <.f Multiple 8ub-Cutaneou.s Cysticerci. <^ ^Vlli , I j, Ibid., 1891 ^ C ' — ' J 1 1 / ^ • , ' - •' ' ^"'^ ^'-^(*/ '^-^-^ .<:^W.U, /;^. „ .. ^^_^^ •'' C »> K >t V .' <^ X V V >^ "^XN<^- ^C>-vv. ^ ^AtO) ''^XLfi. ^"iii 1 ^nii a <^XL.u V -7 C /^ f 'f ^ /^< irff /Z « ;* ye ^> y'tii i.< ( U /■v. ■7 / V. ^. /r^l \/m. / ' Ct /^" /-ere . CI, '/i i/ C Y '^i^f^ (TtC i I ),l C i £, ^/l. «^' ^ ^■ >>> C /„ -m^^" (1^ » ^ /^-^/it ," <--<» c^ ^ v./. . ^ / t <;'«- i^te-c ■» t vv ». /*- ^^<^t^^C<.r^-^ /^-Cc^ (T X V >t V ^Zvv<_<-^-t c c,-t> T^fc-^A -^C s^^.^^^^ Ct-~ A n^./Ou^i^, I_X--^i^ ' <^^>* 'A,^^ LfU-v^ - S't^'i--«-*-»4«~ * *jtM^ '^'^^^ ^v^< -V«*4 <^ X V V K/ t^-cve. T^tlltT^c c^J^l^L^^^ A-' itv/T in-» 7"t^ tli^->- t-v^ ^< 'c: X X < ^-z/' ^ ,-«-< T-n- ct-i- 1 ^r C N^V >-l/-i/< 6 'h tr6- CIV c A* L,v -«-<.c* 4-. O.U. " c K )( X I X V..^,^. ; ,;_ A/--,^..X^i ' ^^ U^Jt^x ->i.i A'o/f; .-^(.A^ ^2 A. l'*«A,-t, ^/ /'7 *v, 'C !^uV ^->J^^ . S'f'^ Jf. %^'■ /-, 1881 il '^ :fi J i I'""! 11 THE / '" ^-^ ti/ < /.-]iody wasted ; bed-sore on sacrum ; carbuncles had almost healed • grey hepatisa ion o three-fourths of left lung ; ulcerative and suppurative erdocarditis of op of one of divisions of anterior papillary muscle with exudation in contiguous chordai tendineaj ; numerous infarcts in the kidneys. Af ^JJir*! uof "■; ""^""^ ^"'*^' '^'■^y'"'"^' large and powerfully built. Admitted May 1. th, 1881 with pneumonia. Had had two previous attacks of inflammation of the lungs Rigor on the 11th, followed by fever, cough, and pain in right side. M When admitted, consolidation of lower two-thirds of right lung was determined. ^'-' ' Delirium set in early, llesolution did not supervene and the fever did not abate at the usual time. Patient fell into a low typhoid state, with delirium and free diarruva. Temperature range from 102= to 105°. Petechias appeared in the skin. Doatli on the thirtieth day. There was no heart murmur. A Hf ops>/.-Extcnsivo ulcerative endocarditis of mitral segments and of two of aortic cusps ; lower top of right lung airless, heavy, linn, and on section granular; spleen large; infarcts in kidneys; numerous infarcts in intestines: purulent meningitis. Of those seven cases, in five the endocarditis came on during the course of smiple pneumonia. Cases V. and VI. were complicated by surgical disease. In the girl with fractured legs the endocardial j uschief appeared to develop with the inilammation of the lung, and not to be secondary to the fractures The patient with carbuncles was much debilitated and succumbed to an extensive pneumonia, \\hethei the endocarditis Avas present before the onset of the pneumonia remains doubtful, but I think it scarcely could have been, as the general condition of the man was improving before it came on. The association of tliese conditions in .such a large proportion of cases is very striking, but the relationship between the processes is not easy to trace. Po fjir as nno may iud"e the pneumonia in the above cases was the primary morbid change. In all it w"as of tno ordinary lobar variety. Cases of ulcerative endocarditis of the right heart have been described, with extensive secondary changes in the lungs, but in none ot my cases was the pulmonary process of a pya^mic character. I have not specially stated it in the condensed reports of the cases, but it is worthy of remark that all the patients were either debilitated at the time of the attack, or were hard drinkers. Many constitutional affections predispose to endocardial iiiHammation, . s . , notably rheumatism, less frequently some of the exanthems, and to these we may J 1 I 4| 1 ill now add pneumon.a, wj>.cl> is regarded by many as a constitutional .liscase Tin fortunately ti.e forn. of endocardnis winch accon.panies it appears to b nTore ofVcn of a serious nature, judging at least from the evidence bel'ore us. With onr sent knowledge, the most, I think, that can be said on this poTnUs «i a i n " f™" cases of inih.uiniation of the lungs there is a tendency to T rativ; d'aTS' In a former paper* on tlii. subject I called attention to the fact that inSn, t.on of a diphtheritic character had been observed in other organs nnn 1' '" Particu irly in the colon, in which region Dr. I3ristowe met withdi", Ld L ^"^^^^^^^ turn m four out of sixteen cases. There was purulent nieningitl i^^ fou/of til' seven cases above reported, which was doubtless secondary to the endocTrditl (r.) A very considerable number of all the cases of ulce ativrendo fr^^V occur in connection with local inflammatory processes of an rheaTthy te f this group the cudocardiik puerpemli, of Virchow is mo.t rm,!, ^^ ^'] not unfrequently complicates the endo- and periletri irLrr Tn'' "'"^ l-arturition. It is further met with in acute ^ZTotl^^^J^T^ gonorrha.a, and m pya>mic states. In some cases it is very difficSt to srwh fl lie pya.mia has excited the endocarditis, or whether the for^r has C 1 cjefonnity ; \., the sanii':^:h:n^n bli^^^^^^^^^^^ Z^^^^. ^-t deformed valves with recent ulcerative changes de^ S of ^'^ T'^ ""'^ aneurisms Probably the great majority f£^l^^;:r^f^ occur m this connection. These cases 7,.„nllv „ i ^^^^^^.^^ «" t^e valves heart disease, with little or no f e ^fae? ^, J X s " "f 1^'" T"^^^^^ «^ symptoms so striking in other instances 1^^. ' ^F^'""'"^ '' P^^'"^^ i-egular fever, or sijns of ex te ive embol sm ^^^^^ '''' r' ^'"' ''''' «^'«^*' the process going on but the clin cal p S ^^^ "-."^^-^ ^i form. It has long been recorrnised that , Wm , ' ^"'""'"y infectious proneness on damaged valves to o tt . ' f '"""'' ''''''''' ^'^^^^ '^'^^^^ plication, the valves wer ll e sub c of t . r P"f ™oma with this com- of the segments ^^^l^^:^ ^ '^"^t^ "l^^ disease, with extensive ulcent°ons n, d 11 • '"'^^"^'^^ ^^ chronic heart segments was met with, n f^^^^^^ ^" T' ^°"^'*^°" «^ ^^'^ blood supply may as Virchow ~T T f ' ''"'^ conse(juent defective in sclerotic va^vel'to ulerl^^^^^^^^^^^ '"^ ^^""^^"'^ *^ '^ -^^^ this tendency a predisposing cause. ^^^cordmg to Lancereaux t chronic malaria is also theS^c i:^ttt^:^Xru''] '''-' Y''' '-''' ^ ^- P"^- in conhned to the left side. tC^^:^^':^'''^''' ^^^^^*'"" '« valvular and remarkable variety prevails. Th'r 1 ay be V's' ' r" "IT' "'"^"'■"'' ^^^ ^ • Archives of MaUcinc, Fob. 1881, New York, t Air/itixs (niu-rala, 1873. much ex has beei pyiumia. post-mor twelve cc was also is natura the rapid to, the ill being frc tlio term The expn vlcerenne,' affected v often fissi a thin fit On sectioi The consi: are intimi large, is u thickness two instar tive outgr( chronic he more acut and they a of the va suppurati\ formed, ai cases occui with pus ; vegetation In my vegetation! in all the c in a specin definite spl enclosed in similar ap| some write: In this ( tions of the growths of to point ou1 plastic vege The rela Virchow, El elements wl stand in the fliscaso. Un- 30 more often Vith our pro- liat in certain inclocai -litis. It inflanima- pneumonia, critic exuda- four of the ocarditis. endocarditis y type. In cuous, and 3 following :sioiially in ay whether 3 not been his form is ?, in most ons, which !ry diverse vith great irotic and :1 valvular lie valves imples of r pyteniic en slight, nature of nfectious h special !iis com- 'lich two ic heart I of the efective indency ition of I is also >ints in lar and , but a stance, ithout mtich exudation nothing deserving of the name of a vegetation. My evnerienco has been tliat tins variety is most common in the puerperal sLT nn d 7n py.^m,a. Son.etimes it is diiHcult to n,ake out the erL" r. ti eul:,;"^, " pos -mortem stannng of the membrane has taken place. In only one of he twelve cases of the primary form was the lesion of this nature ancf in this tho o was also a good deal of swelbng and infiltration about the bse 7Z Ir t IS natural to suppose that lesions of this kind would prove more an" rous by he apjd u,fcction of the blood with sn.ail emboli ; and in the case u frefe red mg free. 2.) For he great majority of the cases of t ,e prinmJy E t e term "ulcerative" hanlly expresses the precise anatomica 3 tTo^' Ihe expression used by French writers is more correct, " /V,./: "^v " "^n ^ i:T " ''° '"^".^""^ ^'''"^ substance and vegetative outgrowth ' To affected valve presents irregular nodular excrescences of a greyishldSe colour often fissured, cauldlowerlike ; the surface either quite smooth an 1 overedt^^^^^ OnZ\ :r ^""^ °''^"""''" ^™"^ '^^P°™r'' «f the texture o the n^ s n sectum the cut surface may be uniform and fleshy, or bnlzen and g an a ' Ihe consistence is not very great, the masses crnmblin, on firm pressiire Thev are intimately united with the tissue of the valve, w uch, if tl Zet'ation ^s arge is usually indistinguishable at the site of attachment ; indeed fh; whole thickness of a segment may be involved and the mass spring from both sWes In two nistances the vegetations were of a fleshy character, not friable Trulcera t ve outgrowths which develop on the sclerotic valves ^f patients the subi c of chronic heart disease, resemble closely in coarse features fhose met wit lin tl^ niore acute process^ Small calcareous concretions are not nncommrn n them o 1 1%^^^^^^^^ ''S T '"'" n"'' -^<^om,ani.a by perforations and aneurS ot tlio valves. (3.) In a small group of cases the endocardial process is nppurative and the tissue is bathed with pus corpuscles. An Xess mav be formed, and after discharging, leave an ulcer. In Case VI. o the g "un of cases occurring in pneumonia, the tip of one chorda tendinea was soft and ba.ed ^vlth pus ; m am.ther case there was a purulent deposit at the base of a la 4 vegetation in a sinus of Valsalva. " In my previous paper I have dealt with the histolocrical characters of fb« vegeations, and would here simply state that the microcC 1 rbe "pr s nt n all the cases examined by me. A peculiar arrangement of the n was led n a pocmen obtained from a cow In addition to the usual forms the e were ncCt:™ie: *"/:""" -^-^'^-^king like aggregations of micrococ enclosed m capsules.* In two specimens from man I have met with somewhat r^'wrS"^""^- ' "'-' ""^ ^^^" ''' ^-'^'"^^ ^^^--^« ^-^Tdt; In this connection I may state that micrococci are not peculiar to the ve-^eta- tions of the ulcerative form of endocarditis, but exist in the small boad^ike ™t growths oi the rheumatic and other varieties of the disease, as Kbs was li fi'st to point out My experience tallies with his ; in seven spedmens of veTrnos o plastic vegetations which I have examined, all contained micrococci. ihe relation of rhe micrococci to the disease has been very fully discussed bv Virchow, Lber h, Klebs, and others, most of whom hold that fhey arcthe specific eements which account for the peculiar malignancy of the disease'^id thaftht stand in the same portion in this affection as the_baccillus in anthrax There 8 arc some points wl.ich should, I tliink, make us hesitate to accept tJ.is view with out further evidence. .Micrococci abound in all forn.s of endocardial vegeTaMot -m the warty outgrowths of rheumatic endocarditis, in the vegetati^) fs „f " d clerofc valves, as well as in the excrescences which develop in the Tcu?o '^I- t.ve form This latter is a malady which runs the course o'f n ilXe dtl and may destroy life in four or five days. The micrococci are sunnos ^to 1 n access to U>e blood and to excite in some way endocarditis ; at Z ra " tT ^ flounslnn the vegetations which are regarded as centres for the dltribut or of l7 germs throughout the body. In the majority of cases en.boli are ar ied It f om the vegetations and infarcts produced in the different or4n 1 otlnr casas, equally malignant, the vegetations may remain unbroke^a^,^' no cm n1 :Sst r he b^ tr ^r '" ^ ™^ °'^^^^"^^^"" «--- ^i^e mi:; 1 i r ,« exist in the blood during the course of the nvilnrlv v^.. xi found in the infarcts. The occurrence of mLoe tf in ^he Zltl7 7T''''. rheumatic endocarditis and in the extensive ulceS out^rt ' LT h"' "^ with in old sclerotic valves are facts strongly op^oled to t le vt^^ poisonous nature. The micrococci annpnr L hlT I T *^"'"" ^P'^^^^'^ Klebs states that those of rCZ^'^SL^^. X^^! ITa^r-f tint. I cannot say that these differences have been constaT nT , -^^ which I have examined. It seems a pertinent wuestlnto.sk if / '^'T'''''' form of endocarditis, the micrococci are so note t ^Vv in ot " '^'' "^''^'^^^ they are equally prevalent, should they be inert Of con rsP f T' "' 7^'''^' the micrococci may be of diflerent kindVnrnn "\'^"''® '^ "^^V be urged that resistance offered by the tissues ?o thr'n^rr ''''''■'' ^"'''''^^' '' '^^' '^'^ that it is only in we^ ned and Ml, h P'"f 'f^^^T ^'^"^« ^" ^Jifferont cases, or There is, I tlfink, ^i^^t^^rZ^lX fT '"'^ ""'''''' ^^-- the conditions under which end di is fefeZ^^^^^^^^ Tf '''''r " ^'° ^^^^^^ the patients are the subject of somfo ht constitrt "1 r^' '""""^^^^^ '^^' say, predisposes to it. What de erTines tl e nri f "^ f ?''"'' ''^''^' ^« ^° do not know, but the soft locSveSon^^^ the endocarditis, we development of micrococci. They IvLZThTJr . '"^^^'^'t "^^"« f«r the ponents of endocardial outgrowth' aXf br n fibriU 'r .'' '""''^ "°™'^^ '^"'"- and among which the micrococci abou- I s e';^ e,:^^^^^^^^^^^ 'r '''''' common elements in .a 'iPrit^a nt ^..a j- i '^^"''^"'^ "lat these structures are '-i'y^moJZ:rL:z:'^z:^jzrH^^ '?'"' '""""^ *""■ either for Iho develonmcnt of tl,rn ,'! *" '"r H'cy »ro responsible w«, ™ .he ,ra™ for ^j lui: tT; *»:' ^ 'nT^^rT' """*'• yet a very positive opinion. ^-vmence does not, I think, warrant as i I i is view with- 1 vegetations tioiis of old icuto ulcera- Jtivo disease >scd to gain y rate they •ution of the irried away la other no emboli occi do not constantly etations of uentlymet eir specific es, though . brownish specimens malignant ! in which rgod that r that the ' cases, or es thrive, we study ibly that -h, as wo ditis, we i for the (lal com- eposited ures are y diflfer- lonsible iracters ■rant as '§ h J, \^ > ki" < ! fill I X l.Y vnnw TMK "Canada Medical & Surgical Journal," Montreal. Fbbiiuary, 1882. • » ON THE BRAINS OF CRIMINALS. WITH A DESCRIPTION OF TIIR liRAIXS (PlATFS I. ANt) II.) op TWO MURDERERS. Bv WILLIAM OSLEIl, M.D.. M.R.C.R, Lond Pressor Of the In.i.Ues of Medicine i„ McOiU Unive.it,. and P.,.eian 10 llie Montr..'al yuneral Hospital. [Hewi h'-/'i «. .V;ii,„-n:„„,;.„, ,v.,„,.„„ ,„ .„,„„„„,, Menially „,1 bod.ly, we are largely the result of an here- n 1 i' '■■■. ,'; V u 1 1 t li^ of till face. That a faulty physical basis can have no other soqupnco >}nu a faulty montal am) moral constitution is acknow- le(l;,'t'(l and actcl uj* '\v every one, ho far as idiots and iinl)ociles are concerned, hut that mental and moral oI)li(|uity is invariably tho outcome of an ill-conforracd or ill-developed brain is a doc- trine novel and startlin;,', tliou;^!! lo^^ical enou;,'Ii from the stand- point of modern physical fatalism. Kndcavoiirs have recently been made to jnit this theory on firm grounds by showing that in a lar<^c number of criminals tho type of brain dillers from that in the law-abiding members of the community. Anatomists and j)hysiologists have of late paid much attention to the conformation of the brain surface, and the convolutions and fissures are now studied with care and minuteness. In a typical European brain, the cerebellum is completely covered by the cerebrum, and the general arrangement of the g'"ri and sulci is such that there is rarely any difliculty in mapping them out and assigning their proper names to each. Thus on the external surface of each hemisphere we recognize two fissures which are constant and invariable ji position — the fissures of Sylvius and of Rolando, (^central sulcus.) Other fissures constantly present, but less definite in their arrangement, are : the inter-parietal^ which passes through the parietal lobe, tho parieto-occipital ; separating tho parietal and occipital lobes, best seen from the median surface, the superior (1st), inferior (2nd), and ascend- ing (3rd) frontal sulci and the \st and 2«c? temporal. On the median surface, the calloso-marginal, the parietal- occipital, the calcarine and collateral are well marked and distinctive. The convolutions or gyri separated by these fisKures are re- markably uniform, and, though often inters.otod by t;«ii sidiary sulci, can usually be determined without ditficuity. Of these, the only ones which need be now mentioned are the three frontal, 1st, 2nd and 3rd, tho general direction of which is parallel to the longitudinal fissure and the two central gyri which bound the *^am:? of Rolando on either side. Ir, tae typical brain the main fissures are unconnected with iii^'ii other ; ti -.'s the fissure of Kolando is isolated and does not unite with the Sylviuf. lissurc I.elow, or tho aseciuVuv^ fn„.tnl or asooM.hn^r parietal sulci o„ either -wle. The Sylvian fissure does not join with any of the- suU;i ahove or helow it. Prof IJene.likt of Vienna has ma.lo a special stu.ly of the brains of cruninals,* an.! believes that he has met with peeuli .ri- .es suffic.entlymarked to warrant tho following proposition : • The Lrain, ot annilnah rMbit a deviation from the normal type, and cnmtnals are to be viewed a» an anfhropolomraf variety oj their .pedes, at least aounujst the enltured raees " Ihe two pocuharities on which he lays stress are (1st) tho con- fluonce of many of the primary fissures and (2nd) tho existence of four horizontal frontal ;,7ri. He proposes to establish a eo,^ fluent fissure type of brain, and he illustrat(.s its most im,, rtant characteristic by saying, " that if we imagine the fissures ^o be water-courses it might be said that a body fioating in any one ot them could enter almost all tho others." This, of cou se means the absence of numerous bridges of nerve matter winch normally separate the fissures-defects, marking an inferior de- velopment of the brain. J3etween the normal type with isolate I fissures and the type with confluent fissures there will naturally be ransitions, but he calls attention to the number and variety of the connections in his series of the brains of 22 criminals as supportmg the truth of his proposition. He states that the brains of individuals in the lower grades of society approach nearer to the -nd type, and it is probable, though, as yet, full data are wanting, that the brains of the inferior races of men also conf.rm more closely to this than to the type with isolated fissures. Let us see now how far he has been able to establish the truth of this view. Of 38 hemispheres from the 22 criminals tho following were some of the most interesting points :— " I. The >8Mre 0/ i^o/anio communicated with ; (a) jis. Syl. completely in 18, incompletely in G. (i) with ^rd or ascendiny frontal, complete in 11, incomplete in 2, * On tile Rruitiu of fV-minnlt! Vt^ 1-^- Tn " ^ (Woo. ((iniispliLTic arch .,^ g „ Anterior curve (tip of Fr. lolio to Fi's! Roi ).' u' » Midille curve (from Fis. Uol. to Par.-ocrip Fi.s ) ' * " G '' " Posterior curve (from Par.-oc. to tip of Oceip. lobe')' '.'. <^'.l .. * Centmlb./J. med. t\'isseiiiic/t/l., No. 40, 1880. f I 8 i^ylvianfismre (Fii/.l'jy'm addition to the normal asoendingand horlzonal rami, presents a radial branch which passes into the frontal yyri (a), a short radial extension into the asc. parietal (b) and a shallow communication with retro-central sulcus (o). The fissure of Eolando (F.R.) or central sulcus is separated from the F.S. by a very narrow bridge of brain substance. It has no other connections. There are four well-marked frontal gyri [1, 2, 3 and 4] ; the extra one (2) appears to be formed by the splitting of the' superior or 1st gyrus, though its base, where it joins the asc?. front, gyrus, is in the position of the middle or 2nd. fr. gyr. As can be seen in the plate, there are two radial sulci which pass from a point just behind asc. ramus of/s. Sylv. and ascend almost to the loyig. fis. They are deep, and the hinder one has a crucial extension in the position of the 2ndfr. sul. The sulcus inter-parietalis presents a well-marked radial por- tion which passes up behind the ascending parietal convolution m Its whole length (asa. pariet. or retro-central sulcus) ; the sagittal part passes back into the parietal lobe and divides into two branches, one of which (d) curves round the supra-marginal gyrus and unites with the 1st temporal fis. ; the other (e) ascends to the median border, and is continuous with a sulcus which joins the paneto-occipital. The asc. par. gyrus (retro-central) is well developed, as are also the angularis and supra-marginal. The horizonal (or sup.) occipital sulcus is well developed •- It does not join the par. occip., but sends branches into the^v' cmms. It appears to join the -Ind temp, sulcus, but the brain as lacerated at this point, and it is difficult to make out th^ connection. The l8( temporal mlcm is 8»ngly marked, passes up and Jons the mter^arietal. The 2,uj( u.np. ca„„ t be ,ve7n,ade out on account of the laceration. 'veu maae 3tro„°J!;'d™t° r*™ '■''^- ■^' "'* """"-"""^•"O' >ulcn> is sttongly developed, presents numerous perpendicular branches an ermmates by two, one of which J) ascends „ t e „,, ,' Posmon belund the retro.«„,r.a ,,„,., the other (^) curves round and divides the oyrm fornicatm from the pre-ctmem Cov Muadnlateral),cxtending to within a short distance of the calcarine fissure, and uniting with the.A's. cmclata. The gyrus fornicatm, in the anterior half of its extent, pre- sents a well-marked sulcus running along its centre. Jheparieto-ocdpital is deep and well marked ; it has a branch (/O which curves over the border and unites with the inter- panetal. The calcarine fissure unites with thej.«r. ocdp., and the conjoined sulcus communicates with the mssuraLpo- campi by a wide groove (0. The sulcm collateralis ^mx, the calcarine by a large fissure ( /), which ends just at the handle of the fork oHhoparlcip. and i - carvne. Another sulcus (k) passes from it round the under surface of the occipital lobe, dividing the temporal cjyri from the occipital Ihe orbital yyri are separated from the frontal anteriorly by" a well-marked fissure (fronto-marginal of Wernicke) The convolutions of the inmla, normal. According to Benedikt's views, this hemisphere is a-typical in the following particulars;— ^^ (a) The union of the Sylvian with the 1st frontal sulcus. (d) The extension of the calloso-maryinal fissure between the gyrus formcatus and the pre-cuneus. 5!?, fj!^ ""'^^ ^f *'^« collateral and calcarin, fissures. (/) The fission of the 1st frontal convolution into two parts so that there appear to be four frontal gyri-a condition Ihich -Benedikt lays great stress upon as a marked a^iimal similuritu in the human brain. Jv uT' !.'™^" ^'''"'' ^" ^^' ''''''^y «f Rimouski, aged 40, French-Canadian, murdered his wife last summer, and was executed on the 13th of January. He was a short, vel-v power! fully-built man uneducated, and of a morose dispositi^i ; was temperate, and had never before been convicted of any crime ■,t| f I' r 11 .' 10 He had not lived happily with his wife, and quarrels had bgen "•eiiuent ; one day, wheji in the woods together, he cut lier head fr open with an axe. The deed was aj)parcntly premeditated, It out idc that ho had as to came oui in evuioncc mat no liatl ottered money to a man do it for him. After the act and during the trial ho maintained his usual stolidity, and did not appear to take a very deep interest in the proceedings. Indeed, it is stated that he was unaware, until some time after the sentence, that he was to be han.red.' The autopsy was performed, about an hour after his deatl^by Dr. Jlelleau, and the brain was secured by II. V. Ogden, e!a. and brought to mo in excellent condition for examination. Organ large, weighed about 1587 grms. (5G ozs). [PI. JJl The hemispheres, though large, did not completely cover the cerebellum. Membi'anes were normal ; vessels of the pia mater and the subjacent grey matter dcei»ly engorged. Left hevmphere {PL 11, fiy. ^).-Fk\lv. \ separated from ascendmg parietal by a very narrow and groo\od gyrus and johis the inf. front, by a shallow sulcus {a). ° ' Fis. Rolando sends a deep fissure (b) across the upper end of asc. par. yyr., which curves round the margin and unites with >•. cruciaia of iV^ irre-mnem. There is not a well-marked a,c or ^Td front, ml. The \,tfr. ml. lias a short vertical branch' and only extends for 2.5 cm. from a.c. front, gyr., when the Ut and 2nd convolutions fuse, but beyond this it is again apparent. ^na front, sal. has a short vertical branch, and joins ihe fis bylv by a narrow groove. Its anterior extension is well developed Ihe Srd front, yyr. is large in comparison with the 1st and 2nd Ihe «6Y?./mii;. ^^r. is large. The a,c.par. ml. (retro-central), which is usually united with the mter-panetal, and called its radial portion, is isolated, and only joins the fis. Sylv. by a shallow furrow (c). The anc \ar yyr. IS narrow. ' ^ The inter.pa.'ietal fis. runs almost parallel to the asc. par and fis. RoL, being separated from the former by a narrow convolution which joins the sup. parietal lobule. Below it joins Qy I pan be well develuped. 11 "•o'irig gyri Thfi ls< tenip. sid. is crossed in two i)laces by bi uniting the 1st and 2nd convolutions. Posteriorly th°s Tufcu's lias^ two branches-one which joins the l. par., the otlier the inf. occip. The -Ind temp. snl. is not well marked. The sup. occip. sul. joins the par. occlp. ; the inf. occip. sul. sup. occip., sii\il the 1st tonp On median surflice, par. occip. fis. unites with o.^ by a shallow sulcus with^A's-. cruelata o^ pre-cuneus. Calcarine fis. normal; caneus small. Fis. collateralis long, and sends numerous fissures into qm-i Imguahs and fusiformis. Sul. ccilloso-mary. has many fissures entering the 1st front 9>jr. Gyr.Mnicatus is fissured longitudinally. Orbital ami normal ; well m'^xU,\ frontal marginal sul. No external orbital tissure. Insula well developed, and has 9 gyri. Right hemisphere {PL U.^fuj. 4)._i7.. Sglv. joins ^rd or ^^^o.Jront. sul. (a), and the asc. par. (b) (retro-central) by shallow furrows Fis. Itol. unites with 1st front, (c) and asc. par. Qd) sulci by narrow giooves. The aso front, sul. arises by a shallow fissure from the fis. Sylv anci then at the base of the 'Ind front, gyr. joins the Ld front sul. l,t, 2nd and ^rd frontal ggri are well developed and distmct posteriorly. Anteriorly they .re fused and crossed by many secondary sulci. Asc. frontal gyr. is very narrow in Its centre. Inter.parietal fis. has a well marked radial portion (the asc par. or retro-central). The sagittal part passes back and presents three divis.ons-one (.) enters the sup. par. lobule, a second ( f) passes directly back and joins a fissure in the position of /»/ occip., which reaches to the tip of occip. lobe, and the third (a) part passes vertically down and unites with 1st temp, sul and has a branch which crosses the 2nd temp. gyr. Asc.-par. convolution is large below, narrow above. The ayigular, mpra-niarginal and sup. par. lobule are much fissured 1st temp. sul. joins i.-par. ; the 2nd is not marked. Several oblique sulci cross tlu; 2nd and -3rd teui jo'ma par. occip. p. gyr. Sup occip. sul. ! ; ■ * ! I 5, H- ' 12 On the median surface, ixir. occlp. fin. joins sup. oecip. ; the calcarine enters soimint hippoccmpi and joins tho fis. collateralis by a shallow groove. Fis. collatemlis large and deep. The cuneHs is i,mall ; pre-cimeus (lob. quad.) is large and its anterior boundary ill-defined. Calloso-marginal fis. extends to level of base of 1st frontal, and then curves up to the margin of the hemisphere, being in- terrupted by a broad annectant uniting the gyr. fornimt. with 1st front. Beyond this there is a short extension which joins a complex series of sulci in the pre-cuneus. Orbital gyri normal. There is a narrow fronto-marginal sul There is a well-marked external orbital fissure. The chief points to be noted are : — 1. The absence of complete coveringof cerebellum by cerebrum 2. On both sides the pre and retro-central fissures were sepa- rated from >. of Sylvias by very narrow and grooved gyri. 3 The left >.. liolando joins fis. cruciata oi pre-cuneus, and on the right side it is imperfectly separated from 1st front, and aso. par. sulci. 4. The inter-parietal, on both sides, joins the 1st temp sul and on the right side is much more developed and joins the 5. On the median surface the calcarine on the right side enters the scissura hippocampi. There remain two questions for consideration : first, to what extent does Professor Eenedikt's confluent fissure type of brain isTreliarr "'^"'"^.'"^!^^^- ^^ "- community/and how far IS ^reliable as an indication of defective development ? With a view of ascertaining how far the confluent fissure type of bum exists among the lower classes in this community, I have ex ammed carefully 68 hemispheres from U individuals,^dl Uho^ were patients in, and died at, the General Ilospit M^tTf indVv;? c . '°'"^ '^'"*^'"« «^ '^l^^^^'^ter of any of the a^^o^tsor t" T'''''^ ^'''^^"^^' ^^^ results are of occurs in that class frora which che Hospital wards are recruited h. 0. d. e. 18 1. The Fissure of Rolanrlo communicated with — a. Fissure of Sylvius, in 8 completely, in 7 incompletely. h. Frontal sulci, complete in 12 ; incomplete, 9. c. Inter-parietal sulci, complete in 7 ; incomplete, 9. 2. The Fissure of Sylvius joined — a. The F. R. [see above.] b. The frontal in 20. c. The inter-parietal, complete in 26 ; incomplete, 8. d. The Ist temporal, in lo. 3. The Inter-parietal united with— a. The i^. 72. [see above]. The F. S. [see above]. The parieto-oceipital in 18. The horizonal or sup. occipital in 14. The Ist temporal in 19. 4. The Cnlcarine entered the scissura hippocampi m 25. 5. The calloso-marginal joined the par. -occipital in 1. 6. The parieto-oceipital joined — a. The inter-parietal in 18. h. The horizonal occipital in -3. From these limited observations we may conclude 1. That a considerable proportion of the brains of Hospital cases are of the confluent fissure type. 2. The chief difference to be noted between Prof. Benedikt's series of criminals' brains and those which I have just gone over is the somewhat greater number of unions between typical fissures more particularly between the fis. Rol. and contiguous ones! Thus in his set this fissure ccn.nected, completely or incompletely, with the fis. Syl. in 24 instances ; in my series in only 10. In the other fissures the disproportion is not nearly so great. 3. Considering the number of brains of ordinary Hospital patients which present in some degree the confluent fissure type, it would seem more reasonable not to assign as yet any special significance to it until we have fuller information about the arrangement of the convolutions in the various races, and until a much larger number of the brains of criminals of all countries have been examined. I t ;1y '*■! i 14 Professor Bcnodikt's cases wore nearly all Slavonians or Hun- garians, and though Betz of Kioff, a leading authority, acknow- ledged the atypy of his si.eciincna, it would have been more satis- factory to have had a comparison between these specimens and an e(jual number taken from law-abiding members of the same races It may be urged that in Hospital patients the brains should con- form m considerable numbers to this 2nd or confluent fissure type, as many of them are individuals in the lower ranks of life and not a few belong to the criminal class. This applies, how- ever, much more forcibly to dissecting-i'oom material, which, as Dr. Benedikt says, " consists of the remains of those who have suffered complete shi])wreck in life through low grade of intelli- gence, imperfect motor development, or through crimes and vice " In the series of brains which I examined, there were no dissect- mg-room specimens, and it di.l not include the brain of any notorious criminal so far as I am aware. As to how far confluence of fissures is indicative of a low type of cerebral organization we also Avant fuller information. When existrng mhigh degree, there is certainly an absence of many important annectants or bridging areas of brain substance but when we consider the variable size of convolutions boundin.^ the typical fissures, it is easy to see that defect in one part mi«ht be niore than compensated for by excess in another part, and even a nejghbourmg part. In several of the brains which I examined no aMy No. 10, the confluent fissure type existed in an o^l' with a rich convolution system. In the brain of Moreau, the retro-centra fissure on the left side was separated from the inter-parietal by a distinct gyrus,which might as well be regarded as an excess, as absence of an annectantand confluence of two fissures might be considered a defect With reference to the type of four frontal convolutions which Plot. Benedikt has found in such a large number of his spec mens, I will only say that in 10 of the hemispheres examin d 't was observed in a greater or less degree of LelopmenT N ^^fe.e was )t better seen than in the brain of Ilayvern To enter upon the anatomical significance of this would be beside the question on this occasion. 16 Professor Benedikt's conclusions arc those of a thorough- going somatist, who wouM brin;^ all human conduct within the range of organic action. " The constitutional criminal " bo says, "is a burdened individual, and has the same relation to crime as his next of blood kin, the epileptic, and his cousin, the idiot, have to their encephalopathic conditions." And again, " the essential ground of abnormal action of the brain (i.e., I take it, bad conduct,) "is abnormal brain struc ture. His 44 criminals were what they wee because of defects in the organization of their hemispheres : thoy belonged to the ennnnal variety/ of the fjenus homo. No wonder he says " that this proposition is likely to create a veritable revolution in ethics psychology, jurisprudence and criminalities." He wisely adds that It shouhl not yet serve as a premise, and should not, for the present, leave the hands of the anatomists, since it must be re- peatedly proven before it can finally rank as an undoubted addition to human science. Crime is commonly regarded as the result of yieldin- to an evil impulse which could have been controlled ; and this element of possible control is what, in the eyes of the law, separates the responsible criminal from the irresponsible lunatic. The belief m a criminal psi/chosis is spreading, and is the outcome of sounder views of the relation of mind to brain ; and these investi- gations of Prof. Benedikt, to which I have so frequently referred may serve as a foundation to a natural history of crime. But if this is the case, how are we to regard our criminals ? What degree of responsibility can be attached to the actions of a man with a defective cerebral organization ? Where is there scope to eschew the evil and to do the good, when men arc " villains by necessity, fools by heavenly compulsion, knaves, thieves and treachers by spherical pre.lorainance." Any one who believes that with all our mental and moral processes there is an unbroken material succession, must consistently be a determinist, and hold with Spinoza, that '• in the mind there is no such thing as abso- late or free will, but the mind is determined to will this or that by a cause which is determined byanthcr cause, this by yet another, and so on to infinity." For a long time to come, how- 1 h 1 \ s A mM J. 16 ever, the rm.jorhy of inJividuals — includin;^ some who arc incon- sistent in so (Icing — will continue to hold the intuitiouisf. view jiowherc better expressed than hy Shakespeare, when he puts into the mouth of that arch-criminal, lago, the words : " 'Tis in ourselves that we are thus and thus. Our l)odies are our gardens to the which our wills are gardeners ; so that if we will plant nettles or sow lettuce, sot hyssop and weed up thyme, supply it with one gender of herbs or distract it with many, either to liavc it sterile with idleness or manured with industry, why, the power and corrigible authority of this lies in our v,'ill. ' " Theft and murder," as Huxley well says, " wovld bo none the less objectionable were it possible to prove that tliey were the result of the activity of special theft and murder cells in the grey pulp." One thing is certain, that, as society is at present constituted, it cannot afford to have a class of criminal automata and to have every rascal pleading faulty grey matter in extenu- ation of some crime. The law should cntinue to be a " terror tu evil-doers," and to let this anthropolofioal variety (as JBene- dikt calls criminals) know positively that punishment will follow the commission of certain acts, should prove an effectual deter- rent in many cases, just as with our dogs, the fear of the whip exercises a restraining influence— immediate as well as prospec- tive — on the commission of canine crimes. Par.oc Fi Fis-Calea Fig. I. Plate Hg. 2. H- Ih ,i ;. »4 !■ ■^11^ ■ ■ (I' ■ 1 j > ■ ! . ' ' i ■I'll Inter Par oc fin Fig 3. Plate 2 R«tri)-c«it fii. liTrsul- l-'Tr sul /n(er jxarfii Par.ocfis 1 ^ 1 i 1 1 f f i:- ! 1 , ! 1 ''; fl 1 '^ ; 1 i ,,' ;' , . i ■ ' '•'- '■il lfl>l£mil *^ fi m 1' r ' , y^ LVt CASE OF Or.LlTKKATION OF THE POKTAL VEIN (PYLEPHLFlUTiS ADIIESIVA). P.y William Oslei;, M.D., M.P.C.P Lond., Professor of the Institutes of Medicine, MeGUl University, ALontreal. Thrombosis and suppurative pylephlebitis are the affections most commonly met with in the portal vein. A few instances of culcitication and extreme fibroid thickening of tlie walls art- reported. Organic occlusion, by conversion of the vein into a fibrous cord or mass of connective tissue, is a very rare lesion, as in cases of thrombosis life is usually terminated long before organisation of the clot -an take place. Tlie following instance of it presents many interesting features, anatomical and clinical : — J. C, aged 28, admitted into the General Ilospital, under my care, June 17th, 18S1, in a condition of extreme exhaustion, con- se([uent upon loss of blood by vomiting. My liouse-physician, 1 'r Andrew Henderson, obtained from him tlic following history: — Has always been strong and healthy; somewhat intemperate, but a steady worker, lias never had syphilis. No constitutiomil disease in his family. Last September, when engaged in some very hard work, was obliged to give n]i on account of weakness and dull heavy ])ain in the up])er region of the belly. It was nevi'r very localised, and was not aggravated by eating. Patient had to be in bed most of the time, and at about the end of a month had an attack of h;ematemesis, vomiting more than two quarts. Did not leave his bed for some %\eeks ; does not remember whether his legs or abdomen were swollen. Did not go to work until about April, when he got employment in a manufactory as iirejuan. Latterly, he was put to heavy work, piling bags of sugar, and yesterday (l(itli) he had to give uj) owing to feelings of great weakness. Tliis morning he vomited a large quantity of blood, partly iluiil, but mixed witli ch)ts. When admitted in i\w evening he was in a state of great exhaustion; surface lilaiiclit;d ; imlsc veiy small — l.'JoiLe tun 100'^ 'm]iera- respirations, 20. Shoitly after getting to lied h vomited (iadaver: June the folk cular m state, bu no distc oedema i flattened tion ; 01 forcible, tatit)n a i the navel to (he rii. Thci'e wa felt ; are iletected i axillary li dulness i directions examinati pile, filled Urine clen 19lh. i)right, li(ji the neighb Imt rallied tion at th nnirmur w 20tli. } ency to de was very p On the 2 exhaustion, On tlie 2;!d which he di Aulopsi/.- of abdonum In abdon i ...-„ot to be felt below costaUorder ; ai^ . ulness increased, 11 cm. in vertical, 13 cm. in transverse 'In'octions. J>at,ent di,l not complain of p,in durim.. J .xannnation Jiowels have not ],een moved; a lai^e e>;terna^ f: "";"' w.th coagula, was found on the right mar^n of ^ ^ brine clear, and normal. 19lh During tlie night patient vomited a large quantitv of >v.J^ht lapud blood, soaking the bed and covering the t^ " 1H| neigh ourho.d. He was ibund in an apparen^v^in!" a " ;>'t -ll.ed on the administration of stimuLmts. The exaW ' t- at the visit did not elicit any new facts; tlie j^Z;^ iinirmur was not so distinct. ^ 'f,-i^Lnc 20tli. No further hu.niorrhage, debility extreme, and a tend- On the 21st and 'I'M patient remained in a state of profound ;;;2;;;;^^;---e^-epeated syncopal attacks, dui4!me of oit!^!Z::^:t' "'" ■'--!-' ^^J-"Wn,nched; no distension of . Hi n en , cu aneoiis ven.s not visible ; slight cedema of feet i" abdomen the coils of small intestines were of a very d b h •I :i r. 'ill Ir t i i ■ II 210 lU;. WILLIAM OST,Kf;. slate colour ; ppritoneum smootli ; colon distended ; no exuda- tion ; liver and spleen did not appear below the costal border. In thorax a few ounces of serous fluid in each pleura. Heart was flabby and pale ; chambers contained small clots ; valves were healthy. Aorta normal. Lvngi pale, a;deniatous at bases. Splcai greatly enlarged ; weighed 67") gnus. ; was intimately adherent to the diaphragm and stomach. Capsule was very thick, in places wrinkled, and a firm, semi-cartilaginous plate existed at its convex border. On section organ cut with great resistance, creaking under *lie knife; the trabeculai thickened, rough, and in spots gritty. Some of the veiris were dilated, and contained thrombi. Near the hilus was a wedge-shaped calcified mass, the size of a walnut. The artery was very tortuous, and at the hilus presented a group of small saccular aneurisms, the size of large peas ; the coats thickened, partly calcified, and one of them contained an old thrombus, which had softened in the centre. TAvcr small, and closely united to the diaphragm and to the abdominal wall on the right side. It measured 25 cm. in breadth and 16 cni.Jrom front to bade. The shape was retained, but the left lobe was almost completely atrophied, only a small thin tonguelet remaining. Tlie surface was smooth, but towards the right border and behind, many fibrous bands passed between the capsule and the diaphragm. The capsule on the under surface was oparpie but smooth. On section, tissue uniform, pale reddish-l)rown colour; acini distinct, but no perceptible increase in the inter-lobular tissue. The anterior border and the remnant of the left lobe were firmer, and the connective tissue strands between the lobules could be seen. The h.eimtic veins were of full size. Portal canals not numerous, small ; artery and duct distinct (condition of portal vein will lie described under venous system). Microscopic examination showed the liver cells to be some- what fatty ; the connective tissue on the greater portion of the right lobe was not specially increased, l)ut at the anterior border and in the small portion of the left lobe th. secreting substance was a good deal atrophied. , Gall-hladdcr contained a (quantity of yellow bile. Gall duct normal. Hejiatic artery almost double the usual size. Stomm li([uid m could 1)0 here and were two end ; the wer(! scan memlirani Tntcstin ont. Eec the sphint tion of enl Kiihici/t quantity c and bladdc VenuuH the portal beyond its with ill-de tissues. I ]ienetrated the; natural tlie tissue v colour. Tl taceous or organ were sheath was duct in the any special in immediat The remaini in the follo\ splenic and tion, the siz there a calci; with the ui; '"^ CASK OF ODMTERATION OF TFIK PORTAI, VKiy. 211 Stomach was capacious and containe.l a quantity of dark I.<1-.I -Kxcd wjth food. Veins Loneatl. the muscular coat -uld l.e seen dilated and tortuous. The n.ucosa was pale horo and there znarked with spots of capillary injection. There were wo snudl superficial losses of substance near the cardia end the tissue about them was not injected, and their bases ^vele scarcely as deei. as the submucosa. About the pylorus the membrane was manunillated, and on section very toul-h Mcstmes contained dark tarry fa-ees; mucosa pafe ihrou^^h- out. Eectunr presented a number of enlarged veins just within ho sphmctn- and the external tumour was found to L a collec turn of enlarKod and thrombosed veins. Khhin,s of normal size, pale, a little firm. On section a Uv.o quantity of thin watery fluid oozed from the su a I Z iiiul bladdw normal. I'^eter r««,,,,, .Vv«.-0„ dissecting tlie gastro-I.epatic omentnm 1.0 l».rtal v.n, was tou.ul to W obliterated from a „oi„t 2 n Sh'iiViis;''';"' -"'"r*'' '"'° "■■ '-«"'-■. «brou, c :; tiMo ,s I, tins stato ,t .ntcreJ tlio l,il„s of the or-an a.-il ronotratcd tl,e n.ain divisions of the portal canals ; „o°tr ace " t ,c natnral a,>,,car„nce of a vessel could he seen. On seetion e «„e „s spongy, not indur.ated, and son.ewhat redd,' „ colon,. Ihe,.e we,v no ,cnnant.s of a thro.nhns, nor any crc- taoeons or ca e.hed portions. The main brand, s withi,^ t e . Sa,, were also ocelnded ; the connective tissne of GI "so, ■ lie th «s ahnndant, and firn.er than nonnal. Both arte y a, , ■luet rn those parts conld be slit open readily. There wis not any special eonfaetion abont the l,il„s, and iL liver snbstanc! ... ".....ed,ate neigI,b,a,rho„d of the portal canals looke., .1, li.e rema,n.„g p„rt,on of the portal vein and its branches Ce ... the followtng condition :_J„st bey.a.d the junction rf, plcn,e and snpeno,^ nresenteric was a large saccular d lata ...-. tl.e s..e of a walnut, with thickened ^alls, and he,t a I tl. e a calched plate beneath the intin.a. It vas i„ co„ta"t ^•.ti. the under surface of the right lobe close to e 1 ,s If'";" "• P""";.-, presented several small sacenli, the h t t '^fwb.cl. conta.,.ed atbennnatous plates. The mcse, " !'■ ' ' r ■ ' . :»f 1 1 \ i .' I liij 5 . lilii 212 ])!!. AVILI.IAM nSLEI!. 1 raiiclies worn TiKidtiratcly eiilar^'od. Splenic vein admitted tlie index finffcr freely, and all its branches were dilated. .Several of tliose on the anterior margin of the spleen were fnll of firm tlironihi. The vasa brevia iVoni the fundus of stomach were dilated, and some of the larger branches contained tbrombi. The left gastro-ei)iploic was almost as large as the splenic, and at the curvature presented several large dilatations, one of which ad- mitted the top of the thumb. The gastric vein emptied into the dilatation just beyond the junction of the superior mesenteric and splenic, and was nlso enlarged. The walls of all of these vessels were thickened, the intima a little roughened, and in spots ciilcified. The i/iferior mesenteric was moderately en- larged; the hasmorrhoidal branches were distended. Inferior cava noruifil ; openings of hepatic veins presented nothing unusual. Among its branches the lumbars a])])eared large, particularly one passing by the side of the third lumbar vertebra. To the left of the aorta w\is a large vein nearly cfpial in size to the inferior cava ; it terminated below by two branches, one of which ])assed over and joined the junction of the external and internal iliacs on the right side ; the other joined the connnon iliac of the left s' le. The ap})earance of the }/arts after dissection suggested a diuible inferior cava. Unfor- tunately the liver, together with stomach, pancreas, and spleen bad been removed before this condition was detected, so that the upper termination of this vessel cotihl not be made out. Two large branches joined it above, but their connection could not be traced. The Uieiea were large ; nuiny of the branches of the internal divisions were thrombosed. The (liiqj/irai/maiic veins formed ;i close plexus, particularly in the o'soi)hageal region, which uuiterl with the veins of the coronary and lateral ligaments of the liver. The lesopliagcol veins were numerous and large, and formed a rich netwoi'k about the curdia. The veins in the suspensory or round ligaments were not dilated. In the thorax the lower intercostal veins were veiy large, parti- cularly one running along the lower margin of 10th rib. Tiie vena .'cjjfjos major almost equalled the inferior cava in width, and admitted the index finger easily; the azygos minor was also of large size. lleiiiarU—^\\v\\ a case as the above presents nuxiiy points of CASK OK ODUTEIUTION OF Till.; l-OItT.VL VEIN. 213 interest. SucMeu and violent La-mateniesis in a yoiu..^ nian • no a.sc:tes no enlarged abdon.inal veins, sn.all liver/large'spleen' HHd a locahsed nu.rnuu. in the epigastric region-lhe diao.noS was no easy, btit it lay. I thought, between cirrhosis ^f the hver, splenic anremia, and an aneurisn. F., ei,rho,sis as a cause V 1 moTi; ""•" """^T-^'^f ^-y ^f spirit-drinking, din.inished ^. lume of hver, increase in size of spleen, and the existence of piles ; against were-the age of patient, and the absence of many iniportant signs, as gastric or intestinal catarrh, ascites, and enlarged veins. The well-nourished state of the man tl nuderate enlargement of the spleen, and normal aspect o the splenic Ihe suddenness of the attack, tlie brightness of the vomited blood, together with the existence of a localised murmu m the epigastric region-the origin of which remains obscure- suggested the occurrence of a small aneurism, either of the aorti or cnie of the branches of the celiac axis; but the Ine^lrlL t ot the live and spleen, seemed fatal to this view. Altoo.ether - spite of the absence of many of the important sym^ ^ ^ usually present, the most satisfactory diagnosis appeared'to 1 l.ortal obstruction from cirrhosis. The evident reduction in the volume of the hver was strongly in favour of this view, and as I hud also met with several instances in which severe luemorrha.e uKl been the initial symptom, I was the more inclined to reoaPc It as an auoimdons case of this nature. The history of a lueniorrhage in September, followed by an obscure illness of some months duration, pointed to a chronic malady jll.o history of the case offers no clue to the cause of the obliteration of the vein, but we may suppose it to have taken place m the way in which veins usually become occluded, vi. by 1.0 formation of a thrombus which organised, and was ulti'-' . e y converted into a fibroid cord. Apart from marasmatic cund. ions, in which portal thrombosis occasionally occurs coagula ion of blood in the portal vein is met with-lst, 1^ an 1 in tumours in of tlie liilus, which coi iipress the main trunk ^!l)atic omentum ; 2d, by extension of infl neighbourhood in the gastro- iunmation from tl if ■ ,1 HI A: le ii\i K » 214 IMf. WILLIAM OSLKI!. jB B I. bile passarrps, as in cholangitis from ohstruction by gall-stones ; and .''.d, b}^ tlie extension of inflaniniation or transference of emboli from suppurating or ulcerative foci in tlie territory of tlie portal vessels, but in these instances the thrombi wjiicli form rapidly soften, and supi)urativo i)ylephlcbitis is the result. I have met with cases of pylethrombosis from the above causes, but, so far as can be ascertained, none of them have prevailed in this case. The only possible source which is suggested by the post-mortem is the cretaceous area in the spleen, reiu-esentin" the final stage of a small abscess or infarct, which, when in an active state, might have induced, by direct extension or embolism, the pivletjirombosis. The state of the liver is worthy of note. Though shrurds< and Osier. State,' t: be compi There in which occlusion nierous c of the li branches means of ised, and balanced. that the e symptoms by Sappe coronary \ discharges also conin passing in and in the diaphragm ment dihiti the portal a redistend the small \ I have rec( iiarrowin<>' O increased I the presenc (4) certain lietzius, wli anastomosii the inferior exist betwei In this cas carried on There were cesophageal liv(,'r interco ' / iiV/toir's ^ CA.Sl.; OF OnLITEHATION OK TlIK I'OHTAL VKIN. 2\, stato.^ the portui blood cannot replace the hepatic if the latter he completely excluded from the organ. There is no more interesting sul^ect of study than the way in wluch channels of collateral circulation are establishecr a occlusion of hu-ge vessels. In the case of the portal vdn n w moro.. opport.,mtios for this purpose are aObrded in ZlZ. of the hver, m winch the obliteration of many interlobula branches necessitates the development of circuitous rouU^s l; rneans o vvluch the blood-current in the portal systen. is e Ll- sed and the reduced carrying capacity of its vessels coute - ha an ea. _ , ,,,,, ,,,,^^,.^.^^^ ^^ ^^^^^^^^^ .^ ^^,^ con.pensat on that he mrhosis may reach an extren.e grade without produc n symptoms. These collateral channels have been fully lescrbd V Sappey, and are chiefly :_(!) the anastomoses between ho coronary vems of the stomach and the oesophageal plexus, wh h discharges znto the lower intercostal and a^.o! veins " alsocommumcates with the diaphragn.atic vessels; (2) 'v passing ,n the coronary and suspensory ligaments of the l^e ana m the ad es.ons which often form between the liver nd diaphragm; (,) .n some cases a sn.all vein in the round iZ ment ch utes enorn.ously, and affords free conununication betw^fn the portal vem and the epigastric vessels. .Son.e regard t las a red,stended umbilical vein, but Sappey states thatlt i he nKall vesse s wluch he describes as the ..n. poric access^^ 1 have recorded an instance'^ of advanced cirrhosis, with --reat narrownjgof the portal branches, in which no s^mpton^s o ucreased blood-pressure existed in the portal systen. owino- 'o the presence of this vein, which was as large as L little fin^e 4) certam ven.s, forming what is known as the system If' Let.ms, wluch, ong.nating in parts of the intestinal canal and anastomo.ng with the radicles of the portal vein, discharge' i o the inferior cava or its l>ranches; (5) the communications which exist between the superior and inferior ha.norrhoidal plexus In this case the collateral circulation appeared to have b n earned on by the first, fourth, and fifth of these channe s Ihere were extensive communications between the g^.tric and a'sophageal veins, an.I through the latter with tl liv(;r intercostals. The vasa hi ic azygos and •ci Vurh hvir's Avchiv, Ixvii ia and others about the fund us Monimi/ (lencndJIospUal R,pufl.s, 1S8U. ' -k' v: >• ?'- ■. '' 1 , ■;• U"', . : !»■■ -l,' ^,1:'"/ Hi liir. CASE OK OPLITKltATION OK TIIK rOIJTAL VKI\. of tlio stnni'icli were IiiVhly tloveloiJinl, atul jdiiu'il the dense tKjtwi'i'k tibijiit tlie OM'tlia ami tlie tliiiplini^niu in lliu inunediiite vi(.'inuy. Many of these hrai'.ches were pluy',iied with thrombi. Dunhtles.s a hirLje share in the supplementary circulation was taken hy the vi'ins of the system of lletzius and the peritoneal branches emptyin ' into the cava. The lari^'e vessel to the left of the aorta may haV'' been a j^reatly disteiuled azvLjos nunor which Ilenle iigures as ji)iiiinL( with the left iliacs, but unfortunately its connection couhl not be made out owing to the removal of the viscera before the nature of Uie lesion was suspected. The l)lood in it probably r(;aclied the a/ygos, which was of large size. In the case of obliterated vena cava, recoi'ded in this Juitrndl} 1 mot with a sinrlar vein. The hu'inorrhoidal ])lexuses were not greatly distended, but the branches of the internal iliacs, particularly on the left side, were very large, and many of them contained thrombi. The epigastric veins were not dilated. The collateral circulation must have existed for some time parhai)S for years, and was fully compensatory. The somewhat sudden onset of the final symptoms may reasonably be attributed to interference with this free cir ulation by the thrombi in the gastric veins, and in branches of the internal iliacs. * Vol. xiii. K 1- v/» %AI.(lr. i». .1. r.„(rall.Ii.(( i; i „d. \Vi,scnscli;ilk 1^ h M. i"» , ! • rebor don driftcii Forn.bcstaiidtoil don nintos. Von Prof. Dr. fls|,.r, MeGill Univorsitat. Montreal, mitgeteilt und veroffeutlicht*^ T, . l i . ''^^«y''^J-'''"«iety" das. in einen. Tro en ut ^',t" !^""««" '-^^^ten es uns klar, wir siets die«e KoSen in Hwl •'""^^"? I''''" ««"«'"">«". der anderen Seite n e Bh!uZT 'T^'''''" /'"^<^«"' ^vahrend auf CapiUaren) gan. de"slo„ K " ^T" «,^ ^'-^^ '•'«"' Venen oder einielte ElL^ente Sukn d Teineli N^ ^''"' ^^•'"^'"" =^'^ ^-- des Entziehen efB tes dteh ' K • "'^t^ T "" Augenblick den^selben sich bewegt haUen ^^"''P^'-'^hen , d.e vorher frei in dnm Naiuen ..8^ t±'' ...^'""^^"^^ vordemonstrirt und sie unter diim Nauien „Sc ul'liz,,', gninul *) s. Proceedings 1874, No. 153. ii'te Massen" und „S «f><;ifnLTZKs r. H j'i ._ •I 'I 1: 1 ' I llrl I (' 'II KoiptMcliLMi" (Mii^futiilirt. Zweift'lios I'jillen sio mil Zimmichmann's Elt'iiKMitarkOrpercheii iind niit IIaykm's llilinatobluston zu- Maiuiiiuii. NeiKntliti^ra hat Bizzu/mki*) dieser Sadie fVisches Intcre^irte zu~ gowoiulet. Walirenii icli jedocli die Riclitiifkeit der UeherHelirift Beines AiifKatzes: „Kin iieuer Formbestatidteil des Hlutos" zu be- anstaiiden wnije, ^'eHtelie icli, dass ich Tatsacberi begc^fiiefe, welche neiiie Aiit^icht bekraftigeii iind den Eiiifluss der bere^rten Kiirper auf das Geririneii iiiid die Klimipunfonnation dea Bliites dartiin: 1) Dis Faser.xtoffnetz, das sich aiif der (ilaspiatte mis dem IJliite aiifseheidet, ist in der Kei^el dicliter uiid starker da, wo sich S( iiri,izi;'s Kleuieiite am zahlreiclisten vorHndeii, als z. IJ. in Schwache- I'iillen, bei Septhilmie, Phthisis u. s. w. '2) Der Veiliiuf der Endokarditis Itrinirt, \\ie all^emehi bekannt, fibriiiuse Wucheruiigeri hervor. Ich babe in nianchen solchen Aus- wCichsen — nio^fen sie warzi^er oder ulcerativer Natur sein runde eorpusouhlre Eleniente j^ef'unden, die init Sciiui.izk's .,Kurnchen- liaufen" identisoh sind**). 3) Bei eiiiein alten Manne, der an Carcinoma ventriculi litt, W!ir an der Aorta ein aul'serordeiitlicher Befiind. Hie war sehr iilberomalos und stellenweise verkalkt. Gerade iiber der liil'urcation land sicii eine grau-weiise Masse, etwat* abgephittet, 3 — 5 Ctm. im Dnrehniesser, sich jedoch 1,5 Ctm. nber den Rand eriiebend, mit wehhem sie test verwaaheen war. Es sab sich wie eine Neubildung an und ich liielt es anfani^s fiir eine secundare Krebsinasse, welche die A.ler diirclibrochen babe. Nach genauerer Priifiing zeigto sich jedoch (lie i-anze Masse als zusammengesetzt aiis kleinen farblosen, eng aneinarider geschlosseneiiKorperchen, die in )eder Beziohim.r sich identisch mit den individuelleii Klementen von Srmn/rzK's „Kornchen- baufen- verhielten. Jede Monuchkeit, sie irrtiimlicber'Veise fiir veranderte rote oder weifse Bhitkorper zu balten, war nusge^chlossen Welter ianden sich (i oder 8 kleinere Fiecken an der Intima auf einer Balggeschwnlst aufsitzen.l. Das Fasernetz in diesen Massen war nicht erkennbar und an keiner derselben befand sich coa'^uUr- tea Blut. '^ A f^ '". n'r' ^^"^" ''°" ^"»' ' « PUentha ™ ncd tot- :„, that he is at fault. What l";." rl™ hersel , she syph, .cd ? Most writers ,l,i,* that a «!„ ho! , , '•" ° '^'''"''""^ '=''''•' " «°"'»"'inated in some dc™ it: ::t:r:::;rto'ThS,f „'•"''■ ?:" -^ - of np3 it would «ive^he\lr:SL^:^r' -^r^^^^ IS sometimes known as Colles's law. The next oases illustrate some interesting later manifestations. Case II.-Girl, aet. 13, showing severe ulceration of throat then became b nd • cnrf^il K,. n.. n n , -^ » ' ^"" tins also cured;.; hid t-retW^^^^ "T ^^* '^^^' pain, but some difficult; irsTvl:;;::^'- '^^ -"^'^^' ^^ --^ /'m.«^ C.nrf^^.-.n.- Small; welf nourished ; has not th. syphilitic countenance. Teeth~JJnn<^r . T i • ^® orndpri nf f»,„ 1 , ^eec/i— Upper central incisors are ::uil int:.rs'p;:ifiet:*'S" T '-t-™-^^^- ^"' " fte tongue or cheeC Itt he r Mlrf """'"f ' "" "" ease ; the uvul, a.,d veh™ are .'„ ,b " """""" *^- ii'i 1 :'*.-,'' ^H . '^ ' ^H 1 ) ■ I' ■ m 1 m i ' i 1 j ^^^1 Iff*'"' ni! ^E I 1 ',ll H )' I J 1 1 t 1 ) i 1 .1 , iw 1 i '1 ^H i 11 i^H i i :i\ y\'l SUMMER SESSION CLINICS. the orifice of the Eustachian tube ; as low as can be seen in the pharynx on the posterior walls arc cicatrices with reddish fleshy outgrowths; nothing else noticeable. Ei/es are apparently clear, but on careful inspection both corneoe are seen to be slightly turbid and hazy. She has had interstitial keratitis, a common affection in secondary syphilis, which comes on usually between the twelfth and sixteenth year, is specific, and if properly treated, generally curable. Secondary acijuired lues in man rar-^ly destroys the structures of the throat. In the inherited form the throat afltction is apt to be more intense and phagadcenie, as in this child. Ear trouble is not uncommon in inherited lues. In this instance it may have extended from the pharynx ; but middle ear disease may occur without throat complications. In this case the disease in the pharynx is not progressing. She is on potas. iodid., grs. x, t.i.d. To do any good, these cases require early and energetic treatment, as the ulceration is rajjid and destructive. Case III.— Girl, tet. 23, admitted Feb. 10th with Bright's disease ; dropsy of the legs and face. Family history uncertain. This girl presents, as evidences of inherited disease, large tibial nodes, onychia, and a suspicious-looking spot of ulceration on her forehead Nodes are, in acquired pox, common on the forehead, clavicles, tibiiiR, &c., and are the result of specific periostitis, caused by virus in the blood. They may be absorbed, or go on to the formation of bone. They arc also important features in inherited syphilis. Nodes produced in the congenital form differ fr(>m those produced in the accpiired, inasmuch as they affect more often the bones of the upper and lower extremities, are generally symmetrical, are much larger, and may occur over the whole extent of the bone ; they are rarely painful, and often disappear under treatment. The tibiae of this girl are enlarged, thickened, and misshapen: almost a uniform node from ankle to knee. The fibula on the left side is thickened, especially about the lower part. I remem- ber, on several occasions, hearing Mr. Hutchinson call attention to the fact that these large nodes were often mistaken for Rickets. I pass around one of his plates illustrating this form of node. CASES OP INHERITED SYPHILIS. 5 Teeth-Uv^ov incisors eroded at the root ; upper ones well forced nothing suggestive about the.. NaU.Z the thul nng and httlo fingers of right hand are mal-for.ed, rou^h dt' •l-scoloured, scUy, and are typical instances of (^^./.v! ;^. a' or psoriasis of the nails. '^ ' You noticed that I examined the teeth of these two cases with spocia care. I did so because these organs so.etir^ valuable oi- even positive evidence of inherited syphilis. Mr Jonathan Hutchinson first called attention to thfsVact, and I have here for your inspection his Plates illustrating the subject. ihe teeth in case II. would be called by some "specific," but they are not so and I gladly take this opportunity to in pres e ver ha been led to regard as distinctive. At the Congress as year he complained very justly that men had not sufficiently tudied lis writings on the subject, and were too apt to regard any ma formed teeth as syphilitic. The facts are briefly th^ : 1, leeth giving mformation are the permanent ones 2 The TaitdT Tf " T'T''"^ ^"^'"••^- ^^ Characters'are : d wai fed, stunted m length and breadth, and narrower at the cutting edge than at the root. Anterior surface has usually the ename well-formed and not eroded or honeycombed ; the cut .ng edge presents a .inglo notch, usually shallow, sometimes deep, and m that notch the dentine is exposed of ani;rT'".v"'""'"^ '^ '''' surface, are indications an eaily stomaUUs, an inflammation of the mouth, perhaps from mercury, or associated with convulsions ^ Children who have been the subject of syphilis frequently f;:;:;t^%77?^--«^^-^-'P^>y«-gnomy!recognizible^ a glance Ihe ollowing are chief points \n ^ S^phimic counte- nance : 1, forehead prominent, especially the frontal eminences ; 2 saddle-nose, bridge being defective, owing to early coryza and nflammation ; :], often striated lines from corners of moifth, and the skin is colourless and rauddv. I m fl^ ssible after this date, hut it is more nnocrtain, and the possibility is great of permanent damage to the organs and of the establishment of chronic parenchymatous nephritis. The favourable signs are diminution and disappearance of the dropsy, increase in the amount of urine, with reduction in albumen and maintenance of normal urea excretion. In the most rapid cases three or four weeks at least are 'locessary before the condition of the urine becomes normal. I nave kno\\ n the albumen to disappear, while the tube casts continued. Circum- stances which warrant unfavourable prognosis arc long duration, persistence of the albumen in large amount, material reduction in urea and the onset of symptoms of uricmia, some of which are sudden and rapidly fatal. What are the indications for treatment ':' Mild cases would probably recover, indeed, have done so, left to nature. Case III received no special treatment for four days, and improved durin" this time. The rest in bed, recumbency and the quiet do much, but there are few cases which do not call for active interference. In the early stages, where the congestion of the organs is marked, the urine reduced in amount and bloody and the lumbar pain present, dry cupping the loins and warm fomentations do much good, acting as derivatives. You know on general principles that the first thing to be done with > i ..cutely inflamed organ or part, is to give it, if possible, func ki rest. With the kidneys this is impracticable, but we can relieve and assist them in various ways. A spare diet and rest diminish the amount of solid materials to be excreted. Purgatives and diaphoretics call to aid the bowels and skin, which supplement the action of the kidneys, and, as it were, help them in a friendly way when they are disabled. In the early stages and in mild cases, there is no necessity for severe purgation. Keep them loose by a daily dose of Glauber's Salts (Soda Sulph. 5ss), and perhaps an occa- sional Jalap purge (Pulv. Jalapjie co. 5ss). In the more chronic cases, where the dropsy is great and uraemia threatening, hydra- ACUTE imHllIT.S DISEASE, 13 l\ }!,'>'A^\tlu<-nr/nn ; of the former raay bo given n^x of the Fl. Ext. ovory two hours until copious sweating is induced ; of the latter a hypoderniic injection of ,', to \ gr. But of all measures at our disposal to j)roduco sweating, the hot air both h in my exp.rience, the b -., \\h; easiest employed, and has the additional advantage of be ng in mui / instances a diuretic, so that after a most cojuous swii inj^ of the disease, the most im- portant points are as follows : It is an affection which attacks all ages-from infants to persons in advanced life. The maiority of cases occur, however, in the middle periods of life, and males are more frcjuently affected than females. Of 85a cases of B J! m \ J I I fvte^ij ■ '■'!') i J ;lll I 1 : 1 ' r! ■ il i I'll 18 SUMMER SESSION CLINICS. pneumonia witliiu ten years in this hospital, 2C)l) were males and 88 females. Of 00 autopsies of which I have records, only two wore in children under 2 years old. The great majority were in adults from the ages of 25 to 45. Though healthy, robust persons are affected, it is specially prone to attack debilitated individuals in a community, and persons already affected with some disease. Season would appear to have a great influence on this affection. The months in which we have the largest number of cases are March, April and May. Next are the autumn months, or rather the early winter months, November and December. During the full winter time, January and February, the cases arc not so numerous, though they are more numerous than in the summer months, the time when such cases are fewest in number. These are facts based on the 853 cases of pneumonia admitted into the hospital, as contained in the statistical report of Dr. Bell.* It varies in different years. We have not as many this year as last year ; and last year we had not as many as the ycpr before. You will notice from this that it would not appear to L in the coldest months that we get the greatest number of case. ■)f pneumonia, but in those months in which the variations of 'emperaturc arc marked. Next, as to the morhid anatomy oi the affection. The term lobar is frerpiently applied to this form of disease in contradis- tion to lobular. In this form of pneumonia the rule is for cither a considerable portion of a lobe, an entire lobe, or the whole lung to be involved in the disease. You rarely find a pneumonia less in extent than the area of the palm of tho hand. The lower lobes of the lung are more frequently involved than the upper lobes. The right lung is more frorpicntly involved than the left. In the 60 autopsies to which I have referred, 40 occurred in the right lung and 20 in the left. An exception tV rule, which states that it is most frequent in the lowc. lo.^eo '3 the pneumonia of old people and of drunkards. In '■b'^se it most frequently involves the upper portion of the lung ; hence the ' Montreal General Hospital Reports, Vol. I, 1880. ¥« PNEUMONIA. 19 tcnn apex pneumonia. And this variety sometimes presents special clmioal features, which are of great importance. The stages of the disease are as follows. They are usually spoken of as four in number : (1) The stage of engorgement. (2) The stage of red hepatisation. (3) The stage of grey hepatisation. (4) The stage of resolution. We rarely have opportunities of seeing a lung in the sta^^e of engorgement; but we can sometimes gather what the condition IS from a death which takes place early in the di^oase. A very favourable instance for the observation of this occurred a few years ago, owing to an unfortunate accident by which a patient too.< two drachms of solid morphia instead of two dracliras of the Liquor Morphine. This patient died in the course of 12 or 14 hours, and at the autopsy we found that there was a commencin-^ pneumonia in the lower lobe of the right lung. This part was heavy, feebly crepitant, contained much blood, and portions ex- cised from the superficial part floated, but in the central portion m four or five isolated areas, about the size of marbles, the lun-^ was firm, and had the usual appear. . ,o of red hepatisation, and no doubt represented the commencement of solidification ; if he had lived another 24 hours, he would doubtless have had uniform hepatisation of the lung. In the stage of red hepatization, the characters of the Inng are exceedingly well marked. We have had throe autopsies this week on cases of pneumonia ; and I have reserved for this lecture two specimens, showing the condition of the lung in the second stage. On inspection, the first thin- you notice is that the surface of the pleura over the affected part has lost its glistening appearance ; it is turbid and lustre- loss, or, as you sec in the second specimen here, it i^ covered AVith a distinct layer of lymph. Now, my experience is that this superficial pleuritis is a constant feature in pneumonia; so soon as the inflammation reaches the pulmonary surface, it of neces s.ty involves the pleura. You may have, as you see in this hrsc lung, only turbidity of the pleural surface. You may have as you see here, in this second one, a thin sheeting of fibrin ' '■I i't J ''is , ; I ) 1 r ) i ■ 1 ;, \ 1 t\\ I i t /I .! iv/'i 20 SIIMMEH SESSION CLINICS. but you also may liiive a layer of fibrinous exudation liom half an inch to au inch aiid a quarter in thickness. I'.'Mo one spoci- mcn which shews ;^encral hepatization of the iung, unu a unitbrm sheeting of exudation over nn inch in thickness, extei\ ling from apex to base. Secondly, the lung in red hepatization does not collapse ; it is full in volucie. Thii'd, !o the touch it is firm and nowhere crepitant. There is a solidity abo''t it resnmbling one of the solid or',rans, as the i'/er — hencfj the appropriateness of the term hepatization. Indeed, with the eyes dosed y<.'U cou-d not U'll by touch a portion of liver from a portion of ho^.atized lung. h. lifis lost the crepitant feel of healthy lung. On section, the api^carariOe is the following: — The surface is of a uniform roddir^li 'i! li ti.e color varying very much ; in (lie early stage a bright red, in the later stages a dusky red, a ^ you see hero in this specimen. Not much fluid bathes the section. On close inspectioii, you can see that the surface presents numerous small fine granules, whicli are very characteristic of this' stage of the disease, and which consist of fibrinous plugs filling the air-cells. Usually they are not of the same intense red as tlio alveolar walls, and can be seen in contrast to the portions about them, though in the early stage these fibrinous plugs may be just as red as the surrounding parts. The lung is friable — breaks very easily. This is in marked contrast to healthy lung. Try to tear a portion of liealthy lung ; it is done with great difficulty, and you cannot easily put your finger into it ; but with a bit of pneumonic lung you can put your finger in with the greatest ease, and it breaks with an irregular fracture. The bronchi, more particularly the smaller ones, often contain fibrinous plugs, the consistence of which varies much, some being simply muco- purulent, others being distinctly fibrinous and firm. The pul- monary vessels are occasionally thrombosed. In the third stage of the disease the picture is considerably modified, more particularly as regards the colou' ' the lun<^, which is changed from a reddish to a greyish yell . greyish- white. The ''<"■: ion is no longer dry, but a 'sid' . Ae (juantity of purulent n: ::<■• r bathes the surface, or can ' ,;. • ozed from it and this matter looks just like as if it came inr. ■ > fresh abscess. 4i <'' PNEUMONIA. 21 In this portion of the lung of the sccon.l specimen, you see it passmg to the stage of grey hepatisation ; an.l you see here, on the knife, the purulent substance, which can be scraped from it Ihis grey colour is due to two cause.. Li the first place, there IS much less blood in the lung, owing to compression of the alveolar walls by an increase of the contained cell elements ; and secondly, the colouring matter of the blood-corpuscles exuded into the air-cells in the stage of red hepatisation under.^oes changes and gradually becomes dissolved. In this portion you see that grey hepatisation is in the early sra-^e There IS not much infiltration of the lung. In the late stage of .rev hepatisation you may have the lung so infiltrated with puslhat the term pundent injiltration has been well applied to it It looks saturated with or soaked in pus. There is the same friability about the grey hepatisation as about the red, and the chan-^es of the bronchi and pleura remain the same, ° Before speaking of the stage of resolution, it will be better to speak of the histology of the process, and the followin.^ briefly are the chief facts known with reference to it. In the sta-'e of engorgement the blood-vessels are distended, particularly the capillaries of the alveoli ; the epithelium of the air-cells is more granular ; and some describe a nuclear proliferation, an increase m the cells. In the second stage-red hepatisation-there is an exudation from the blood-vessels into the air-cells consisting of fibrine, red blood corpuscles and colourless blood corpuscles and mixed with these are the products of proliferation of the' epithelium of the air-cells. The fibrine coagulates, and the cells are entangled in its meshes, as you see in this plate taken froL Delafield's " Pathological Studies." The number of red-blood corpuscles within the air-cells is very considerable, as you will see in the specimens I will shew you afterwards with the micro- scope. In the stage of grey hepatisation, the chief change is an enormous increase in the number of leucocytes. Each air-cell appears to be distended with a plug composed of closely-packed colourless elements. The fibrine fibres are much less distinct, and the red-blood cells are no longer to be discovered. In many of the cells fatty degeneration can be seen, particularly in the ... , -jp. , . . . f '.a i'^ ( if it #, f 22 SUMMER SESSION CLINICS. \ % lar<^or ones, which results from epithelial proliferation. These changes are well shewn in this plate from Dr. Delafield's work. The tissues of the air-colls undergo little or no change, with the exception of the epithelial lininp^. With regard to the stage of /vso/x^io;/ — the terminal stage of pneumonia — that in which the lung is restored to the normal condition, we still lack satisfactory evidence of the precise nature of these changes. The elements within the air-cells undergo fatty degeneration. This we can see in the ordinary gray hepatisation. This is, in reality, the essential change. By this the cells are dissolved, liquified, and the emulsified matter is either absorbed or it is thrown out in the expectoration. It takes some timo for a lung to undergo complete resolution, several weeks in all probability, and usually, when a patient leaves the hospital, and is appa- rently quite well, you will, on careful observation, ascertain some slight changes in the affected region of the lung. A word with reference to the amount of solid exudation which may occur into the lung in pneumonia. This may sometimes amount to several pounds. One lung — the healthy lung — may weigh a pound or a pound and a quarter, and the other lung may weigh three or four pounds. There may be 2^ to 3 pounds of solid exudation in the lung affected. In the GO cases of pneumonia referred to, the heaviest lungs that I met with were two, one of which weighed over 2,800 grammes, and the other 2,200. Unfortunately, the termination by resolution is not the only one which maj^ go on in pneumonia. .The following changes may occur, though they arc rarely met with : In the first place, in the stage of gray hepatisation there may be the formation of an abscess. The purulent infiltration may be so intense, may infiltrate the parenchyma of the lung to such a degree, that in certain localized areas the tissue breaks, with the result of form- ing small pockets of pus. Now, this is an exceedingly rare termination. In these GO cases, only three presented small ab- scesses which were formed in this way. Cases 32 and 35 both presented small purulent foci. In one of them, two of the pockets were as large as walnuts, and in the other they were the PNEUMONIA. 23 size of marbles. Tins unfortunate termination in pneumonia is most frequent in old or debilitated people. Gangrene is a second and still more untoward event In this set of autopsies there were two cases in which a fatal termination was md.iced by gangrene. One of these many of you had an ojiportumty of seeing last year under the care of Dr Ross Dunng the wmter session a patient was admitted with pneumonia, a very debilitated woman, and death occurred within a week from gangrene. There was a gangrenous mass at the upper part of the lower lobe, and the remainder of the lun- was in the condition of red hepatisation This may come on in the stage of red hepatisation, and may be due simply to the inten- sity of the inflammation, but more commonly, it is thought, to the blocking of the pulmonary arteries. Whether the exudation of lobar pneumonia in a healthy man ever undergoes caseation or transformation into cheesy matter 13 still much disputed. Niemeyer and several other German writers think it may. Professor Buhl, of Munich, holds that in any case in which a caseous degeneration is discovered post- mortem though there may bo no doubt about the caseous nature of the change, there is much doubt of accuracy of dia-mosis In only one instance in the past six years have I met wiUi a case that appeared to justify a belief in the transformation of the in- flammatory products of lobar pneumonia into these cheesy sub- stances. The case is recorded in my first pathological report. The last and rarest of all the modes of termination of lobar pneumonia is the non-resolution of the exudation, the persistence of the process, and the gradual onset of fibroid chan-e in the lung (chronic or interstitial pneumonia.) Now, in'^the case of the man Phillippe, who was under our examination here for nearly three weeks, and who died the day before yester- day, this change was beginning. His right lung, us you see here, was uniformly solid, greyish in color, with recent pleu- ritic exudation, and the surflice, on section, bathed with serous fluid. On ci..:, lully inspecting the cut section, three features call for attrition. In the first place, in certain regions you can still see the air-cells with their fibrinous plugs, of a very w tw. i I 24 ?l>rMEU 8EHSI0N CLINICS. opaiiuo v.'-lh oimr.'n./ undergoing fatty clian^'o. Those arc to bo seen ovor tonsideralilo areas. Secondly, there are small pocketH if pus, localized areas densely infiltrated with pus, and breaking down into definite abcesses. The largest of these is about tlio size of a inarl)lc. And thirdly, in several areas of the lung there arc spots which ! ^ '.ranslucent aspect, are firm, smooth, homogeneous, not granular, and have the look of a recent connective tissue. These are spots of special interest to us, because in these areas a fibroid change is goin'» on in the lung ; and, as you will see in the specimen under the microscope, the alveolar walls are infiltrated with fibrous elements, and actually the fibrin- us plugs themselves filling the air-cells are represented by and transformed into a new growth of con- nective tissue. This is an exceedingly rare method of termina- tion. It is the iirst good instance of the kind I have ever met with. A few words with resj ect to associated morbid con Luons. The condition of the heart in autopsies on pneumonia is very characteristic, so much so that anyone with tolerably lar^e ex- perience cnn make a slirewd guess at a case of pneumonia from the condition of the chamijcrs of the heart. They are usually found distended with firm clots, so firm thai they can be with- drawn from the blood vessels ; and, as you saw in the cases this week, the clots could be withdrawn from the pulmonary artery to its finest .Tiificun us. Th - is no disease in which you meet with fibunous clots of the same degree of firmness and extending the same length into the veins. The excess of fibrine in the blood in fLis disease accoiints for the exceeding firmness of these clots. It is very rare to meet with ..iher morbid conditious in pneumonia. We usually fin 1 the organs healthy, exce[.t the shght changes associated h ' '.^rh fever, if of ' i,g stand- ing, the turbidity of the v;i us . ms. The state of th°e spleen IS ot some interest, particuhuly as to the point wh-fher pneu- monia is a local disease or a general essential fever. Professor Fredreich, of Heidelberg, calls attention in one of his lectures to the fact that the spleen is usually much enlarged in pneumonia. Ih very ti has been ( been of n( change, tli of the kid with pneui chronic at Bristowe c in this aftei cases, a v( ours, it lias instance of carditis is a of cases. we have ha occurred in plication of of cases. In and four of xigor. The single e the palu pain in the s shortness of under your i lias pain in t are the pre when you ( whom we lia and short res these feature a case when To analyse of breath is d * Vide papers national Altdic PNEUMONIA. 25 Ih very many of the autopsies tli;,t I have pcrfoniiod, the spleen has heen enlarged ; Init in fully half of the eases the o.-an has been of normal size. The kidneys rarely show any important change, though, as I will tell you in the next locture, the state of the kidneys influence the prospects of an individual effected with pneumoiua. In a vjry considerable number of the cases, chronic atrophic clianges are met with in the kidneys Dr.' Bristowe called attention to croupous coUUh, a sort of dysentry m this affection. He met with it sixteen times out of some 48 cases, a very considerable proportion. la these GO cases of ours, It has only occurred on f'.o occasions, an.l there was one instance of croupous or diphtheritic gastritis. Ulcerative endo- carditis is a complication of which we had a consi.lerable number of cases. Out of the twelve instances of this disoase whidi we have had in this Hospital in the past few years, seven have occurred in connection with imeumonia.* Meningitis is a com- plication of which we have also met with n considerable number of cases. In the GO autoj.sies there were five cases ,.f meningitis, and four of these were associated with endocarditis. V«p \ hours amount to half a pint. In none of the above cases has the expectoration been excessive. In debilitated persons the expectoration may be more liquid, and of a prune- ju.ce colour. In old persons there may be very little expectora- tion. Ihe ^.i.. at the outset is full and bounding, ranging from 1 to 130. Ihe heart acts forcibly; the arteries are well filled. As tho disease advances, the pulse gets weaker, and requires watchm- with great care. Increased rapidity, with feebleness or intermission, should at once attract your attention as the treatment hinges largely on the condition of the circulatory system, as ,s well expressed by an old maxim, " sine puha nulla therapeia. The urine is usually high-coloured ; the urea is increased, the chlorides are diminished. Nitrate of silver gives no reaction ; albumen is occasionally present. A symptom which requires special comment is delirium. As I have told you on several occasions, delirium in pneumonia may occur under the following circumstances :-In the first place, from the intensity ot the fever, just as in any acute febrile afteetion an individual may be delirious at the outset. Secondly, in debilitated indivi- duals, and particularly when the apices of the lungs are in- volved. In these cases it may be a low delirkim, or it may amount to a heavy stupor, with occasional mutterin-s Ihis form is particularly seen in what are called asthenic cases where the patient is much de!)ilitatod, and in pneumonia attack- ing aged and enfeebled persons. Thirdly, the most important perhaps is the delirium accompanying the pneumonia in individuals who are accustomed to take largely of alcoholic liquors. Yesterday you had an illustration of this. A youn-^ man was taken ill on Friday ; he had a chill, and has since been m I i\: I : '>■ > \ M it ii D !■ I 4| 28 SUMAIEB SESSION CLINICS. suffering witli the usual symptoms of pneiiraonia. We found him in tlie ward restrained by the nurse and an attendant. The cheeks were flushed ; but what attracted attention at once was tlio restless eye )f the patient, and his anxiety to get out of bed and get away. He was actively delirious, and the delirium was of the character resembling delirium tremens. As you saw, he was picking at the bed clothes, and when I went at first to the bed-side he was talking to an imaginary person on the other side of the bed. Tliis feature is of extreme importance for you to bear in mind, because you may overlook the essential charac- ter of the disease. You may treat your case as one o? delirium tremens, when in reality it is pneumonia, complicated with peculiar delirium. I remember an instance of an individual who was confined in a strait jacket, and believed to have delirium tremens. There were no special lung symptoms. A few days after we had an autopsy, and it was found that, he had extensive apex pneumonia. In the majority of those cases the apex of the lung is affected, as in the young man you saw yesterday. Occa- sionally the delirium is exceedingly violent. A few weeks ago I performed an autopsy for Dr. Rodger at Point St. Charles on a man who was furiously delirious for three or four days during the disease. He required several strong men to hold him in his bed, and he died simply exhausted from the violence of his efforts. The stage of resolution may be supposed to come on with the crisis. In this the patient is tolerably comfortable, — does not complain of much except perhaps a little weakness, and you often have difficulty in keeping him in bed, as you remember in the young lad (Case III.) With reference to the physical signs, I may briefly state the following : — In the first place, on inspection you notice that the affected side does not move as much as the opposite one ; the intercostal spaces are not bulged, nor is the side as a rule en- larged, the latter being distinctions between pneumonia and pleurisy. The apex beat is not displaced. Palpation gives aii in- crease in the tactile fremitus ; the voice sounds are communi- cated 1,0 the fingers through the solidified lung very much more readily than through the air-containing lung of the opposite side. Percussion passing into tympanitic r tensity, fron of that mai quire an ec But usually to the close, more or less surface of th and you feel flatness is u pleuritic effu In the firs hepatisation, at the end of crepitant rak listen to in th by the crackl the fingers oi tised, the bre; character, sin sterno-clavicu scapular regie is simply the i out of the bro not transmitte tied lung, bee exudation, am always have ( cases of pneui feeble, tubulai stages you the more abundan These persist lution proceedi able to follow PNEUMONIA. 29 Percussion in the early sta-e, when the engorgement is just passing into red hepatisation, gives, over the affected area, a tympanitic note, which may be of very varied degrees of in- tensity, from a full tympanitic, such as you heard over the chest of that man Phillippe, to a flat tympanitic note that may re- quire an educated ear to recognize the tympanitic quality. But usually in following a case of pneumonia from its inception to the close, you meet with tliio tympanitic (luality of the note more or less marked. In the full hepatisation, if it reaches the surface of the lung, you then get an absolutely flat or dull note, and you feel an increased sense of resistance (>n percussion. The' flatness is usually not so ivooden as in cases of extensive pleuritic effusion , In the first stage, and as the engorgement is passing on to hepatisation, you have what is called the pneumonic crepitus ; at the end of inspiration you hear a series of extremely fine dry crepitant r-iles. They are the finest and the dryest nlles you listen to in the chest, and may be compared to the sound made by the crackling of salt when burning, or to the rubbing between the fingers of a bunch of hair. When the lung is fully hepa- tised, the breathing becomes distinctly bronchial or tubular in character, similar to the sound you hear in the bronchi at the sterno-clavicular joints or adjoining the vertebn>3 in the inter- scapular regions. You must remember that this bronchial sound is simply the normal sound which the air makes passing in and out of the bronchi, but which, in the case of a healthy°lung, is not ti ansmitted to our ears with the same intensity as in a solidi- fied lung, because in the latter the air-cells are filled up with exudation, and transmit the sound much better. You will not always have this evidence— bronchial or tubular breathing~in cases of pneumonia ; in many instances it is weak, and has a feeble, tubular character as resolution proceeds. In the later stages you then begin to have rules which are raoister and much more abundant, and accompany both inspiration and expiration. These persist for a very considerable [)eriod of time. As reso- lution proceeds, the dulncss usually dimimslies ; and as you were able to follow in that case of the lad (case III), certain areas of 1ft '. ! I: 3. |P' iin ■ f 30 SUMMER SESSION CLIMCS. the lung cleared up entirely, and you got a full resonant note. It is net at all uncommon, as in his case, for the base of the lung to remain slightly dull for a long time ; that dulness may be due to diminished resonance in the lung, or to a thick layer of pleuritic exudation in that region. The heart sounds present no special changes further than that the second sound at the pulmonary cartilage is increased in intensity. The profinosis in the disease is usually good ; but it depends much upon the class of individuals you have to treat, Thus the prognosis in cases admitted into this hospital is not as good as in the cases outside among the better classes. The mortality here is exceptionally high, in some years over 20 per cent. A large number of the cases die within 48 hours of their admis- sion. In the 170 cases of pneumonia treated by Dr. Howard during 20 years, the mortality was between 5 and (3 per cent. In some 40 consecutive cases which I have had in the past three years, most of them in this hospital, there have been but three deaths. Among the circumstances that influence the prognosis are : 1st, Age. As you may suppose elderly individuals do not resist the fever as well as young, healthy persons. 2nd, The habits of the individual. Drunkards and persons debilitated from any cause aro exceedingly bad subjects to take pneumonia, and it usually in them early assumes an asthenic type. That is one reason why our mortality is so high. We get sent in here chiefly the lower classes and debilitated individuals ; and very many of the cases of pneumonia are in persons in the habit of taking a considerable amount of alcohol. 3rd, Existing disease is an important factor. In persons who receive an injury as a broken leg—and then take pneumonia, the disease is more liable to run an unfavourable course than an healthy person. Inter- eurrent pneumonia, as it is called, is always more serious than an attack in a healthy person. Of all aflfcctions that would seem to have a bad influence in pneumonia, chronic renal trouble comes, I believe, first. In looking over the records of post-mortem f<, some 00 in number, I was surprisc of the other pneumon a but looking over my reports of »,(-„„,« eases of l.neu,„„„,a ,t struck me as not a lit e remarkable! l! wa» the healthy part of the lung neither ^ge* "XT ous. llns state of collateral cedema is doubtless impomnt ;„ some n,sta„ees, though not as much so as some " iTk it Anot er effect of the impe.led How of blood throu^L Z .t ::..te u ^ot:} ;?z:Tstt't t t- '"''''-'' Then acnin in n n v . , J. Tl condition, in the carli out any vie here nor th fever. Tin heart. Of larly if reso majority of Shall we g viride, and t they are not to the chest in this hospi to the patiei with apparei What sha And how lor rule is for re ten days the in which no fever keeps quietude, 1 mation of al seventh or eij completely re the fifth and i cleared up sa I will just s individuals ai tained yesten I do not kn( a few days di * Canada Lan PNEUMONIA. 35 you may remember, two years ago, the case of a man in ward ' : '' L ^'W ^^'''''^' ^^'•'^^ '^''''^ V timely venesection to XXV > Ihe relief vas something remarkable. Tlie only other cond,t.on, I believe in which you can bleed with satisfaction is n the early stage whe.e you have a full, vigorous man, with- out any v.ce of constitution. Twenty ounces of blood is neither here nor here n. such a man, and it will reduce his pain and beai t. Of course uKhviduals may die from exhaustion, particu- larly If resolution does not take place, as in case IV ; but in the majority of fatal cases of pneumonia they die of cardiac failure. Shal we give arterial sedatives-digitalis, aconite, veratrum v.nde, and the like i Except at the onset, and in vigorous persons, bey are not indicated. Antimony I never use. Local treatmen; to he chest IS often advantageous. We use poultice, very much m us hospital, and they are soothing to the ,,ain and grateful to !.e patient. I never use cold, though I have seen it applied with apparent advantage in German hospitals What shall we do if resolution does not take place normally ? And how long can a lung remain solid without dama^^e ' 'Ao rule IS for resolution to begin after the crisis, and in a week or ten days the lung ,s pretty clear ; but there are many instances in which no crisis takes place, the lung remains sol'], a sli!. fever keeps up, and the patient may cause you mental lis- quietude lou may fear the breaking of the Inng and the for- mat..,n of abscesses, but even if resolution be delayed to the seventh or eighth week, it may ultimately follow and tl^ lun. be comj^etely restored. I reported* one case which was delayed t the hfth and another to the eighth week,and then the lung in both cleared up satisfactorily, and the patients made good rec^overies will just supplement my remarks on pneumonia of debilitated dividuals and drunkards by shewing you this specimen, ob- tained yesterday from a patient of Dr. Wilkins. a feeble old man 1 do not know his habits ; he came in delirious, and after a few days died with cxcensive pneumonia of the right apex of * Canada Lanett, December, jyso. ': :!'i 1:1 If % V 36 SUMMER SlESSION CLINtCS. III! the Iiing. You see here the whole of the upper lobe, with the middle lobe, uniformly solid. It weighs over 2,000 grammes. There is a pleuritic exudation over the surface. On section, you see that it is of a reddish-grey colour. I show you this to impress upon you the lesson you should have learned from the case you saw in the wards yesterday, as it is somewhat similar to it, and on account of the fatal issue of so many of these cases. No. V. leucocythemia; Gentlemen, — There are certain diseases which affect princi- pally the blood and the organs of the haematopoietic system. Of these the princi[)al are : — 1. Ancemia. 2. Chlorosis. 3. Leiicooythemia ; and 4. Lymphadenoma, or Hodykins'' Disease. These are characterized by profound alterations in the constitu- tion of the blood, and certain of them are accompanied by definite changes in those organs of the body which we regard as the blood-making ones. The form of anaemia which particularly belongs to this class is that known as pernicious or essential. Of the affections characterized by an alteration in the struc- ture and appearance of certain of the blood-forming organs, the most important are leucooythemia and Hodgkins' disease. In these affections, either the spleen alone, the lym[)hatic glands alone, or the spleen with the lymphatic glands are affected. In the former we have, in addition to the changes in the spleen * Hteuographica! rv';t>!-! hy .lams-s CvankshaWj Ksq,, B.C.L and lymph terized by the term, ] there is no though tli( identical ; 1 to it. I ha Smith and case illustri and yet one and well. — • Vervi moulder, bu in Montreal dead of an i strained whi of hands an the belly be^ in left side. blood in stoc him about I^ Trenholme, i ment of the i of several pi be : dropsy, ness, and sho the patient I better in him We will nc he presents. larged abdom not nearly as not present a much better t healthy look a breathini: is. i ■ 'n examuiat I LfcTi« OCyTUEMlA. 3t \ and Ij^raplmtic glands, a special alteration in the blood, charac- enzecl by a great nicreaso in the colourless elements. Hence he term, Leucocythemia, or Leukemia. In Hodgkins' disease here ,s no such mcrease in the number of colourless corpuscles, though the characters of the changes in the organs may be Identical ; hence the term Pseudo-Leukemia is sometimes Jm to It 1 have here to-day, owing to the kindness of Dr. Lapthorn Mnith and of the patient himself, an exceedingly interesting case illustratmg a disease met with but rarely in this country" and yet one which it is very important for you to know accurately' and well. The history of this case is as follows • -- Vervais et 39, has been a healthy man. Has been a moulder, but for the past eight years kept an hotel. Always lived in Montreal. Never had ague. Mother died at age of 80 ; father dead of an accident. Got hurt 17 years ago in the left side ; s ranged while lifting. Ill now for 13 months ; began with swelling of hands and legs, which continued for five or six months ; then the belly began to swell. Had pain in belly, and noticed a swelling in left side. Occasional vomiting in morning. Never passed blood in stools, or vomited it. No palpitation at heart. I saw him about New Year's in consultation with Drs. Kingston and Irenholme, and we found great oedema, with ascites and enlarge- ment of the spleen. Since that time he has been under the care of several physicians. The chief symptoms have continued to be: dropsy, for which he has been tapped three times, weak- ness, and shortness of breath on exertion. Within the past month the patient has improved, and I see a great change for the better m him. We will now examine the patient and ascertain the synptoras he presents. The first thing you notice is that he ha« an en- larged abdomen, with slight dropsy of the feet and legs ; this is not nearly as much as it was when I saw him last. His face does not present a specially cachectic appearance. He is lookin-now much better than a month ago, but has not got ,,uite so good a healthy look as when I saw him first about the New Year. The breathing is, you notice, a little short. The mhe is about 108. On examination wc find the following .- le abdomen is if: 38 SUMMER SESSION CLINICS. uniformly distoiKied, not more on one side than the other, and raeadures about 4-" inches. A few large veins arc seen, but they are by no means prominent. On palpation, the abdominal walls yield ; they are not tense ; there is no increased sense of resistance until the fingers reach the left side of the abdomen. You then feel a distinct solid mass. It is firm, hard, and reaches below the level of tlie crest of the ilium. There is a definite edge, and at about the level of the navel and at a distance of three inches to the left you feel a distinct notch at this edge. This resistant mass can be felt well into the left hypochondriac region, and far back into the left lum!)ar region. On percussion there is a dull note, while over the greater portion of the abdomen, a flat, tympanitic note is obtained. In the umbilical and the hypogastric region there is a distinct wave which can be seen and felt on percussing one side of the abdomen. So that we find here a large collection of fluid in the abdomen, and ev. i- ,!?es of a tumour mi the left side. The liver cannot be fe]<. V";'.).v the ribs ; its upper limit of dulness is half an inch belo. . ,i supple. The chest is well formed. The apex beat is in tbt; i'orth interspace, and just within the nipple line. On auscultation, a soft, systolic mui-mur is heard. The lungs appear normal. The lymph glands are not enlarged. Now what we have found here, gentlemen, is simply dropsy of the abdomen, with oedema of the legs, and a tumour on the left side of the abdomen. 3'he tjuestions are, first, what is the nature of this enlargement on the left side ? What is the cause of the dropsy ? and of the tumour here in this region ? You would think at once of an enlarged spleen or kidney. When I saw this patient with Dr. Ilingston and Dr. Trenholme, the doubt was whether it was renal or splenic. It is so far back in the lumbar region ; it is not very moveable ; and it was thought that perhaps it might be an enlarged kidney. But, on the other hand, against that are the facts that the !)order can be felt very distinctly ; a notch is evident ; and on percussing and palpating towards the left hypochondriac region, it is found that this mass emerges from below the ribs on the left side ; the dull line ex- tends nearly to the level of the nipple. From its position, the distinct fe from the 1 an enlarge As to tl place, to t of simple i causes uid called splei spleen of h you can d the blo(jd V an accurati now, so far the spleen, blood. If decrease in it a case of not ; but if puscles gre; to twenty, c leucocytheir and we find eight red on tion of the affection, m find also tha red blood coi There is alsc Of me cat everything t( of middle f quently in cl of an infant affects males which have b is one which I have lately \ LEUCOCYTIIEMIA. 30 distinct feel of the edge of the notcl, and tl.o way it ni.orges from he left hypocho.idrium, there is no ,l,H,ht about its beh,. an ctilargcd sploen. ° As to the cause of that cnlnr^omcnt, you have, in the first P ace, to think of chronic malaria ; then, in the second place ot simple splenic enhii-ornent not induced by ' Ha but hv causes unknown to us, accompanied hy an.«mi . sometimes ca le ' 'f r ) ) 1 ■ i I' Hit •I i ''ii I a ,i IMAGE EVALUATrON TEST TARGET (MT^3) // 4 i< (/. 1.0 1.25 2.5 2.2 20 18 U 11 1.6 — 6" riiuiugifipiuu Sciences Corporation 23 WEST MAIN STREET WEBSTER, NY. 14580 (716) 873-4503 .^'«^ %^ ^i;*" 40 summj;r session clinics. i-l ! particularly of American cases, and I have been surprised *o find how few were the cases in which any definite connection with malaria could be ascertained. We know very little, in- deed, of t'^e circumstances which induce this affection. Of the morbid anatomy, in the splenic form the spleen is chiefly involved, and it forms a large cake, as it is called. The size of the tumour may range from a couple of pounds to 16 or 17 pounds. Some of the largest abdominal tumours are of this splenic variety. This one, from a patient who died under tiie care of the late Dr. John Bell, is the largest specimen we have in our museum ; it weighed 7 pounds when it was fresh. Here is a second, not so large, and a third, larger in proportion than the others, as it was taken from an infant eight mouths old. The organ in this affection is large and hard. It is in a condition of what is called chronic hyperplasia. It cut? with difficulty ; the section is uni- form and the trabeculge of the gland are unusually distinct. On examination with the microscope, we find that the change is chiefly in the network of adenoid tissue of the gland, whicli is greatly increased ; and between the little meshes are the spleen corpuscles. In a large number of cases the lymphatic glands are also enlarged, more particularly the lymphatic glands in the neck and in the axillia, less frecjuontly in the groins and in the internal glands. The enlargement in the lymphatic glands is simply hyperplasia. They are enlarged and firm, but otherwise look natural. In addition, in a very considerable number of cases of leukaemia, there ar ) definite growths of lymphoid tissues in organs in which we do not usually see such growths. Thus for instance, in the liver you may have definite tumours, whitish in appearance, varying in size from a walnut to a hen's egg, composed entirely of new growth of lymphoid tissue. These may also occur in the lungs. The glandular elements in the small intestines are sometimes enlarged. The tissue of the bone-marrow has attracted attention in this disease. It is converted into a reddish, soft, pulpy material very much resem- bling spleen pulp. It is believed to play a very active part n\ the production of many of the features of the disease Neuman, Hosier and others speak of a myelogenous form of leukjcmia,' induced b changes ii the condit to the inc may prest corpuscles coagulatio heart file first case opened th precisely t one of Vir an absce?s filled the ; With re attracts at the left hy men. Ac( patient bee that they a ceed.s. In and of the throughout dition of tl essential s; The foil leuk;emic finger, yo drop of the brown colo greyish-red as one raigl but the cole on tho inert the red-bloo profound, ai you tind the LEUC0CYTnE5:iA. #1 induced by changes i.i the bone-marrow. These are the chief changes in the organs and parts of the body. In post-mortems the condition of the blood is otten found most remarkable, owing to the increase of the white corpuscles. The blood, when clotted, may present a greyish-red appearance, or in clots where the corpuscles have separated from the iiquor sanguinis, before coagulation has taken piace, you may have the auricle of the heart filled with a substance looking like pure pus. lit the first case reported in Canada (by Dr. John Bell), when wt opened the right auricle of the heart, Dr. Bell exclaimed in precisely the same terms as are related to have been used by one of Virchow's assistants in a similar case, " Why, we have an abscess of the heart," so puriform did the clots look that filled the right chambers. With reference to the symptoms of the disease, the first that attracts attention is usually a sense of fullness and uneasiness in the left hypochondriac region, or in the upper zone of the abdo- men. Accompanying *;his there is usually failing health. The patient becomes languid, the appetite is impaired, and they notice that they are paler than usual. Dropsy of the legs soon suc- ceeds. In the patient you have just seen, dropsy of" the legs and of the hands appear to have been his first symptom ; and throughout the case it has been the chief trouble. The con- dition of the blood on examination is, of course, one of the essential symptoms of the afifection. The following are the characters by wiiich you mav know leukiemic blood : In the first place, when yoti prick the Hnger, you find that, instead of the deep purplish-red drop of the normal blood, the colour is changed to a chocolate brown colour, or even, when the leukaemia is very intense, a greyish-red colour. In this patient the colour is not so marked as one might expect from the number of white-blood corpuscles ; but the colour, you must bear in mind, does not depend so much on tilt- increase of the white-blood corpuscles as the decrease of the red-blood corpuscles. In a case where the anfemia is very profound, and the number of red corpuscles much decreased, you find the blood almost of a chocolate colour. On examination J ft w • i ' *, '. I t n 42 StrilMER SKSSION fl.INICS. with the microscope, the colourless corpuscles are greatly in- creased ill number. Instead of seeing two or three white-blood corpuscles in the field of a No. 7 Hartnack, you may find as raany as GO or 70. In tact, one usually supposes, on first exami- nation of leukiemic blood, that the white-blood corpuscles greatly exceed the red in number. It is rather a hazardoas thing to estimate, without accurate measuremnt, the proportion of white- blood corpuscles to the red. The red-blood corpuc:.les ai'e always more numerous than they appear, for the reason that they collect together in clumps. You do not see how many th'?re are owing to formation of rouleaux ; whereas the white corpuscles remain isolated, and so they look much more numerous. Secondly, the colourle.'^s corpuscles frequently present great variations 'n size. You will notice this in the slide of blood which I have here for examination. Some are mui.'h larger tlian normal ; others are smaller. In cases in which the lym|ihatic glands are greatly involved — lymphatic leuktemia — there is a much larger propor- tion of small white cor|)Uscles. Thirdly, the red-blood corpuscles usually present a somewhat paler appearance than usual ; occa- sionally there are gi-eat discrepancies in size and irregularity in the outline. Fourthly, you may have, added to the blood, an element not seen in health, namely, nuclear Mj-blood cor- puscles rt'hich exist normally in the bone-marrou. These occur not unfrequently in leuk;Braic [)atients. In the last case I had they were remarkably abundant. In one instance, in the field of a No. 9, I counted ten nucleated blood corpuscles. I never before saw them .so abundant. Lastly, Schultze's granule- masses are, in certain cases, vei'y ar.merous. These characters you will see in the specimen of blood which I have taken from this patient. Among other symptoms in connection with leid<;v;mia, hemor- rhages take a prominent place. In some Instances hemorrhages occur very freely, and may be the very first symptoms which a patient complains or. In one of Dr. Howard's series of cases (Montreal General Hospital Reports, Vol. I), vomitin- of blood was the first serious symptom that the lad had. In another in- stance, which I believe to have been a case of leukiieraia, the I girl died to this a marked i rhage ini is a grav simply t( one case througho patients i perature. his tempe marked. the condi doubtless haps he which woi mind that on the pc This patie The pat largely de and deveh particulan the blood i associated. The trei a hopelessl bad to wo occasional the patient that the pa due to the without be spleen was out in some either died remedies v LEUCnCYTUKTIA. 43 prl died of tlic most profuse lia>raatemesis. She appeared, prior to th.8 attack, to be in fair health. We found at tl.e autopsy a marked increase in the colourless blood corpuscles. The hemor- rhage may occur early in the disease, or as a late symptom, and 13 a grave omen There is usually vomiting ; it may be' due simply to the pressure of the large spleen on the stomach. In one case o Dr^Howard's, the vomiting was a persistent symptom throughout. Diarrhoea is occasionally met with. Most of these patients are febrile. There is a slight evening elevation of tem- perature. Ihis patient has not had much fever. I have taken his temperatuie several times. The dropsy in this man has been inarked^_ This may, in greot part, be anajmic, depending upon the condition of his blood. The marked dropsy of the belly is doubtless due to interference with the portal circulation. Per- haps he has enlarged glands in the -^rnro-hepatic omentum, which would account for the dropsy in this case. But bear in mind that enlargement of the spleen alone, without any pressure on the porta vein may account for the dropsy in the belly. Tins patient has a heart murmur, an.^mic in character. The pathology of the affection is still, unhappily, very obscure, largely depending upon the fact that our knowledge of L growth and development of the corpuscles is still wanting in so many rZT . V' '"'^ "'^'^^'^^ "" '""P^'''' ^'-^ the condition of I'oclated' blood-making organs should be intimately The treatment of this disease is highly unsatisfoctory. It ig a hopelessly incurable affection. The patient usually goes from bad to worse. Two years sees the termination. There ar^ occasional intermissions of the symptoms, periods during which he patient im,,roves a good deal. It is one of these intermissions that the patient you have just seen is in. It may be, of course due to the remedies ; but these intermissions are known to occur' without being influenced by the medicines. Excision of the s,. leen was the remedy proposed many years ago ; it was carried ou in some 18 or 20 cases without any success. The patients either died on the table or shortly afterwards. The chief remedies which have been used have been directed either '■I I . . .1- In III: *■' iUi. i: i ■• ' V 1 r » 1 1 ) '1 1 ■k' s,' : 1 1 ^ ^\ f i 1 j' 1 I , ( 1 1 : ^ 1 ^ ;■ J J i 1 1'. ■ 31 44 ^fMMKIl SESSION CLINICS. towards rcducihg the size of the spleen or improving the general condition of the patient's health. Among the remedies used to reduce the size of the spleen have been electricity, which has proved very serviceable in reducing tlie size of the organ. Quinine, also, and ergot, given internally or injected into the substance of the organ, have been used. Of the medicines used to imi)rovc the general condition of the patient and the blood- making powers, iron, arsenic and iihosphorus are the ones com- monlv employed. This patient was on arsenic for some timo^ and also, I believe, on phosphorus. He is now on iron, and attributes largely his im[)rovement to the large doses of iron he has been obtaining. Tranfusion has been practiced in some cases, in the hope, [lerhaps, of giving the patient a better blood ; but this has proved futile. In a i)atient — as in this one whom you saw here — with extensive dropsy, you have to relieve the distressing symptoms by tapping. This man has been tapped four or five times. There is one symptom that I did not refer to, namely, the condition ot the retina. This comes in under the symptom of hemorrhage. Many of these cases have a form of retinitis wliich consists of hemorrhages into the substance of the retina. This man's retinte are normal. The patient has been sent to one of the wards. We will go in, and some of you will have an oppor- tunity of examining him. These cases rarely occur in the hos- pital. There has been only one in the past ten years; and I am sure we are much indebted to Dr. Smith for allowing liis patient to come up here, and giving us an opportunity of seeing him. X i-l K >x li m I CESTODE TUBERCULOSIS. ' ■ A Successful Experiment in Producing it in the Calf. By PROFESSOR OSLER. M.D. McGill University, and A W CLEMENT, of Lawrence, Mass,, student in the Montreal Veterinary College. (Reprint fioiu the American Vbtkkinahv Kevibw, April, 1S82.) It is a curious fact, and (ine that requires further study and explanation, tliat wliile the Taenia Saginata is tlie common tape worm of this country, its larvae, the measles of beef, are very seldom met witli. On the other hand, wliile T. Solium is hy no means so prev- alent, yet its larvR!, tlie measles of pork, are not at all infrequent. Cobbold* refers to this, and states that " not a single instance has been recorded of the occurence of these cystic parasites in the United Kingdom, except in our experimental animals." Of course much more fresh beef and veal is consumed than fresh pork, and the former is, as a rule, less thoroughly cooked, and it may be, as we sliall state hereafter, tliat measly veal is not as readily detected as measly pork. The prevalence of tape worm is directly dependent upon the efficiency with which the meat inspector and the cook per- form their duties. No infected carcass sliould escape the one, and a measly steak or a fillet of veal from the kitchen of the other, could be eaten with impunity. Experimental proof of the relation between the beef cysticercus and T. Saginata was offered by Leuckhart, who, in 1801, successfully roared the measles by feeding a calf with ripe segments. Mosler, Giu-n and Zenker, in Germany, St. Cyr., in France, Perroncito, in Italy, and Cobbold and Simonds in England, have repeated the ex-. ♦Parasites, 1879. ^r Ml' (■ i 'pii 'i '?- the first week no special cliange wa-i ol>served ; the animal fed well and seemed lively. With the exception of the observation made just after the feeding, the temperature did not rise above 102-5°. The pulse range was from 11 2 to 1 W. The fccces were soft, one day mixed with a quantity of gelatinous material. No segments were observed, but microscopicnil examination on the third day after feed- ing determined the presence of numerous ova. In the second week the animal did not appear so well. On De(!eird)er 2(1 the tem- pei-ature rose to 104-G^ The pulse kept over 100. of moderate volume. On one day the animal seemed stiff in the limbs and disin- clined to move about, Init next morning was jis lively as before. The f(eces kept tolerably consistent ; no ova were found on subsequent examinations. During tlie third week there were no special symp- toms to attract attention ; the food was taken very well, and super- ficial observation would have judged the calf to be healthy. The temperature kept up over 103° and on two days above 104°. The pulso decreiised in rapidity, sinking below 100, the range being from 86 to 95. In the fourtli week the temperature was above 104° on five days, and the pidse was a little quickened. There were no intestinal symptoms ; muscles not stiff, and beyond a slight weakness, the animiil did not appear very ill. During the fifth and sixth weeks the staim quowHH maintained; temperature, between 103° and 104°; pulse about 90. During part of the Clu-istmas vacation the daily recor examples, easily overlo.>ked in dressing the arcl b le of a tape worn., or even many segments. And, thirdly, a very pait'f wlihr 'Tr"'" ''' J"'"^^ "> ^^'^ table, the centra S^W " " """' '' ' temperature sufficient to kill *Dio Parasiten des Mcnschen K„che„n.ei.s,or „nd zum 2te Auflagc 1881. I m Li eL [Rfprir.lc.l from Tin Mi i,i,m Niu., July 2.,. iS,S2.| N, /^"■J'r A CLINICAL LECTURE ON EMPVKMA \N1) ITS ANTISMI'TIC TREATMENT.' Ih-lhvn;/ al Ih, M,.nlrc.,l C.ncal //os/^ita/, J,,,,, .-.fth, !•' hfl: IIV WIl.r.lAM OSI.KK, M.D.M.U.CM'. I ond -■KorHSSou „„ , ,„ .ssT.TUTHS O,- MKO.C.NH, Mc<;,tL UNlVKHSlrV. \ \ .i-.mi.k.micn: I wish to speak to y„i, to-day on the siibic.t of empyema and its trcatnic-nt bv the antiscpt ? n>cthocI. You saw yesterday a case whicli was o, c - d- :icarr:;,o:?t;""^ '-'-'' ^"" ' -•'" "- --• '» >- '^ Mary S., a-ed twenty-seven, was admitted June .ih. Is unmarrie.l, a servant. .\„thin^ special in he family history. .She has been a heaUhy ,ir VoZ weeks aoo she had chills anver the tube, tl septically ' antiseptic Th recti y I side then bandagei as soon as the disci.... last night, dressed tl had saturated the tow and , ere placed d w was placed outside this, and th e rule IS to repeat the dress m .4 irges get to the edge. Dr. Duncan he case again, as the disch.irgcs luze; and it was dressed *Die Parasiten des Mcnschen Kuchenmelsternnd zum 2te Auflage 1881. aK.iin this morninir. \'ini li n,. ,,, . ■ *■■""'■'-■ '"'-'>'' ''™.iu;:,r,s:;,'.''''!,;,';,';,';;;: /, cr ^» i '■ , i 1 ;ii i s B*' li v.ry weak and dcbilitaid n „.-•,, ^""'''t'"". 1" the result; h.nvevor r , , ,^ ''''l /^^ave fears as chest was dressed w he I'e er e I I '''''>' "'"'I' ■'"'^'-" «1kc of the dressin l-n^ "'^' '''^^ liar^cs reached the (cAle. the te^;" ;;• . ' . """^ ^^-^"^k^ '•'^ --emained i J feeble, the temperature 'li^^charKe j,r„t less, and t fall in le a satisfactory recovers CASK 11. was under our sessu)n. 'I'l ^i^'" sweating and con^iSliieti^JlS^ii^X.;^' Reprinted from the Archives of Medicine. Vol. vii. No. ^TA^riTTiiir"" \ 1 1 fi yet tlie iiH estimated and tlt'sli, slight and the iiniscn 103°, so 1 teinpei'atu tlie third, Avliicli led was no sue at tlie peri is the qnlj the tenipe; very great more sevei of ripe 86^ the eggs ii ness 'f th( How its " nieasl first place, is not so o are sure t have j?asse once cat'jh losce, but r Secondly, the infectt only one c Calves aiM bile of a • much gres than pork cot)ked. parts of w the larvae. I thought also at the time that he had some affect ion of the apex of the iiL,dit hm^^ as there were rales ... that leKion. There was universal dulncss over the left side, with the exceptii^n of the infra-clavicular d the usual physical signs of effusion. Dr. region, an ou Fcnwick operated :n the way I have described to y -.. the case was dressed antiseptically, and the lad made a remarkably good recovery. He entered the hospital on the 2Sth of May, and on July 23d he left completely lell having gained in llesh and with the healed. 1 exhibited this lad al quite before the .Medico-Ch irurs'ica 1 S so, with the other one ocictv, a nd 3th them the result was everything that could be wished. :a.sk III. was also under obser\at a man named Clarke, aged about fortv-threi ion last suinmer- in the hospital for a coi He iiion on the right side. There f weeks with pleural effu- was irregular fever, and e susi)ected that the thiid was jjrobably purulent. Or. using the hypodermic needle, we found that there was pus, and he was treated in the way I have already de- scribed. The pus was drawn off, and a.tiseptic d'rcss- '" ere applied every day or every second day, ac- inars w cording to the amount of the discharge. This man was s admitted April 19 and discharged Julv 4, perfecth well, having been seventy-five days in hospital. The tube had been removed several weeks before he left the hospital, and at the time of his discharge the breath sounds were audible at the angle of the scapula. He had improved in general health, and he went back to his work. I saw him several months aft he had kept well. erwards, and These three cases of e tinctl mpycma stand out verv dis- the fc y in my memory, inasmuch as thev are amoiii in tins w instances in which I have seen good recover dis case. It serious thing for isalwavs reu'ar ded les its an exceedinglv a person to have pus m tl le pleun le cavity. The liability to constitutional disturbance, tl difficulty of geUingthc suppurating pleural membranes to granulate and heal, are well known, and render this disease extremely difficult to treat satisfactorily. I iidc r the antiseptic phm I believe many of these difficulties are obviated. In these cases the temperature af'ei 'ipeiation, particularly in the man Clarke and in the second case, remained normal. and it would seem that *Die Parasite, des Menschen Kuchenmeistcr «nd ziun 2te Auflagc 1881. if there is no discharge, this treated antisept jority of instan tlisturbance. C will be difficult .ipparatus: perl siiable that you specially to'sur circumstances, 1 Init where you h, follow out' thest ii'on as you cau tlwroiii^h ih-iii)ia !he c/it-st, and if have excellent empyema. A tl Iieve, essential, ; not appear to ni; mit the chest or vided you have large, and in a sit piete, then I do Hut if you have make a counter^ and wash out tho followed: A drai washed out with i'Hline. I have s Hay, and I mus children, satisfac rare. It is notori^ of cnipyema are records of such c; rate of mortality, know of is that' 1 boston City Hos drainage and a frt of the affected sid ol nineteen, and l)royed. These rt ;iiitisept:c precautii ' Hosp dilated, r Reprinted fr Li . J • ^"^>-'i'ic, like ail ordinarv ah'^mac u.ii,>.-. Hospital Reports, 2d Series. 1877. ^C p. £ i >N I I m : m i I. r* i ^r'-M ;1 dilated Reprmted from the Archives ok Medicine. V^T^ITl^^r^^^-yT^^^^ t I 1 il Ill ' ( jet tlie sin estiiiiiited and tlcsli. sligJit iiud the imisou; 103°, so t tenipenitu; tlie third, wliiciJi led was no sud at the peri is the only the tempei very great more sevei of ripe seg the egg8 ii ness of Hit How its " nieasl first place, is not so o' are sure t have passe once catch losoe, but r Secondly, the infecte only one o Calves tkiii bile of a i much grea than pork. cooked. ] parts of wl the larvffi. t wish you to think that it is only under this for i do no plan that cases do wcl As you are aware, in this \vc chest hrst; and the rule is in a case of e man we aspirated tlic nipyema to draw off the fluid with the aspirator at least once. (ew cases do well with a single aspiratio )n,and in childrci' this is almost the rule. I5ut in adults, unfortunatel the case usually ^rocs from bad to worse, unless ' '■'■' free openin,-; is made. In these four cases th s a very e inter- costal spaces have been of sufficient size to admit thi tube. In some instances the space is not larj^e enoui^h, and you may have to resect a portion of a rib, to '^vt plenty of rt)om in ordei And now a few ^a'ueral remarks on the disease. Ir some cases the fluid the outset. In the case of this first drawn off, was turbid, of ppcars to be pm-ulent almost from woman, the fluid, when I cream-vellow color, ind probably became purulent sliortlv after its form tion. ()f course, the oidinarv sero-hl ' Pl urinous fluid of eunsy cont.tins ninnerous Icucocvtes, and the c version o a m; f such a simple effusion into a purulent Uter of multiplir.ition of these. Purulent fluid on- one is simplv the serum dei In debilitated sely inriltraled with the leucocytes IS persons the fluid is much more apt t( become purulent than in the stronj; and healthy. There is !)ut one invariable and sure means of ascertainini,'^ whether the fluid is pus or not, and one that is easily applied. Take your hypodermic needle, and thrust it into the chest, and d die >f( some of it. mpk enough method, but one which is not often enough re- sor ted t Tl lere are numerous ijractitioners th the country who never think of using the hypoderm needle except for jjurposes of medication, where rougliout ic )f almost as much mi porta nee i n d of pleural effusion, or of doubtful dul terior part of the chest, you need i thrust the hypodermic needle into th lagnosis. ness, in In the IS It IS cases It IS so simple an operation that it docs pos- lever hesitate to e regions affected. ome, described a the indications you get from it are of th Professor liacelli, of R ago a new sign bv wh and i)uruleni e( woman, no Harm, whil e greatest valiii fe\ year' k y which to distinguish between simple "usions. I tried it in the case of the )ut It was not very satisfactory. It is as fo' ws : The affected side of the chest is auscultated, and ♦Die Parasiten des Menschen Kuchen:neistcr und znm 2te Auflage 1881. Ci AJ f-' 'i i 7 peis It he Muid IS serous, the voire soimds arc con- veyed to the ear ; if ,t is a purulent tluid, the wl,is^,e c I sounds are not so conveyed. In some instancesthis method proves useful, and in some it does not. In one case, particularly, it proved to be correct Another point worth notin- is that, in cases of simple > Itision, the patients usually lie on the affected side "licreas. in .ases of purulent effusions-why it is I do not know, but it has been specially noted by Dr. Chur ton, of Leeds, and I have obscrVed it inysel -they usually lie on the opposite side ^ \Vhat becomes of the effusion if it is not removed ? I may be absorbed. Adhesions form between t e pleura in certain parts, and you may have multilocu Ir empyema, which may be cured naturally, thou' -111 be a stru.^ule and tax the vitality ofVhe Tien t may perforate into the lun.- to be discharoed th ou"; the bronchial tul)es, which I think is a very favorable nay I he cases we have had in this hospita of per' ^i na> v^c]l. f^^r.Ross has had two such cases which Ur. VVilkins has a case at present, recovered perfectly. .^. I believe in the wards, in which the pus perfo'ratedVhe luuK and was discharged by couKhino. It may alsc^ perforate the diaphragm, but thatis rare. It may er- orate e.xternally (empyema necessitatis) anddischanc for months or leave a permanent pie iral h da A point to be borne in mind, in cases of left-sided 'env pyema when they begin to pass towards the su fi S ■^ that they sometimes pulsate, and the pulsation IS exceedingly likely to be confounded with la of an aneurism. In the chronic cases the patients have inegular fever, and the prolonged dischar> e is likeK ;o .nduce either amyloid'diseas'e of the o I'^L, o e^^ ie,;^t:;s:'u;;;;fti:^i!.fr^^:s;'sr^in-,f^^- specimen, which was taken from a case of em^ en w.nch the patient died of acute pneum.nia^if £ o^.posite lung. Y ou see here that the lung is tlattenec^ •f hi ;} \^uvu<>«unt«i» »iiv*rfi« dilated. *. UVjK, >IUiJIIV.1-I. , »v.i«ivo wii v-irccKTrunu nose Pupils shghtly contracted, reactto light ; ophthalmo Reprinted from the Archives of MEDICINE, Vol. vii, No. 2. April, i882. '. r> yet tlie h^ estiniatedi! and tle.sli, sliglit and' the iniiscii,: 103°, so t teinpei-atit; the thii'd, wliicih led was no sue at tlie peri is the only the tempei very great more sevei of ripe aeg the egg'3 ii ness of th< How its " nieasl first place, is not so o- are sure t have passe once catch losoe, but r Secondly, the infecte only one o Calves anc bile of a 1 much grea than pork, cooked. ] parts of wJ the larv8e= 8 Among the advantages of the antiseptic method in empyema appear to be : (i.) Ample provision is made for free and continu- ous drainage. (2.) The avoidance of putrefaction; in none of the cases were the discharges in the sUghtest degree offen- sive. (3.) The ease with which the operation is performed and die small amount of trouble entailed in the subse- (|uent dressings. (4.) The healing is more rapid, and serious conse- cpiences, as amyloid disease and phthisis, are less likely to follow. Note— July [I, The patient operated upon on tlic 4th. Has done remarkably well. Temperature normal, except on one evening; dressings changed now every third day ; discharge very slight. *Dle Parasiten des Menschen Kuchenmelstcr und zun, 2te Auflage 1881. [Kepi A CLIl ■,, . i Dilhh W I'KOFKSS (iIJN'TL subject 01 method, ated upoi clinical n Mary : 6th. Is 11 family hi weeks age cough or Callum, V June 1st, tf.rbid, gri by this t had risen mended t was notec flushed, t( chest, the fight. Th the tactile of the steri Ropo; dilated. Pi Reprinted frc Li ccii^ y /tittt,^ r/ CC J ' i^ii ^ /^ C^t. 1 1 ^/ t**-* Aiti -^ <3-> /' r// /^ h-^n^-r- a^f^ i.i. tvi^/. .iteuz. " A/// f^'^^'l"'"'^'-' '■'■"">''"'"■; Mi-.imA,. Nkws, July 29, iS,S2.] f^ ' ' ■ itu ^ ¥t-*^<-*-^ (C-^i^ A CLINICAL LECTURE ON EMP\ EMA AND -^' ' ITS ANTISEPTIC TREATMENT.' Dcnv.',-e.l a/ tkr Afon/n-a/ G,;n;-al Hospital, Jmu- j.,//,, 4 m I ■ I ■?■ ill BY WIIJ.IAM OSLKK, .M.]).,.M.R.c.]'. I om, PKCPKSSOK UP TilE INSlTrUTHS OH ME.,IC1N,5, MC.^ILL CNIVKKSM V. Gkntlkmkx : I wish to speak to you to-day on the subiect of einpyema and its treatment bv the antiseptic n ethod. \ ou saw yesterday a case which was oper- •itccl upon in this way, and I will (irst read to you the clinical report. ' Mary S., aged twenty-seven, was admitted [unc 6th. Is unmarne. , a servant. Nothin- special in the family history. She has been a healthy ^irl. Four weeks ago she had chills and pain in tlie left side- no cough or expectoration. She was attended by Dr. Mc- tallum, who diagnosed pleurisy, and on Thursday June 1st. drew oft with the aspirator three pints of i.ibd, greenish yellow fluid; the patient was relieved by this tapping, but on the 6th the temperature mended to come to the hospital. On admission she uas noted to be pale, fairly well nourished, cheeks flushed temperature 103°. On examinatior of the chest, the left side did not expand as mucn as the u MrHh f >»tfcostal spaces were not so distinct, the tact le fremitus u as absent. Apex beat to the righ of tlie sternum. On percussion there was dulness over 1 Repoitfd l,y Mr. S. A. Abbott, of "tl^HansaVd Stuff ' dilated. » V 11 trr^w \j I Pupils slightly contractej^j;eac^^oji^. ophthalm Reprinted from the Archives of Medicine, Vof^liy^^r^pTiTiiir I • r' l< ' r ) lit > :ll 1 'J-: III t] 1 tc tl VI w. at is th. vei mc of the neg its firsi is n are hav< once loam. Seco the i only Calv bile inucl than cookt pm-ts the la the whole "-^..except in the - --clav.u a r H.on. '^\ .3 deS'orjSn; a,;^ tile Jl^in w.^ llype.f heti. (hwSulUU on tie breathing was exceechnKl>- weak -"'•ar'";\c^nS:^r^^rs^r"SS^^; '::.l;'sn rued and tv-one ounces of pus removed ; sl^e ,r cle> able relief fron. this. The respnat.ons uxrcd. ed fron. about forty to twenty- our in the ^Z and the --pe.ature re.n.ned at^ou^^ the mornniK, reaching loo in the ""^^^'^^ ^^^ ^ ,^^ E^^thelsStSs-:^J::n^^^^^ K.r Ui n was performed by Dr. Fenw.ck in the follow- n^ wav. He made an incision in the eighth inter- costal space on the left siae, on the outer margin of the fnV,?sr nul ir re<^ion, just at the lunction of this with SSSa' xi ..n--egi■""• ■'■'-i''henn,;'h i-ascin unich I have had the i)at ents treated un tho weir l'^Tu^''''\ ""' ^^ ">' >■ ''^^^ ^''--'"-ua •X S-ul:^!)''' ''?' r''"^ V'^"' "■^^''^'' i" H'i'^ ^^ay was r ^ rss; u h '"^^ '^'''' ''^''^';^ '"' ^^'l'" "-^^^ admitted June rp, r.SSo with empyema of kft side; all the nhvsir ,1 s^the' ;;s['h';d 1 "^ ''"' '"^^ !" '^-'- - "-^E In V, ' ,''''''" aspiratetl once by Ur. Ross ■ a cj^",ernr2"'"' ' '"'^'^ "'^'^^ ' respiration;!;'"!; n tin ' ^ ' ' ^^^■'-'''^""K'- "le tube was inserted v^f ^. aili'd^b^JuSVJnd wru?;Sv^';?if 1^ tii c oi tnc cliessin>,r. !• or some weeks he renninorl a? o'y ^'xfr^'T'"'"" ^'""" ">' -casion!ui -T ' , as 103 . Alter about a month he beiran to imnrove h^ discharge, ot less, and the side of ^he 1^3 e^an ' o ;iV •■ u !'''' ■'' t''V''^^'"^»t of '^''"»'t t^vo months he wis matenally better, dischar.^e very slight, and o tl e^ 1 of September he was d schar•'"">' practitioners it is not dc- s ,ec , I ^ ' ^'>"^''''' ""'^'^^ y-H. devote yourselves speciall) to surt(ery. This method must, from these bl'irlr:'"! '" "'"fi"-';^'-"y '<' hospital praJi" bu uheieyon have a case of einpveina vou can always o low out these general rules :' OV/ ;-/^ .y //,, ;,^,^;', have excellent success in the inajoritv of cases of enipyema. A thorou,d, withdrawal of th'e pus is I be- lieve, essential, as wdl as thorough drainage It d cs not appear to make much difference whether you wall ou the chest or not with carbolic acid or iodine or v.ded you have an effectual outlet. If the orifice is large, and in a situation where the drainage will be con Hu 'if von ^'° ""' '''""^ "^^^'''""- ''-■ -^ "-e- y. 15iit If you have a narrow orifice, you may have to make a counter-opening, and put in a draina'a-.tube ioih^S '^'^ ''"■•-■f^'^'> . Thil is the method "^n^y lofloncd. A drainage-tube is put in and the chest is iodi T Thu.:'' '"'"'-" ""■^"'''^ -'^'- "'• -ith ddute vu ind f 'r" '' r""^ '"■'">' ^=^^" ^'-ealed that ^^a , and I imist say that, excepting in the cases of rare. It ,s notorious that the results in manv instances of empyema are most unfavorable; several -ent records of such cases have surprised me bv tl ei li,! rate of mortality. One of the best series of cases fSon cltv H '•'^ir';'"' ,•'>' i^'-- !• ^■- I^lake, of'tl.i t^Z^^^^.^ H-spital,' who, by „>eans of thorough t ?;^rr T"-' "l'^'"'"{.^ I" the dependent portion of the affecied side, was able to cure thirteen cases ou o nineteen and two others were verv gix' t v im Moved Ihese results were obtained with'out speci 1 antiseptic precautions, and I refer to them with pie isi' e Hospital Reports, ad Series, 1877. .\ n" 5"Tiro~^^B It- t f ', 4-^ ^ 1 s * 1 1 '^ 1 "' ' 1 1 ' f 1 quesl,„„s .ntelhgently. Face flushed, venules on che"ek, and mI ^j!5!f^_Pup»l^sMely^o«^ .ea, :„ light fopS^hT:! Repr-nted from the Archives of Medh "v^I. vii, NoTTTATi^Tiiir'' H 13 n are hav( one* lOBOt Sec( the Onl;; Cal bile iniK thai coo] parts of iM the larvae* the case ..ualh- .o'Ln'bad' u/ ^^' ul! ess'^'lS;: free open.n- ,s niacle. |„ tl.cse four V ,s s th, ' In? ^ ?:t.;;£;:ri: ™-i,,™it :■''■?"--- enough nifthod, |,„t „nc wliirl, k ,^ r. '^ *""''''-" sorted I,.. Tliereirei m , ""t often enoiiuh re- thecotunry ;o„ex7hi/i:"'f'\''^''^"^'''''?'''V'''"''^^''"^ needle except (V r n ,n o. . nf "'J'"^' .''"•' 'lypoderniic of almost as ,n cl Zo '. .- '"'^''l'^^^'''""' "''^'•■^■as it is of .pleural efT:;;;;;,! ; ' r.; Sfi;; cur""" 'r ^^^^^^^^ terior part of the rl„.J. """'^""' i uiness, in the pos- thrust hehvpolcrni^n;.r''r''1 ''''''' '''^^i'^"' to It is so si„,p,[: an o "a u ' hu U in' '""'T" ^"'^^'^''• the indicatii.ns y<.,/.'et f / ', ' h "" ''^'™' ^^''i''^' Professor 15 , cell " ,f .'" ""^ ''' •^''■^■'t^'st value. " "jj g yjL ' j j M i pM *Die Parasiten des Menschen Ktichenmeistcr unci zuni 2te Auflage 1881. in. hen seen at questions inte dilated. Pu] Reprinted fron L.i r 7 veycl to ti.e car if it i/ '; !' '""/' '"""'''' ^"•<-' '^-n- ""t know, |,„t it has I , '■'^',"«i"n -ul.y it i, j ,|, --!llyliconti,e,;,:o':;esic;;'"""' '^ '"y-X^thcy pleura in certain pa's" Z, ' ■ u.T 'V'"' '^'-■'"■'^'^" '''-' '/ >»^'y Perlora^^ nU i J k n t . h ^'"^"^ ""-" ''^'"^"'. tl>e bronchial ,„l,es, Sh7 i^v"]'''^'"'^'^ ''""^'.^'^ way. The cases we have lA, H V'^- '■'^"'•''^io foration into tlie h.n./ n,^l ''" ''"^P'tai of per- i"K^Iy well. I)r & InV Ir i'T''' ''■'^1' ''""^ ^■•^''•e.!- recovxTcciperfectly/ I r wf n V' '"''' '^"^'-'^ "'"eh 'relieve, In the u^ rds, n^ c Uu': ' ''''' ^' ^''''''''• li>n« and was disch-n ^e I I , '" Perforated the perforate the diaph ^^l.^ ,;;';;'^^''"^- '[ '"^'y also forate externally enim c',, ,, '' '•' '■}'"■ '^ '"^y per- for months or leave "*-* '-■^^"■"''*) " ; in none of the '■'"Kesui the sli^rhtest degree offen '3.) Theca iind the si se with uhieli the oprrati <|ueiit dress nail amount of iroiil)| m IS poifo niL;s. e cntaded in the sul lined )se- U-) The heaii qiiences, as annloid likely to follow. ' Noti\~Ji,/y //_ -I'll I'K' is more ra Pi 11, and uiseasc and phth serious conse- sis, arc 1 ess 4th. Hasd verj except on one cveni Ih " ne lem.ukably well. 'I IJaticnt operated ui) ■ril day; discharge very sligh dressings ch.ihged )n on the emperature normal, ght. now evcri the lies its lire is I are ^v-<^ ^^^hll^(.^L-J ^ ^// ///./'^~ ^^l^- VY/^- ToM.'^-^/c^CLu 7^ rC ft. *- C I. li y ^ /^ iTti. t-C /^^A u/.. > t7 ^4^a/" '"f- ■■' c^^zz: ■ 1 t.t/'»-» 'J.^nT^ '/ 1^^« — ' »''C.^^^ (i^CC^. ftu: '^'I^^ClUBlB. • *Die Parasiten des Menschen Kuchenmeister «„d zum 2te Auflage 1881. The chie the syniptc ceded the a anparently 1 changes on! J. VV., ag, was admitte For past fi taken a gocx good health got up at nij usual. For had occurrec ing of the 4t though still £ i-omplaining feeling. In 1 excited all ni cessantly tall 6th the deliri hospital. O He passed a bed. In the When seen at questions inte dilated. V\\\ Reprinted fron L.t M\ mi! UREMIC DELIRIUM AND COMA AT A VERY EARLY STAGE OF INTERSTITIAL NEPHRITIS. Bv WILLIAM OSLER. M.D., M.R.CP. LoNn PK.P.SSO« OK T„. ..s.„„BS OK MHO.C... Mc C... CO..HO.. MONTR.... The chief points of interest in this case are • r.Wh the sy.pto.s with dehriun, ; (.) the nlTa, "wi^^ w il" f ceded the attack-a prominent factor in some instances mX apparently normal state of the kidneys, which gav" evident o changes only on microscopical examination. J. VV., aged 44, a large, i)o\verfiiliy-biiilt man niKv-,,, t got up at night to make water, and he passed r.fh ' usual. For about a week he hLd been g "^^J.^^" T^ ^T had occurred among the men in his department n: t ' mg of the 4th h. had a chill, and felt unwelUU dav nV'u though still ailing, he went to work, but et rn d Tnth . ' ''^' complaining of soreness over the wLle bodv he^^T !,"""°" feeling. In the evening he becamTlSs . ''"^ ''^'"^ excited all night ; could'not be kept in bed but walH T' '"' cessantly talking and directing hfs ::en1; ^ttt ^'Sn the" h pi a^^'orad"'"^'' T' '' ''' '-'^-^ '- -" broug t o K ^ T \ ^ restless night, and was with difficultv kpnf ;» bed. In the morning (7th) he was quieter; temperature 1° When seen at the mid-day visit was quieter. Lut d^d not ansi; questions uUeii.gently. Face flushed, venules on cheeks and Repnnted from the AKC^I^^T^ir^i^i^ii;^;^^^^^;;-^^ ■,ll:' 1 ■!•■ ,' ? -V i' ' ' ' i < i-?' 'J' .' I i I .1 II I ^1 if ■ J) > 2 ARCHIVES OF MEDICINE. scopic exiiniination of eyes negative. No special symptoms in chest or abdomen. No dropsy, nor oedema of ankles. Heart's impulse not forcible ; apex in normal position, but difficult to feel ; pulse full \n volume, tension plus; radials not stiff. Urine was passed in bed ; that drawn off with catheter, high colored, sp. gr. 1039, highly albuminous, with numerous finely granular casts, many of unusual length. Toward the afternoon he slept. In the evening was very torpid ; did not know his wife. Tempera- ture normal. On the 8th, after a quiet night, he was very drowsy, roused with difficulty; pulse 120, temperature 99^^°. Pupils of medium size, react slowly. Passed 24 oz. of urine ; same char- acters as before noted. Toward the evening he became deeply comatose ; the respirations increased. He was bled to 20 oz., with the effect of reducing the rapidity of pulse and respirations. Pupils dilated ; temperature rose to 103^°. Thecoma increased, and death took place at 3 a. m. on the 9th. The treatment con- sisted in bromides and chloral in the early stage ; purgatives, pilocarpin, and vapor baths. Autopsy. — Brain: Arachnoid turbid at base and over the sulci ; much serosity about the membranes, which stripped off very easily. Several slight ecchymoses in gray matter of right hemisphere ; one at top of ascending frontal gyrus was the size of a small i)ea. Ventricles contain a moderate quantity of fluid ; walls not softened. On section, substance of the organ not sjjccially moist. The arteries at the base not atheromatous. Heart weighed 382 grammes ; valves healthy, muscle substance of good color; walls of left ventricle measured from 15-18 mm.; cham- ber, 8.5 cm. from apex to aortic ring. Aorta presented a few scattered patches of atheroma. Nothing of special note in lungs, spleen, stomach, ox intestines. Kidneys: right, 190 grammes ; left, 175. Capsules detach readily and leave smooth surfaces; no- where granular. Organs cut with moderate firmness ; cortices not diminished ; medullary rays very distinct ; intervening vascular regions with the tufts injected. Arteries at bases of pyramids not unusually prominent. Pyramids look normal. Renal arteries not atheromatous. Altogether, the niacroseopic appearance of the or- gans did not appear to substantiate the diagnosis of urjemia which had been made. Beyond a slight increase in firmness the glands certainly did not present appearances which would have attracted further attention had not the symptoms demanded it. On microscopical examination the only striking change was in the Malpighian tufts, a number of which were found atrophied and surroandei where the a small ho the tuft a]: proliferati( was a very about ever atrophied rating the trophy of no hyaline where hea there were tubules. ] in the inti midal porti ORIGINAL OBSERVATIONS. surroanded by an increased growth of fibrous tissue. In some, where the process was far advanced, the tuft was converted into a small homogeneous mass, without nuclei ; in others, portions of the tuft appeared normal. There did not appear to be any special proliferation of epitlielial elements within the capsule, but there was a very general thickening of the delicate zone of fibrous tissue about even healthy-looking ones. In the neighborhood of several atrophied tufts there was a small-celled or nuclear growth sepa- rating the tubules. The small arteries presented decided hyper- trophy of the muscle elements, particularly in the circular coat ; no hyaline degeneration of the intima. The epithelium was every- where healthy-looking, distinctly granular, but not swollen ; and there were no collections of epithelial ^//^J/vV observed in any of the tubules. Except in the vicinity of the atrophied tufts no increase in the intertubular connective tissue was noticed. In the pyra- midal portion some of the tubules presented finely granular casts. m • . f Parasite Bi (From Can i jufj — 'V ON CP]RTA1N Parasites in the ttloocl of the Fro Bv WILLIAM OSLEIi, M. D. g (From Cana,i;,n, Natnrullsf. ^''•I- X, No. 7.; jii ■ *li s ; ( ?i f (I'n IN TH Fellow of the 1! seopical Soo iMcUill Univi Tq my Pra whilf the St {Rana Mitg'u body like ii which liad uot water on the slides of sevei to it, ami I n description :— triangular in narrow oiul is a broad band aD<;;le is prol dulatitiii' l'rin< the appearanc other, the wc and tenuity u Rea (From CitihuHaii Naturatist. IW. .V, .\'.'. 7 J ON CERTAIN PARASITES IN THE BLOOD OF THE FROG.* By William Oslei!, M.I)., M.li.C.l',. L(im.. Fellow of the l!(>.viil Microscupiciil Society of London. I'lc^^iilent of tlie Mijn- soopiciil Soeiet.v of Montreiil, I'idfessor of tlio In^titntes of MoilieinL', McOill University. Tn my Practical Histology cla.^s, duiiiio- tho winter of 1881-82, while tiie studeut.s were working at tiie blood of the froo; (Raiia Mugicm), I noticed in one of the .slides a remarkable body like a flagellate infu.-orian. I thought that it was one which had got into the blood at the time of withdrawal, from the water on the web of the foot. Meeting with examples in the slides of .several other student.^, my attention was again directed to it, and I made .several .sketches and wrote down the foUowini; description :— " Finely granular protoplasmic body, somewhat triangular in shape, about the size of a colorless corpuscle. The narrow end is prolonged into a eilium, while the other presents a broad band of rapidly undulating protopl'ism, which at one angle is prolonged into a long la.sh-like process. The un- dulating fringe and the cilia are in constant motion, iiivin" the ap|iearance o'" rapid waves pa.^sing from one corner to the other, the waves of protoplasm gradually increasing in length and tenuity until they have the appearance of projecting cilia. * Read before the Montreal Miemsioiijial Soeictv. •;■ f '■' i ! V . A f No nucleus ciui bo M Tlmuuli iu (-oiistant iictiou no change of locality t.ikos place." Fi- I. projection ai continued to (»iMo.)l|y allied to Opalinidiv?, from which however, it difters essentially, as well as f,„ni In/nsono cillnta generally in possessing no eilia." (^,ruby described it as a para- sitic cntozoon, while Siei,old - states that it is not an indepen- dent or-auism, but simply an undulatin- membrane .swimiug freely. Dr. Gaule f lias advanced some rather Htartlins; views concerning this little body which lie believes originates in, ""or is a transformation of a colorless blood cospuscle. He states that on the warm stage the proces,s of conversion of tlic wliite blood cor- pu.selo into the I'ri/pxiwmmu may be readily followed and takes place by the development at one margin of a vibratile cilium and a rapidly undulating membrane. He recognized four or five types of these transformed blood corpuscles and calls them " Kymatocytes." They may return to their original corpuscular condition. I have tried to Ibllow these observations of Gaule but without success and adhere to tli pinion that we liave to deal iiere with a minute parasite, the alHnities and life history of which have yet to be worked out. They were not abundant in the blood of my frogs and were only met with in two. I have not found them this season in any of the frogs in my tanks. This session my attention was called by a njember of my His- tology class to what he thought was a peculiarly elongated white corpuscle in the frog's blood, but which I recognized as another » Micrographie Dictionary— Undulating Membranes. t Anh. f. Anat. u. Physiol. (I'liy. Aht.) 18S0. ^ • ii.; ' i ii' ■h»/ ir tM H I. * if parasitic Ibrm. Tin; bluod cxriiniiicil by llie .stuilcDt on that day was taken IVoin two bull IV.. us (/»'-/„,/ Mii;jirns). hnt only ono contained the jcira.sitcs. 'J'jic (iri^anisni presents tin; roliowinj? characters: — Body an elongated (iv.ij, saus:i,t;c-shaped, ends coni- cal, one sonictiuips narrow and prol()nj;ed. licni^th somewhat more tii;ui h:ilf'a red eorpiisele, Tlie protoplasm is iiomogeneous and more translucent tli,,n tint of colorless corpuscles and shows two or more -mall central vacuoles (?) with a lew ,u:ranuk\s. Movements slow and creeping, accompanied by ;ai occasional bend or twist of the body, uo on at ordinary temperature ; a little accelerat.d but not altered in character on the warm sta>;e. The tail-like end tliou-li prcidne ,1 ,|,u.s not lerminato in aeilium Fii. the kidney < on the addi a number o very clearly. tioii to the ] In blood fi te seen well pusclc with ( five times, ai and r. This and did not s sen ting no tra « ^^ seen tl.e kKlnoy of the ^,•o,,^ Witim, th, r.\U tl.ey e.in best be se... on tlie ad.htion of salt ...ihaion ;{ . I l„iv.. \\nvu]. after tryin" a number of solutions, tl,,,t I'iloeirpin • bri,,^. them ou't very cloMrly. In one fro- tlir i..eaivi.o„Mo,,u.oi,:-;;^^':;^:'''-,:-;;;;'^'^.- int.. two „,,1„|,, ;„ II .,, I " ' I "Iy2'» «i-» .livi,l,.J "■■""lli.l..^-i.. .1... li.n„c.,- ,1,.. .,„i, I ;,"""''■■" "'"' "'" '■<»- ;d...o«.ipee::';;ii'rr:,:x-';:™^';«™..ii... i>i.»ii^^::ar:;:i::L"!::,::r:„:S"*"^'r'^™"-- * Read I m , , '1 ■ 1 ^ ! 1 cilli'il till' I'ctncyst, the iiit'Tll 'il tin' t'ii(l(i('n>t, iinl tlii' liorsi' .xlioo sli;i|i('(l (|i>k >ii|)|iiirtiii_; till' ti'iilacli's till' li>fthiif)hiir attciitioii is tin' I'l rtiimlfl/ii m'Hjiiifv'i iil' Lcidy, dcscribcii by liiin in the |ir(i('i'rdiii._'s of the Acidciiiy hy bays, where it is found encru.stinj,' ious, uprij;ht sticks, and the stems of ru>hes. My attention was early directed to this form as it exist.s iti extraor- dinary profusion in the Desjunlin can.il, whicli leads from Bur- lington Bay to my native town Dundas. The wooden sides of the canal ba^in in the months of July and August are almost uni- formly covered with this m.iunificent species. The growth bejj;ins about IJ to 2 feet below the surface and extends in depth i'or the sanij distance or even further, rarely, however, deeper than six feet. The mas.ses form extensive .sheets usually a few inches in thickness, or el.sc beautiful symmetrical projections, ()-12 inches in thickness, which spring- either from a bed of l>lie Polyps or are i.solated. In the summer of 1S(J7, durinii' a visit of my friend, tho Rev. W. A. Johnson, of Weston, I showed him tin,' masses, and we airreed to subject them to examination with the microscope, not haviiii,' any idea as to their real nature. Jud^'c of our deliiiht when we found the whole .-urface of the jelly was compo.''ed of ,i collection of tiny animals of surpa.ssiiig beauty, each of which thrust out to our view in the zoophyte trough a cresceat-shaped crown of tentacles. Recognizing it as a I'olyp we were greatly exercised as to its po.^itiuii, piesentiug as it did in tlu! met MpecicN do in the Am Alplieus Hj course of pii On exaniini are >een to areolju, whi a.ssume hex. lar areas tin occupied. \ tentacles giv entirely disa This species polyps over c tation. Thee tentacles are tho thro.it.gl the areoiaj, w at various st; the den.se a^' gelatinous nii of the polyps ing to the an a radi.ite m; often a reddi." the {iresenee ( present a jelli the developmc excretion or h( depends. \V| colloidal proje rushes the mo fore you gives I have meaMii which was 1- weight [) lbs. ofthc.se creatu the marsh on ( through the 1 would not go i 1 > in tlu) .....tluMl of ^nnvlli, m.c!. variation IVo.u ihc .,nli„ary Hproi... ,lt..scribe.l m .,ur zunl„.i.,..l ,,.xt b.-uks. H.mnily m 11... AnM.ri.,.M Nutunii.t lur ,|..t y ,r vvc .net witl. M." AlplKMis llyati's p,,H.rs „„ tl,. l'n.si,.vv,,t.,.r l'nl;yzoa. then in o.nn>.. .,1 ,,ubiu;:.ti..„, an.l obt anud lull inr.mnatio., thnvtVu,,. On..xannnin-thcsurf:.L-o..ra mans ol' iVctinatulla ib,, p„lyp,' are >ee,. to bo arran;;..,!, an .ee„ in tl.r spirit |.rfpa.atimi. in cl,..se arooiic, wbich, bein- crowded and enuipre.sed lonetbcr, oft.Mi assume bex,..onal outlines. K.on, tiie peripbery of these inx-u- lar areas the polyps project, the central part bein- as a rule un- oceupu.,1. When in the water the pn.trusiun of .!„. innumerable tentacles ^ives a fine velvety appe,.r,u.cc to the surlaee, which entirely disappears on tonebin- the polyps or ai-it.tinj. the water This species is, bowver, much less timid than >ome others, and tbo polyps ov.T even a small ma.s> do not all withdraw on a >li .ht irri- tation. The color nnhepolypidom is .li,,btb,.,wn, or when'thctcn- tent.cles arc extended, ,, faint rosy ,vd hue, due to the color about the throat., i;limmerin,utbr..uuh them. Towards the central part of the areola.., white, bn.wn and dark >pots are .seen, reprcscntinjr ovul at various sta,;;es of development. The ce ajecium composed of the den.sc a-re;:ation .d' polyps j.s closely united to the subj.ccnt gelatinous mass, which con>litutes here theectocyst. On removal of the p„lyps the surface ol' the jelly presents patterns eorre.spond- in-to the arr.n^^:nicnt of the .u.imal.s, irregular areas jrrooved in a radi.ite manne,. Tin- superliciul portion of the ectocyst has often a reddi.si, tint, and the deeper p,,rts .slightly greenish from the presence of a confervoid -rowth. .M ,„y m isses ,d' lai-e size present a jelly perfectly eolorlos ;.nd pire throughout, '"upon the development ol thi.s jelly, ^hieb is to b.^ regarded as a d..|inite excretion or secretion from the animal, the size of the polyp „,:,.ses depends. Wjien encru>tin- boards they are usually fl.t, lar'cr conoidal projection, uccurrin.i; at intervals. Around the steins^of ru.shcs the mu^l beautiful masses are found. The .small one be- fore you ^ivcs a ,uood idea of the -rac^.iul symmetry of the growth. I have measurements of such a .symmetrical cluster about' a reed which wa.s 14 inches in lenjith and 10 in circumference, the wci-ht 9 lbs. In .some .seasons the luxuriousness of the ..rowth ofthe.se creatures is extraordinary. I,, the still ,juiet w.'.ter in the marsh on either side of Desjardin canal, just before it pas.ses through the Burlington lieigbts, I have met with masses which would not ;;o itilu a Daii. The lar-cst I pan. lave ever seen iiy at m .5 m 1 n it' " j , '1 i ^ '1 'H' M " ^' ( '/ ,, — I I '-am \, tlic bnttdiii in about nine j'l'ct of water. I coiilil liardly believe it was a mass nf jjolyps, but, to satisfy my curiosity, I stripped and went in lor it. With tlie greatest ilifiiculty I brought it lip in my arms, but coukl not yet it out of tiie water for tlic weight, wliieii must have been close upon 25 lbs. It resembled ill form one of those beautiful mas.-es known as brain coral. On account of the colorless natuio of the cctocyst and the ex- tent to which the polyps jirotriide. this sjieeies i,s the most favor- .ible to study the j;eneral arraiij;emenrs of the oruaiis, the perfect transparency allowing- every detiil in the .structure to be seen. I have found it best to cut a thin vertical slice lr(nn the m.iss, containiiiii' on the surface nut more than one or two rows of jiolyps, and eximine in the zoopliyte tiouLvh with a liall-inch U'lass. It is niueh e.isier in this w ly to obtain a view of the com- plete animal tli.in in the livt' box. Tlu; shock of the .section and removal to tin' trouuh causes complete retraction of the polyp.s. and the surface of the cirnoccium look.s smooth, or presents only slight tuberous elevations. corres|ioiidin,ii' to the situation of tlie orifices. On watchim:' one oi' these, the sphincter closino-it may be seen to relax, and the end.s of tiie tentacles protrude through the orifice, feelinu' about from side to side as if to ascer- tiin whether the '-coast was clear." Findill^■ no cause for alarm, the relaxation of the sphineter proceeds, the tentacles are pushed out still further, resultinii' ^it 1 ist in the complete evauination of the polyp. The beautiful cre.-centic tul't i.s arranued in the Ibrm of a horse .shoe, or the letter U inverted, the tentacles sprinii' from each side of the summit of the double outline, tlie mouth being' at base. The number of the tentacles ranges from 50-SO • they arc siguioid in outline and incrca.se sliulitly in leii<;th at the extremities of the arms. The inner rows incline towards each other, the outei curve -racelully in the opposite direction. The surface of the tentacles is covered with cilia, whicii are in constant motion, creatin- a vortex, at tlie apex of which the mouth is situated. The tentacles act ";; , oendently as well as in concert, and thrust and bend in an d,i jtion, pushinir away objectionable matters whicii may have ijot into the throat, or are present in the nei-^hbourhood. Frequently one of the larne infu- soria comini; within-- the vortex is carried down and attemptinti to escape is prevented by the interlacement of the tentacles whicii bendinjr over form a ea-e. The sensitiveness of these ciliated arms is cxtremo and tlirou-h them the creature obtains warninn' of upproacliing danger,, and instantly withdraws itself. From her liangs, whic epistome, a oc.sopha^nis ( The epist the inner an tection for t can be readi appears to k entrance of i with cilia. a dark i-o-e-r animals. \ the (osophau'i dosi'end-:. stomach, into expelled by t The stoma food is subjec cess of di^.es cells upon the Prof. Allman coccuni is a sin ;ind placed pa imm< liately I ol' the food i.s tends the intcf walls and earn From the lov funiculus, ext noeciuni. There is n( colorless fluid 1 gastric cavity, of the eoena'cii by the small p; llespinition tentacles, but sliuiit. The nervous by a definite < fl Kron. beneath the eroscontic lophophore the aliincntary cnn.l l..m,^s. winch presents the tollowin. p,.rts for observation : the epistmne, a valve-hke projection overhauui,.. the mouth the oesopha^nis or throat. (!,,■ sioniaeh. intestine and anu. 1 he ep.stome is a ton.n.-iike „r.an arising at the junction of ho inner arn.s of the lo,,h.,phu,.e, .-o,,! s.rv.s as a valvular pro- tccfon for the n.outh. It poss,.>ses a . t „r n.uscles by whie , it can be road.ly n.ove.l ,.n,l ,i,.rks u,, ,.„„| ,1,,.,, .,,,, , ;„., j^ appears to keep ma,..n.l.,n the rhn.t r.th.r than prevent the -; ranee ot anytlunj, obnuxiou. J.ke the tentacles it is covered w. h c,ha. All t e parts about the region of the espi.tome have a dark m^e-red color, and this oi.os a peculiar b,illi,,ncy to the ■mnnals. A sonu.what funnel-shaped mouth h.ads direetlv into tin' .osopha..us. a short colorless tube, which widens sle-hti; as it •leseeu.k A valve-like construction sep .rates it from the st.nnach,nto winch, as soon as the ,.sopha,us is fnll, the food is expelled by the contraction of the muscular walls Th; ston.ach forms an elonuated tubular cavity in which the ^-od IS snb,ect to a constant peristaltic action durin.. the pro- eossof dto^stlen. The linin. membrane is plicated and the « ^ upon the lolds are of a brown color, containing a fluid which P.of. Allman regards as a biliary secretion. The intestine or ccun, ,sa short broad cavity separated iVom stonaach by a valve ;'-i P -ed parallel to the oesophagus, openin. by an a.nl oriiice ";';;"';;'f< y '-.eath the lopl.ophore. The undiuested residue "f the ood ,s gradually pushed through the coecal valve and dis- nuls the tntesttne and is expelled by the contraction of the ceecal ^.ais and carried away by the action of the cilia of the tentacles Incoecium and the pcri- ^nc cavity. By the action of the cilia which line the interior of the ca.na>c,um currents .are created which are rendered evident by the small pariicles carried round. Rcspirat^^on is probably carried on by the cilia coverin..' the tentacles, but our knowled-,. of tl,;. c .• '" ,ji„,|,j ^' '-'' "' *'"^" function IS extremely The nervous 8y,stem of the fresh-water Polyzoa is rcnres,, a defiint.e irnno'li.^.i ,.,k;,.i, l:. • .. ... ' ' by a definite ily scon in Pectiiiatulla and prc-ents curious contractions and expansions. By tlietro tlic [.'osition of the iua.>'i rve blanches may be seen jnoctHdin^- from this paniriion cliiefiy towards tiie epistomt' and tentacKis. Tlie muscular systiin is well developt'd and the muscles form either sphincteis or elonuated bi anches. \ definite sphincter surrounds the orifices of the coena'cium and closes them lightly when the polyps are retracted, relaxiiiii; again for their pro- trusion. The longitudinal bands arise from the base of the ccenoccium, and parsing up are distributed in three different localities, on the stomach, the base of the lophophore. and the tentacles, and are called respectively the gastric, lophophoric and brachial retractions. By the action of these muscles the little animal can be instantaneously withdrawn, and the sphincter closing effectually shields them from injury and attack. Other muscles are described by Hyatt and Allman, in connection with the epistome and endocyst. The Phylactoloemata are reproduced by budding and true ovu- hition. From the side of the polyps buds arise which develope into mature Ibrms and in this way the colonies are increased. Another method of budding results in the production ot free "emmic or statoblasts, which arise from the funiculus. These present a horny sheath, usually dark brown in colour, and an annulus or margin, which in some species is provided with spines. In Pectinatella, the spines number from 12-20, in Cristatella there is a double row, one shorter, the other longer, 50-1)0 in all, and the extremities are furnished with from 4-t) booklets. The statoblasts float on the surface of the water and the armed ones get entangled in the weed.s. The method of production of true ova was first described by Allman. They originate in a bud-like mass at the upper side of the endocyst and are fertilized by spermatozoa, the testicles being an offshoot from the funiculus. In the genus Plumatella I have determined three Canadian species, (iirtlmsK, vitira, and (li(/'iisii. The members of tiiis genus have dendritic, plant-like cocna'cia, which are tirmly at- tached to the surface of submerged twigs, stones and water- plants. The coonoccium is composed of little hollow branched tubules, divided into cells, from the apex of which the little polyp protrudes, wl ])arcnt polyz the greater specimeti of extent. Tlu secreted is th last dark bn and is contini The specie Canada in th merged logs lily The Crista have a loconu C. Idfc and C conforms to t and number o forms. I ha gatherings, bi: lakes near the County of Mil water's edge, i numerous spec length and ont slow, in those \ inch in the 24 tinatella in pos six points. NOTK. 1 llJlV tinijnislied autli and Magazine ( supposed Pterol eomnmnieation University, in w a sunken boat ii (It'S('rij)tion •' tin: liguro and t'ornii species, are born tlie biise,' tlio ar At the date of P Ills Natnral Hist protrudes, while Mt the othor end it is in communicatioi. witl, the jK.ront polyzoon. Ti.e branches are .irencrally Mttaeiied alon.- the greater part of their length, though souietinie.s, as i„ thi"s spec.Uien oi' P. ar,f/,.s., they ar. Cv,. in nearly the whole extent. The color is owing to thr .e.nev.-t, wliieh when tirst secreted is thin a.,d j .ilv like hnr , h.vo,,,.. consistent and at last dark brown, T II' endoe\>t lies imiiM'i liately within this and is continuous thnui-hout t\u- sy.;,,,, of hranche.s. The species of this o,,n,s :,re uide,y ,ii.(,ibuted throughout Canada m the quiet ponds and n, nsi,.,, aitached to twi..s' sub- merged logs and the under surface of the leaves of the water- lily The Cristatellidiu, the most highly or-anized of the F^)lyzo:, have a locomotive ca^na^eiun.. There are two An.erie:,,, species C. Idac and 0. ophidioidea. The one which I have studied hero conforms to the latter, as described by Hyatt, in both statoblasts and number of tentacles. It i.s not nearly so common as the other forms, I have on ."several occasions met with the statoblasts in gatherings, but have never found the polyp except in the small lakes near the .summer residence of Mr, G, W. Stephens, in the County of M.Kskinonge. Quebec. In Li.c Rouge, the rocks at water's edge, at about the deptii of from one to two feet presented numerous sp<.cimens about an inch .and a h.alf to two "inches in length and one-third of an inch in breadth. The movement wa.s ?low, in those which I observed in a small basin, not more than an inch m the 24 hours. The statoblasts differ from those of Fec- tinatell.a in po.ssessing a double row of hooklets with from two to six points. NoTK,_J l.ave received iVoni the Rev. Thomas Hinrks, tlie dis- t.nj^nushe.l authority on British Poly/.oa. a, reprint tVnni the Annals and .Magaxine of Natural History for Man h, 1880, entitled .'On i supposed Ptcrobranehiate Poly/.oon from Canada." It is based on v ..ommnnication from his father, the late Professor Ilineks. of Toronto University, i„ ,vhirh a short aeeount is j^iven of a ,.olvxoon foun.l on a sunken boat in the Humher river, near Toronto. A.vonUug to the des.T,,,tion .'the tentacles, instead of being disposed in a horse-shoe ligure and terming a rontinuous series, as in the <.rdinarv fresh-water speeie.s, are born., on two distinct erect lobes, which are separate.l at the base, ' the arrang..ment met with in the Ptcrobranehiate Polyzooa At tl... date of Professor Ilineks' letter, Der, 1808, I wa.s u student in Ins Natural History .lasses, an- ticerous cellulosce, and the Echinococcns. We shall consider these in order. TRICHINA Sl'IRALIS. "Anextremely minute nematoid heluuiuh, the male in its fully developed and sexually matured condition measuiini; only one-eighteenth of an inch, while the perfectly developed female roaches a length of about one-eighth of an inch ; body rounded and filiform, usually slightly bent on itself, rather thicker behind than in front, especially in the males ; head narrow' finely pointed, unarmed, with a simple, central, minute oval aperture; pos- terior extremity of the male furnished with a bilobed caudal ajipendage, . . .female shorter than the male, bluntly rounded posteriorly, eggs mea- suring -r;,J,-,T of an inch from poli^ to pole ; mode of reproduction viviparous." — CoBIiOIil). Since Zenker, in 1860, discovered that this worm produces a severe malady in man, a degree of interest has been attached to it, not exceeded by any known human entozoon. The record of epidemics of it sends a thrill of horror through a community out of all proportion to the gravity of the disease ; and naturally enough, for the very thought of myriads of these little worms boring and eating the flesh is particularly repulsive, recalling the tragic fate of Herod, on whom the worms are stated to have held an ante-mortem feast. The hog is the natural bearer of the trichinae, which exist in the flesh, coiled up between the muscle fibres, and are so minute that they cannot be seen on ordinary inspection, but require the use of the microscope. In this state they are undeveloped or immature sexually, and may remain for years in the muscles of the animal without undergoing de- i-i I' ; M. 'Li i^Jji e ytenorative oliaimos. -il 1 Pork containing them and eaten raw, in any form, or partially cooke 1, produces disease in the following way : the little worms escape in digestion, pass into the sma'l intestines, grow rapidly, 'oocome sexually mature, and assume the form of intestinal trichiiue. The females are impreg- nated, and the ova devc!'>p into minute embryos, which are born alive and free. This prucess occupies two or three days, and is usually accompanied with some intestinal irritation. The number of embryos will vary with the number of worms ingested and which reach maturity. They immediately burrow through the walla of the intestine, reach the connective tissues of the abdomen, and penetrate the muscles in all direction, and when numerous reach even those most distant. In this migration they produce irritation, fever, and constitutional disturbance proportionate to their number, and the severity of the symptoms may be such that death may follow, though the percentagt' of fatal cases is small, only about 1.5. Record of Invextuiation. — One thousand hogs were examined, chiefly at the Dominion Abattoir, during the past six or eight months. There was no selection made, bnt the carcasses were taken indiscriminately, as they were found at the time of the visit. Method. — It has been satisfactorily shown by many observers that the pillars of the diaphragm are the most suitable muscles for exami"ition, not alone because portions can be removed with- out disfigurement or loss, but chiefly from the fact that here, if anywhere in the body, the parasites will be found, as these muscles lie in the direct route from the intestines. The examination was made with No. 2 Obj. (Verick) and No. 1 Ocular, magnifying about 60 diameters. Small clippings of the muscle were made lengthwise, then placed on the slide, and pressed out with the top cover until thin enough for the purpose. In only four out of the one thousand animals were the parasites present in the diaphragm, and we may take this as representing the actual ratio, though possibly they may, in one or two instances, have existed in other muscles and not in the portions examined. As to the number in the infested bits, in one case there were twelve on one slide ; in regularly placed on All the Compa figures sh Thus, in ] in the dirt( All of the one series and systei only 1 in 2,800. Trichin infection ;> nine perso which was gastro-inte moderate { berated by harpooned of a family infected ha the father ; room, it is cysts conta had been r( nected ther cases occur fever. In four bodies calcified, an other cases one of ther So that in a nized in this * Canada SI slide ; in the others, not so numerous. The worms wore not regularly encysted but coiled up between the fibres. When placed on the warm stage, they displayed movements. All the animals examined were from Western Canada. Comparison of local iviih foreign reeor., tapeworm— in the community, we issued a circular to the city physicians asking the number of cases under treatment. Replies were returned by thirty-four doctors who reported sixty-two cases. At the Smith Worm Company's office, Bleury Street, about two new cases a week are treated ; some of these, doubtless, come from the country, but we shall [)robably be within tlie mark if we estimate the number in the city as not far short of 200. How many of these are due to eating measley veal or beef, and how many to measley pork, we cannot say, but from the specimens exam- ined it would seem that the beef tapeworm (T. mgiaata) is the more prevalent. Not that the i)ork measle is unconunon ; the record above given shows just the contrary. To explain the greater frequency of T. m>/inuta, wo must 3up|)<)se either that the beef measle occurs in greater proportion, or else the pork is more thoroughly cooked than the beef or veal. Then, too, much less pork is eaten fresh, and the salting and pickling processes are usually suificie?;'^^ to destroy the measles. A point of in- ^Ill ^1- ■/ 12 f f f I* terest is the temperature necessary to kill them. The obser- vations of Professor Perronicito prove that they are invariably killed by a heat of 50°C. or 122'^F. Indeed they were swal- lowed with impunity by iiis students after exposure to a tempera- ture of 11 8°F. Fortunately, the presence of a tapeworm does not give rise to such a formidable affection as the trichina, but the amount of suffering and annoyance caused is considerable, and not infre- quently an individual has to entertain the troublesome host for months or years, so difficult is it in some cases to dislodge the worm. A thoroughly eificient inspection would diminish greatly the number of persons annually infected. Of course a hog might contain only a few " measles " deep-seated in the muscles, and these could readily be overlooked — indeed would be even on the most careful examination. ECHINOCOCCUS. The presence of this parasite in the flesh of pork has not the direct and close relationship to our individual welfare as the trichina or cysticercus, inasmuch as it represents a larval form of a tapeworm which infesis the dog and wolf — never man. The adult worm is very small, not more than a quarter of an inch in length, with only four segments, the anterior of which forms the head, while the hinder one is mature and contains the ova, which are passed in the fajces of tho dog, and if swallowed by an animal may develop in its organs or tissues into the structures variously known as echinococci, hydatids, or acephalocysts. A single egg of an ordinary tapeworm, when placed in suitable circumstances, develops into a single larva or measle (^cysticercuH'), but a re- markable peculiarity in the life history of the T. echinococcus is that a single egg develops into a large compound and complicated cyst, which contains many thousands of larvae — hydatids or hydatid heads, as they are called — each of which, if transferred to the intestine of a dog, might grow into a tapeworm. Man also harbors the echinococci, which may produce very serious or fatal disease. In some countries, as Iceland and Australia, this affec- tion is very prevalent, and many deaths are annually caused by the growth may form '. the hog by special int( rence of ensures a < of a commi which will condition a water. Result cocci were ranged in s ternal >^\ withii 'in out. The the fluid cl were the h Eehinoci affection ; occur. In siderable n who probal from the may be ex| tary regula Dogs are i with the e Iceland, wl human pop of the inhal certainly n in numerou occurrence in man. * On Echir Journal of Me ^, 13 the growth of the hydatids in the internal organs, in which they may form large tumors. Man gets infected in the same way as the hog by the accidental ingestion of the ova, and the point of special interest, in relation to pubUc health, is that the occur- rence of echinococci in the hog— and in other animals- ensures a constant perpetuation of the species among the do^s of a community and a conse(iuent risk to the individuals thereof, which will be great in direct proportion to general insanitary condition and the liability of the eggs to get into the drinkin'^ water. Remit of Uxamination. — In the 1,037 hogs examine'^, echino- cocci were found in the livers of 31, or 1 in 33.4. The cysts ranged in siz^ from a marble to a walnut, and presented an ex- ternal ' 3 investment, formed from the tissues of the part, withii' \iW,i was the cyst proper, which could be readily turned out. The ectocyst and endocyst were usually well developed, the fluid clear, but in none of those c -mined microscopically were the hydatid heads fully developed. Echinoeoecus disease in man is in this country a very rare affection ; not more than eight or ten cases have been known to occur. In the United States it is also uncommon,* and a con- siderable number of the reported cases have been in foreii'ners, who probably brought the parasite with them. The immunity from the disease which human beings here happily enjoy may be explained by the existence on the whole of such sani- tary regulations as reduce to a minimum the risk of infection. Dogs are not numerous, nor are they so intimately associated with the every-day work of the people, as in countries like Iceland, where, according to Krabbe, the ratio of canine to human population is very large, and an extraordinary number of the inhabitants suffer from the affection. The adult worm is certainly rare in our dogs ; we have never met with a specimen in numerous dissections, but its existence is fully shown by the occurrence of the larval form in many animals and occasionally in man. 111! \'M i J % ' '' ' V '' i« »c '■j 1. . |R f 1^ ■ W- ' K " J; w > li Iv * On Echinoeoecus Disease in America, by Wm. Osier, M.D., American Journal oj Medical Sciences, Oct., 1882. \^k Hi I 11: 14 CONCLUSIONS. 1. The investigation shows that the hogs slaughtered for our markets present parasites in numbers sufficient to necessitate a more thorough inspection than is at present carried out. 2. As regards Trichina spiralis, which was found in the pro- portion of 1 to 250, we are of opinion that, considering the ex- treme rarity of cases of trichinosis, and tlie difficulties attendant upon a systematic inspection, a compulsory microscopic exami- nation of the flesh of every hog killed is not at present called for. 3 In the case of " measles," the liver should be carefully examined, and if present in it, the flesh of the animal should receive the special attention of the inspector ; if only in the liver, the entire carcass need not be confiscated. 4. Echinococcus cysts in the liver render that organ unfit for fc i, but in other parts, unless very numerous and disorganizing, they may be cut out, and the carcass remain marketable. 5. The public should be made aware of the possible dangers of eating, in any form, raw or partially cooked meat. The best safeguard against parasitic aflfections is not so much inspection of the flesh, unless, indeed, this is minutely carried out, as care- ful attention to culinary details. 6. To reduce the number of infested h>gs, greater attention should be paid to their hygienic surroundings, particularly in the matter of feeding. The danger is not during the period when the animals are penned and fed on grain, &c., but when they are allowed to roam at large and feed indiscriminately. Our thanks are due to the authorities of the Montreal and of Dominion Abattoirs who kindly permitted the inspection. m t >E m > 4 ^if 'm '■I I. n S -f, . J •'■ 1 ' :*' ■ ll ■l! M I' ■' ' ' ' €' I i: iff. v •■"' ■ ■! :■ "m P '; M i 1 t '1 1 (ii 111 ^ > { t a":! i' ^v ^ REPRWrEnj.Ml()M THE "CANADA MEDICAL .«• «lIU(U('Ar. .roURXAL." CLINICAL REMARKS ON A CASE OF IIODGKIN'S DISEASE. ( ^y■Hh n cut.) Summer Sbssion, :\Ini)ir.\i. F.utitv ^Uihu. (.'oLi.ixiio. By WM. OSLKH, M.D., F.U.C.P, Lond. Professor of the Institutes <,f Mc.licii.e in Mc(iill Univmsity, and Physician to tht! Jlontrcal General irospital. Gentlemen.— The patient before you is the subject of a remarkable disease which was brought to the notice of the pro- fession in 1832, by the late Dr. Ilodgkin of Guy's Hospital. Although others had previously described cases, and Dr. Hodg- kin had not himself a very clear notion of the relations of th'e affection, still, his paper forms the starting of our present knowl- edge, and the majority of English writers have, since 1865, followed Dr. Wilks' suggestion and called the disease after his name. Synonyms of it are General Lymphadenoma or— adenosis, Pseudo-Leukaemia (Cohnhcim), and Addnie (Trous- seau). The disease is characterized by a progressive enlarge- ment of the lymph glands in certain regions, and anaemia. There may be enlargement of the spleen, and occasionally there are localized growths of lymphoid tissue in different parts of the body. The colorless blood corpuscles are not usually increased The report of the case is as follows : R— A—, from near Belle- ville, Ont., was admitted to Montreal General Hospital June 6th suffermg with enlarged glands. Patient is 34 years of age ;' married ; no children. No record of any scrofulous or tubercu- lous affections in his family. Had jaundice four years a 6 bowels. Eowol8 rather costive. Urine is slightly high-colored, r ' I'iTo^' ?''''^' ^^"^ ' "° ^'^•"'"^"- ^'^'-' '-^O ; tempera- ture, lUlb. Liver and spleen normal. Opthalraoscopic exami- tion of eyes negative. No hemorrhages ; discs clear On withdrawmg a drop of blood, it is seen to be of a fairly good color, not watery; on examination the individual cells are seen to be a httle pale ; colorless corpuscles relatively increased • many smaller than usual; fibrin filaments very distinctly seen' Ked cells regular in size. Ilaemocytomoter shows about d million red cells to the cubic millimetre ; a proportion of 1 white to 1;)0 red corpuscles. The patient will now strip that you may sec the extent of the glandular swellings ; rarely will you sco them more pronounced, -brom behind the appearance is even more strikin.r. Fortu- nately for him the large bunches on the left side Imve grown outwards and have not seriously involved the veins and there is no pressure on the trachea. The only interference with the circulation is by the growths in the loft axilla. In this disease much depends on the group of glands involved. This patient tells us that he has had little or no pain and has only the inconveni- ence of these large tumors which impede the movements of head and arms. Very much less swelling of the internal glands may produce intolerable anguish from pressure on the nerves I remember well the first case of the kind I saw. A large stout man, whose only symptoms were terrible pains ^n the back and legs and oedema of the feet. The retroperitoneal and pelvic glands alone were affected and pressure on the nerves produced the severe pains. When in the mediastinum the enlarged glands may compress the trachea or bronchi or the great vessels and bring about a most complicated series of symptoms. The case in No. 11 which interested us so much a few weeks ago— too much, in fact, as he got frightened and left the Hospital- was one of this sort. Extensive pleural effusion on the left side group of enlarged glands above left clavicle and a large bunch of them in the abdomen. I have no doubt of the nature of the case, but the pleurisy was the most prominent feature, probablv dependent on the pressure of mediastinal glands. I pass around ' ll ':\ 1 * Erb, in oighty-lour cases, nienli,)iis that fortv-tliree 'v ere in tlie initial stage and presented no ataxia. m t II it ■•mmtk 'I \l living, three dead; one, a year old, had a rash on the body the other two were still-born. Had ponorrhcua; can get no history of chancre. Formerly tooV sp-nts freely but has been temperate for some years. Has used tobacco to excess, also opium In his occupation as millwright has been much exposed to wet and cold, particularly when working in the flumes, and on several occasions has been for hours in ice-cold water, tor nearly four years he has had what he calls rheumatic pains in the legs, at irregular intervals ; sometimes six months would elapse, and at others two or three attacks would occur in a couple of weeks. He describes the pains as intense, coming on with great rapidity, local- ized often in spots not more than an inch or two in ex- tent which are acutely sensitive when they are present; duration brief, two or three seconds, and .hen they pass away as quick as they came, to return again in a few minutes. Sometimes they have been so bad that he has not slept; in his own words. " they - onld just give me breathing spells! and then 1 had to inch my teeth to bear the next pain." No tinglip, or pins and needles. For about a year has noticed that the eye- sight was failing ; may have been present for a longer time but he was not conscious of it. Fxamination : Patient is a slight, dark man. fairly nourished. Cait is uniffected, Muscles moderately developed. Sensation in legs good; not retarded, Pupils are contracted, round, measure 3.5 mm. They do not react to light (reflex immobility, reflex irido- plegia). Act during accommodation and in associated movements when eyes move upward and inward. Dr. BuUer tested the vision, and reports , Ijg with right eye and j-o\ with left eye. Considerable limitation of field of vision in upper and outer parts. Optic nerves bluish-white in color; margins well de'^t .'d all the minute vessels of the disk are gone, o .j . ■ larger trunks remain, and they, too, are diminished in size. Color-perception for red and yellow good ; he thought the green was dark-brown, almost black. The patellar tendon-reflex is absent. Plantar, cremasteric, and ab- dominal reflexes are present. The eye symptonii, lightning pains, THd absence of knee-jerk, are the chief features presented by this case, and together they are amply sufficient to establish the diagnosis of tabes dorsalis. Let us consider these symptoms a little more closely, and, first, the oc>dar phenomena, which are among the earliest and most remarkable nerve disturbances in the disease, and of great diagnostic importance. When I place the pa^ tient before the window, shade his eyes with my hand, and then suddenly expose them to the bright light, no change takes place in the diameter of the pupils. Tested with a stronger light, the same peculiarity is noted ; the pupils are immobile and do not react to the stimulus. If now, after looking at my fingers at eighteen inches he then directs his vision into the dis- tnnce, the pupils dilate with the relaxation of accom- modation, and contract again when '- 'ooks at a near object. While not responding to tin, dmuhis of light, they are active during accommodation. This reflex immobility of the pupil, first described by Dr. Argyl Robertson, and sometimes called after him, is present in a large proportion of cases of tabes. In 84 cases of Prof. Erl) it was noted absolutely in 59, and diminished in 1 2. Of these 7 1 cases, 43 were in the preataxic stage of the disease. In Crower's address, just to hand, on eye symptoms in spinal disease, the light reflex is stated to have been lost in 48 out of 72 cases. Usually the reflex immobility is associated with myosis, which exists in this man in a moderate df;gree. The only other affection in which this sign has been specially noted is progressive paresis of the insane. Not only is ^. 11 '^wfw; t ' !'. I f. i -1 M m I \ « ' ,1 ! i 1 ■H 1 1^- f ii t the power of reflex contrnc;'>in of the i>jpils lost, but reflex dilatation i.ay also :.<. ■• ,.>pended. If you stimu- late strongly the skin of a healthy person, a slov; i eflex dilatation of the pupils takes ;)!ace, ut in tae majority of cases of tabes ihis does not occjr. We could nof get this reflex on stron? galvanic stir relation of the skin of the neck and shoulder of thi < n.an. The pre- ;;-.e locality of the lesion which causes these early prpil syiiip'o"is is unknown, but if you consult the diagr.un of the pupil centres, which you have in your pi!y5ioloj.;y notes of last winter, you v>.!' see that, as Erb says, the local degeneration causi< g the loss of light reflex must be somewhere in the pathway between the centres of the optic and the third ntrv-js. The chief complaint of this patient •-. a steadily advancing loss of sight, which ophthaliuoscopic ex- amination shows to be due to atrophy of the optic nerve. Many of you have had an opportunity of examining the disks in the ophthalmoscope room, and studying the characters of the sclerotic atrophy— the blue-gray color, the flatness of the disks, the absence of small vessels, and their sharp distinct outlines. With no other spinal affection is atrophy of the optic nerves so frequently associated. It usually begins early, before the second stage of the disease is reached, and the patient may be quite blind by the time the ataxia develops, or, indeed, before there is a suspicion of tabes. The atrophy is progressive, and ultimately, though it may be after the lapse of months or even years, total blindness results. Color-perception is often disturbed ; most frequently patients lose the power of distinguishing red and green, while that for yellow and blue may be retained. This man says that green appears to him dark-brown or almost black. His perception of red, yellov, , or blue is good. There are other eye symptoms, r ^ ^resent in this insta aware of local pals duction c too, are ( common ; vision, wi troublesoi under th( operation I knew a squint wi since becc tion a ge double vii severe pa patellar re squint, or possibility ing for oth Besides complaint at times i which I r so-called 1 are usuall; chiefly the sides, rare and in the months mr of their on is well exp lightning. when a bac each pain, patient say iir this instance, which may puzzle you not a little, if un- aware of their connection with tabes. I refer to the local palsies of the external eye muscles, and the pro- duction of squint, double vision, and ptosis. These, too, are often preataxic symptoms and are quite as common as those which we have considered. Double vision, with or without positive squint, is often a most troublesome feature, and the patient may be for months under the care of an oculist, or, indeed, have an operation performed for strabismus. Some years ago, I knew a gentleman who had intractable ptosis and squint without any other special symptoms. He has since become ataxic. I have at present under observa- tion a gentleman who had external strabismus and double vision for six or seven months, and now has severe pains, bladder trouble, and absence of the patellar reflex. In adult men, the occurrence of ptosis, squint, or double vision, should suggest to you the possibility of early tabes and the necessity of examin- ing for other signs. Besides the failure of vision, the patient has but one complaint— the terrible pains which have attacked him at times during the past four years. The account which I read to you, is a typical description of the so-called lightning or electric pains of tabes. They are usually mistaken for rheumatic pains, and affect chiefly the lower extremities, sometimes the back and sides, rarely the arms. They vary greatly in intensity and in the frequency of their occurrence ; weeks or months may elapse between attacks. The suddenness of their onset, the rapid darting or flashing character, is well expressed in the terms electric, fulgurating, r ' lightning. They fly about from place to place, and when a bad bout comes the patient may cry out with each pain, and they may recur so rapidly that, as our patient says, there are only breathing spells between ^ i .1 1 ': " ' f ' M i ' m 1 I' A ■r i ml ■!:! ^fhM;, /■ \l ^i: 1 • ■ \ 1 t j 1 ly 111 ' ' ' i 8 them and just time to clinch the teeth to bear the next stab. The skin over the site of the pain may be intensely sensitive— hypenesthetic. Occasionally the pains are dull, heavy, and dragging, not sharp and stabbing; this, however, is quite exceptional. Very few, not five per cent., of ataxic patients escape these torments. One other important symptom is presented by this man ; when I strike the patellar tendon of the crossed leg with the rim of th«< stethoscope, there is no response in muscular contraction of the quadriceps extensor, and the leg is not jerked up as in health. The knee-jerk or patellar tendon-reflex is absent, and since I'rof. Westphal called attention to this sign, it has come to be regarded as of great diagnostic value in tabes. Exceptionally, the knee-jerk is absent in per- sons in whom there can be no suspicion of posterior spinal sclerosis; but absence of it in conjunction with lightning pains or any of the ocular phenomena, may be regarded as proof positive of the existence of the disease. Lest you may think that rather a strong statement, let me read you a paragraph from a lecture by Dr. Buzzard, whose work on Disrasi-s of the Ner- vous System I would specially commend to you as embodying the rich clinical experience of an ur. itually acute observer. He says, " It is of much importance to remember that the two symptoms— on the subjec- tive side, pains of the character described, and, on the objective side, absence of the patellar tendon-reflex (with a fairly normal condition of the quadriceps ex- tensor muscle)— are the most constant, as they are probably the earliest of all. My belief is that if we meet a patient who exhibits them both, we do not need the presence of any other in order to form a diagnosis of tabes dorsalis." The patellar tendon-reflex is ab- sent in about ninety-six per cent, of all cases. Among other symptoms which may be present in the first : numbness pronounce curring wi Charcot, a in the se: times thei disease a( finally im mention t( day : A j gradually raised by loss of sex The man life, had s abused his he has bee out any b The testicl varicocele. presented 1 he does c( legs. In haps initia not, in this Chatham, i in a few 3 something You doul taken plac many facts Erb, Gowei between it ably over the first stage are localized regions of anicsthesia, numbness, pins and needles, but more common with pronounced ataxia; attacks of obstinate vomiting oc- curring without olivious cause, ihe cn'sfs x'tis/n't/ues of Charcot, and vesical and rectal troubles. Disturbances in the sexual function are common in tabes; some- times there is at the onset satyriasis, usually as the disease advances, there is loss of sexual vigor, and finally Impotence. In connection with this, I may mention to you an interesting case which I saw to- day : A gentleman from near Chatham, Ont., has gradually become Impotent, and the question has been raised by an eminent American specialist whether the loss of sexual power was not an early tabetic symptom. The man Is powerfully built, accustomed to out-door life, had syphilis about fourteen years ago, and has abused his sexual powers to excess. For three months he has been on a strict anti-syphilitic treatment with- out any benefit, and he is now practically impotent. The testicles are soft and flabljy, and there Is a large varicocele. There are none of the tabetic symptoms presented by the case we have just considered, though he does complain of dragging pains at times in the legs. In rare instances, impotence is an early, per- haps initial symptom in tabes, but whether it is so or not, in this instance, time alone will tell. Dr. Bray, of Chatham, under whose care he is, will doubtless know In a few years. Possibly the varicocele may have something to do with his trouble. You doubtless are aware that much discussion has taken place lately regarding the cause of tabes, and many facts have been brought forward by Fournier, Krb, Cowers, and others to show the close connection between it and syphilis. Statistics prove that consider- ably over fifty per cent, of all tabetics have had 'W i 1 ; 1 ' ■;< fl •1 . -1 ' ^i!< J , 1 ii i I' ' ■ ' ■ ! 1- ni. - \ { ■ m iw; 1 •] 1 1 I '/ [A * I' : J to syphilis,' but whether this is simply a matter of asso- ciation, or whether a Herin'*^ --usal relationship exists, is not yet clear. vj.. siioiiUt be esp.cialh careful in obtaining the history of a patient to ascertain if he has had syphilis, as the treatment may be thereby consid- erably influenced. There are some indeed who regard the occurrence of tabes as in itself a proof of the ex- istence of syphilis, but this is an extreme view and not borne out by facts. In the case you have just seen we can obtain no positive evidence of infection; true, he has been />i the ivay of it, having had gonorrhita, and the death of three children, one with a general rash, is a suspicious circumstance, but he is an intelligent man, anxious to give all details and he seems quite certain that he never had a i, ^re on his penis or any secondary manifestations. It is astonishing ' ow reluctant ome men are to acknowledge the pox. Rven an intelligent physician will conceal the act from his best friend and deceive him grossly, as in the following instance. A few years ago, after a medical dinner in London, the conversation turned on this very subject, tabes and syphilis, and one gentleman was \ery positive about the invariable .i^sociation of the two. Our host stated that he had under observation a medical man, the sub- ject of tabes, who of Ted a s nisfactory refutation of t'> view as he had ver had syphilis. I ascertained thi name of the surgeon referred to, and to my surprise found that it was a man with whom I had been ac- quainted on the continent, and who at the time was undn treatment for se mdaries. Exposure and cold, especially with muscular fatigue, are believed to be potent iniiuences in lae etiology I In the Vicnii; gical Journal, I)r ten sypliilitk-s in o ■irespoii'loiice of Canada Medical an ~i Siir- s S'' v.irt states tliat Dr. \ViNs found only and cases of tabes. It I \m "If I I r of tabes, and in this connection it is worthy of note that our patient has been much exposed to cold and wet when wortcin^ at his trade .is millwriKlu, often up to his waist in ice-cold water. From the fact that he has had lightning' pains for over four years you may gather that even the initial stage may be very prolonged. Tabes is perhaps the most chronic of all nervous Hections, and in indi- vidual cases it is impossible to predict what the course will be. This patient may not become afaxk for years; unfortunately for him, the optic atrophy will almost cer^ tainly be pro-ressive and lead to total blindness. Occasionally the course of the disease is very rapi.l. I had arranged to show you another case to-day, a pronoimced ataxic, with the characteristic gait, etc., but he sent w ord that he was too unwell to come. ' This man has had syphilis, has suffered from cerebral mani- festations, and now for nearly two years has presented symptoms of tabes, the incoordination being now so ;,'reat that he moves about with very great difficulty. When once established, the disease is, as a rule, hope- lessly incurable; it is impossible to restore sclerotic ner^ sue to the normal state. The most we can hope iG do is to arrest the progress and alleviate some of the more distressing symptoms, Where there is a decidedly syphilitic history, as in the case I just referred to, a thorough course of mercury and iodide of jiotash should be tried. It has done him no good, but there are instances on record in which such a plan has been of material benefit. Of course, the remedies in vogue in the treatment of the disease are legion. At present great confidence is placed in nitrate of silver, ii .juarter of a grain doses three times a day, continued for months, mtei mitting every fifth week to prevent de- posit on of the salt and staining of the skin. It seems to relieve the pains, and in some cases the incoordina- I- I i r f - i 1 I \- il 1 II I la tion has disapptMied tliirini,' its employment. We shall put this patient on a |)i 'in^^'cd i omse of the silver, and order galvanism to ilic spine. Rest is an im- portantelenient in the treatment, hut in many instances, as in this one, impossible to procure. When the electric pains are severe, friction (massajje) is bene- ficial and in very bad spells, hypodermic injections of morphia. I have no belief in the restitution by therapeutic means of a sclerotic tract in the spinal cord; as well iniKht we hope for restitution of a group of sclerotic (cirrhotic) liver lobules. Curiously enouj^h, even when decided amelioration does take |)lace or a cure is ap- parently effected, the lesion in the posterior columns may remain unchan^'ed. In one of the recent num- bers of the Anhiv Jin- raych., Dr. Schultze reports a remarkable case whu h illustrates this. A patient of Dr. Krbs' was apparently cured, the ataxia and pains disappeared ; absence of ]iatellar reflex and slight vesical trouble alone remained. Twelve years after the appearan( c of the symptoms of ataxia, and eight after their disappearance, he died of poisoning. At the autopsy the posterior sclerosis was well marked in the lumbar section of the cord, and there was degenera- tion of the posterior root-zones in the dorsal and cervical regions. The opinion is gaining ground that locomotor ataxia is not simply posterior spinal sclerosis, but a wide- spread affection of the sensory nerves ; and taking this view the various peripheral nerve changes, the optic atrophy, which is so common, the occasional affection of the auditory, and the degeneration of the cutaneous nerves which has been described — all come in as part of the general affection. t /tAf S>. L.\^n ■'■"i; Tlllkl) 0)Rirsc-|.K OF TIIK 111 OOlJ. -xrJl„1h;!'h; '••/'"-■ '■'^''^'"' -'^it'^-nn.s.Ies, there art 1. the blood granular bodies ..f various si/e limes ab large. I iiese were first described l)v \fiv Schuitze, and they n,ay be called very a,^ ro|natdy as I have been .n the habit of ,io„ g fo'r years' Schultze's granule masses." I„ healthy idn ; t >ey are not abundant as a rule, though eLntIo : bound'"7n';i,'" 7""""">' ^""^ 'ondition' th V aoound. In all cachectic states the granule masses n^\Z^\ '"^ """'^°"" '''''^">' ^«'»^ notable featu kS.nH ']^ "^"""''^ generally; also in leu- kc^mia and symptomatic anaemia; but it is not a i.^ cZ'o, ''-^ ^''/ '" '^^^"'''""^ an.mia tile- are scant), oi even absent. In the lower animals tl e ,„asses are met with in variable nu.nberr The blood of the young contains them i„ larger pro, o ion than ,n adults. The new-born rat, kitten ra| th ir" S;r%'^'^ ""^' '" ""'''' ^^'"^ advantage for tneir study. So common are they in the blood of misTa irv^;^'^ •'"' ' '-^ "'^' ''' ^' wondered at i mistakes have arisen cone erning the signs of their presence in certain diseases. Thus, in ^ThTlanlt a few years ago, a gentleman described them under e.'.S'"r^"*' "'^-^'"^- i" leuaemic blood,-' regarding them as specific urrharacteristic elemen s I laye been told of a. somewhat prominenrlondon physician connected w.th one of the special hisp tals for chest diseases, who found them so co isSnt 1 ;■ I i iii,ii- ,1 '■^■•'^\ if in the blood of ])hthisical patients that he regarded tlicni as ]ieruliar to the disease, until advised by a colleague of tiieir wide distriJMition. The most extensive observations upon their presence in dis- ease were made l)y Dr. Reiss.' The common opinion regarding them has been that they repre- sent degenerated white blood-corpuscles, or a gran- ular detritus resulting from their decay. 1 first showed that they were composed of distinct cor- puscles, and that the masses did not preexist in the blood, but were formed at the moment of withdrawal by the aggregation of the cor|)uscles. At the edges of large groups, the disk-like corpuscles can be dis- tinctly seen, and in the sulphate of soda solution, such as used for mixing the blood in hfemocytometer work, the corpuscular nature of the masses is quite clear. Hut what led me to this point was the fact of the impossibility of supposing that masses of the size of some of these could pass through the capillaries. Reiss felt the same difficulty, and suggested that in some cases they might produce embolism. In the l)lood of the new-born rat they are most abundant, and the subcutaneous tissue was employed to inves- tigate the condition of the masses within the ves- sels. It was then found that they do not preexist as aggregations in the blo' d, but are in the form of isolated corpuscles floating free with the other forms. By far the simplest way of demonstrating the iso- lated corpuscles in the vessels is to snip a small bit of the subcutaneous tissue from a young rat, and examine in salt solution. In a small artery or vein, there will be seen with the red and white cells small, pale corpuscles about one-fourth the size of the red ones, often in extraordi- nary numbers (Fig. i). A drop of blood from the tail of the same animal will show numerous granule masses, at the edges of which the corpuscles can be U<'ic'lu rt 11. DiiHriis Ri-yniiiiul's Aniiiv, iH7_'. >.^- seen. The corpuscles swell in water, and become pale : dilute acetic acid render;-, them more distinct ; ■ i<;. 1. cdi they stain with carmine and methyl-violet. The corpuscles are discoid, pale, structureless ( Fig. 2). ■ic. 2. a i c J)M "^MJ> and often undergo peculiar alterations in shape, elongating or i)resenting two or three fine hair-like extensions. Tliey measure from ,,',, to ^^L^, of an inch. 1 he largest I have measured was . J— • and the smallest are from ,,J,,, to ^,^,,,. "^^ "' ine tacts above given are Irom my jjajier before the Royal Society in 1874, which was published in the Proccediiisrs for June i8th of that year. A considerable part of th;it communicati(.n was taken up with describing the changes in form which the corpuscles undergo when kept for some hours at the temi)erature of the body, and examined in blood- serum; but the corpuscles were described and figured, and a true explanation given of the structure and formation of Schultze's granule masses. These bodies are undoubtedly the same as those described by Zimmerman' as elementary corpuscles which he found when blood was let flow into a solution of a neutral salt; after the subsidence of the colored elements, the supernatant serum contained, in ex- ' Virchow's .Aroliiv, Hd. xviii. '- i' 1: ■I ;1 ' / i I fi i : i! traordinary mimbers, small, round, colorless cor- puscles with weak contours. In 1877-79, Hayem, of I'aris, investigated these bodies very carefully, and by sj)ecial modes of l)reparation and e.\,.uiination was enabled to isolate them and prevent their aggregation intiriiiing1iaiii. The origin of the (oijMisclos roiiuiiiis a inoblcin — one of many ( onne<'te(l with tlie blood wliich await solution at thr hands of histologists. 'I'o conclude: ist. TIkic is in mammalian blooti a tiiiid corpuscular element, one-eighth to one- half tiie si/.e of the red corpuscle. It can be clearly seer: in the bloodvessels of the living animal or in the vessels of freshly removed bits of tissue. It may be called ajipropriately the third (:or})uscle, or " blood- plate," tliough the latter expression is not a very satisfactory one. 2d. In blood withdrawn from the vessels these corpuscles aggregate together and form the well known granule masses in which the corpuscles rapidly degenerate and lose their outlines. These masses, first de.scribed by Max Scliult/,e, should be known by his name. 3d. There is evidence to show that the third cor- puscle plays an important /-i^/c in coagulation. I i\ I'KOFKSS.lR tIK ^ ; ■ f ' ' i i ^ ON SOME NATURAL MODES OF CURE IN EMPYEMA. ■ ■'"<"";■, 7"'i^' ^o/'i, jssj. ^ y/ii f- ! ■ 'V BY "'ir.LIAM 05..F.:4, M.O., F.RC.P. ,„«, i-KOFHSsoK '"^''"''"nnrKs^KM^jiciNK -■~....,...,,r;-;.-;;^--— -CM. f U( .\1 THE NEW VORK MEDICAL RECO: Sfpticajnn'a Amyloid dt Ins|)i!;satioi tion is pcrh cure may u tlie al)S()rijti einpvema \v in s seiis gihi I ft us fir charged froi report is as Cask I,— //s flm e, a S wt w ith typlioi( liUt presenli ;;nune(l on tlic end of ON SOME NATURAL MODES OF CURE IN EMPYEMA. ^> -1 I ("■1, Nii.KMKv : Most ni'voa Ii.i'.e seen what . //-/ crui do in the treatment of empyema, and I am thankl'iil to say that, by tlie plan we now follow of thorougii drain- af^e with a large caniila and antiseptic dressinirs, we lia\e liad very fortunate results ; hut todav 1 wish to (all your attention to two c-ises whieh illustrate what jVa/itre <'nn do in the way of cure in this formidable affection. Left to itself an em]n'enia may terminate as follows : t. l)y jierforation of chesi-wall. of lung, or of diaph- ragm ; :, kill by septic or other infiuences ; and ;,. it may be absorbed or dry uj). Of these three nicxles perforation is not very common either into the lung or cMernally, while into the abdomen it is very rare. Septicajmia ( laims no small ])roportion f>f fatal cases. Amyloid degeneration and tuberculosis kill not ;i icw. Inspissation of the purulent contents and gradual absorj)- tion is perhaps the rarest of.-ill terminations. .\ natural cure may take plac e by jierforation of the lung or by the absoiijtion of the ])us. and of the three ca»es of emjiyema whidi you ha\e har a week before operat- inir, and ujeanwhile to improve his general condition as ftr as possible. ( )n iNbav isi. «vithf)ul anv aggravation of sNuiploms, he beuan spilling; up pus, and in tlie course of twenty-four hours filled the spittoon (capacity 26 02s.) 'I'he counh A\as very troublesome, not ])aroxysmal and the juis was brought up in rounded masses sur- rounded l)y c'ear mucus, /u/ //w.ov it looked hke pure |)us, but the isolated sputa resembled closely those of < hronic phthisis. -No clastic tissue was found ; i)us cells were the only elements On Mav .•^d the area of dulness was fmnid to have diminished considerablv, and at the angle of tlv scajMila bre.ith-sounds could be heard, distant on tranquil respiration, hardiand distinct on d-a']) inspiration, and these acconijianied liy j\-ry fine cripitant rahs. Yox r-^arly tliree weeks the expectoration rf piis con- tinued : the amount at fust large (15-22 ozs ) was by tile ccth reduced to a ("ouple of ounces daily. The dulness gndually diminishe 1, rind l>y the 13th a comparatively 'lear note was obtained on the jjortion ot the infra scapular area next the spine. Iheath-sounds weak but i|'iite audible ; moist sounds on deep inspira tiiin. il's gencrd condition im])roved rapidly, temper- ature I)ecame normal, and he was discharged June 4th. A slight area of dulness remained in the outer ])arl of the inlra-scapidar region. While under observation a loud, roi third and not at th( the right of this pa I may : been in tl interest tl the result That ai coughed 1 ledge of t opment o favorable appear to knew of il empyema and expec Traube a Natural tion,' has tions, as a physicians Hippocrat mistaken, physicians Greene^ r Dr. R. L. medicine i assistant V butions to zed this gr There a 5 loud, rough, systolic murmur developed, heard in the third and fourth interspaces to the right of the sternum ; not at the apex or at the base. It was transmitted to the right base, and was tirst noticed during auscultation of this part. I may safely say, gentlemen, that in no case which has been in the wards this session did we watch with greater interest the progress . of the disease, and we can regard the result with equal satisfaction. That an empyema may perforate the lung and be coughed up has been known for centuries ; but a know- ledge of the fact tliat this may occur without the devel- opment of pneumothorax, and constitute one of the most favorable modes of termination ot the disease, does not appear to be very widely diffused. Hippocrates, indeed knew of it, and in several places speaks of recovery from empyema (after pneumonia) by perforation of the lung and expectoration of the pus. Traubel in an article published in 1872, entitled "On a Natural Mode of Cure in Purulent Pleuritic Exuda- tion," has called special attention to the fact, and men- tions, as a curious circumstance, that he alone, of all the physicians who had written on empyema since Hippocrates, had obserxed it. In this however, he was mistaken, for it had not esca])ed the notice of the Irish physicians in the palmy days ot the Dublin school. Dr. Greene^ narrated several cases of the kind, and the late Dr. R. L. Macdonnell, the first professor of clinical medicine in this school, and who was at the time clinical assistant to Dr. Graves, in his important paper " Contri- butions to the Diagnosis of Empyema,''^' clearly recogni- zed this group of cases. There appear to be two ways in which an empyema i (.) 'l\ln' 1 Ges.immelti; Heitrrige, I!d. iii.,s. 44, 1878, 2 Dublin Metlical Journal, vol. xvii., 1840, 3 Ibid. 1844. 1 ^? may discharge tlirougli tlic lung ; first, by opening into a l)ronchus and the foiniation of a fistula ; and, second, by a local necrosis of the piilmonnry iileura. exposure of the parenchyma, and a soak.nge of the jjus through tlie spongy lung-tissue into the bronchi. In the first way pneuniotliorax usually develops and aggravates the danger. When the pus perforates by a large and free opening the patient may be sufTo( ated by the sudden gush of fluid which is passed to the tubes more rapidly than it can be expectorated. Several cases of this kind are on re- cord. The establishment of a bronchial fistula may be followed by temporary relief, hut permanent recovery is rare. In the second wav the pus is usually discharged without the formation of pneumothorax, and we must re- gard this as one of the most favorable modesof termin- aUo'i in empyema. 'I'raube^ was certainly the fir.sf to i.'''i,: a s.ttisfiictory exjilannMon of the process, as he had fi» opportunity of studying the condition of the pleura an! lung in one of these cases, and found on the lower ioiie an oval area two and one-half by one inch with the pleura destroved, and tb.e lung-tissue fully exposed, but no direct communication with the bronchi. That ])neumo- thorax does not occur he explains on the view that wiiile the powerful coughing efforts < ompress the chest, and are sufficient to drive tne pus ihrougli the exposed lung tissue into the bronchi, the affected side is immobile, or nearly so, and the slight expan; ion during inspiration has not force enough to aspirate air into the pleura. Greene, in the ])a])er already referred to, clearly dis- tinguishes between the two classes, stating that " in cases of effusion a copious and ]»uruleiit exi)ectoralion is a fre- (]uent accom])aninient, dejjcnding in some insances on a fistulous communication established between the seat of the collection and a bronchial lube, and that when such a communication has taken place it may be recog- i I.u';, cil, il I. ni/c(I liy Avcllkiunvn and cli;ir.\( tt.ii\iic si;,'ns. IJiit in f)ther iiist.'incfs tlif t\|ie(toialiijn nia\ \>u KjtiaM < onions nnd piiniUnt. while all the phvMcal i,i,^ns of , ,,rii- rniinKalii.ti arc aj.scnt. and where, ronsc(|i ,v, the syinptonis in (|in.-,ii<)n( aniiot be rderrcd lo surii a les- sum." In tiic latUT . iiui= jc 1.' r l-li.cilUsC, etc., 'w;). r I ) 1 , I' ^ ^■Mi* IMAGE EVALUATION TEST TARGET (MT-3) // %// .?' ^' ;! J S tipirntion. at tbc angle of tiie sra|)ula. Tt was as fine .is and rcscm'jled closely, the i:ineumonic crei)inis. In U\\. otiur cases of ])leurisy I have observed the same phe- ncnitnon a>. the effusion was ahsorlied, and was not a litile |ni//,led. Dr. Macdonnell, already referred lo. also noti'd tliis, and described it in another l)nper, "On Occiurence (jf Cixpltus in I,i;ng after the Absorjjtion ol I'leiirilic I'ffusion.' '^ Is it, however, in the lung ? I mentioned to vou at the bedside that il might he />ku iifi\ due to tiie < cntact and friction of the two surfaces after the absorjjtion of the fluid, and if so it is in corrobo- ration o( t]ie\iews of I)r J. R. learning of New York, v.ho holds that the pnemnonic cre|)itus is not a pulmon ary but an interpleural sound, due to the friction of the sti( ky surfaces. The patient before you. who has been in hospital a few davs, illustrates a very different process, but one which is leading to a satisfactory termination. Case II. — Empyema of seven months.'' standing , ah '■orptiov. of the flu d tenth retraction of the chest , local perforations of the pienra until subcutaneous abscesses. — A. i) , aged twenty-three, from the Kastern 'I'own- ships. of good stock, and always strong and healtliy (lives the following history ; Quite well until November last, when, while lifting a lieavy stone, he telt a .stabl)ing pain in the "ight side, which continued at intervals for 'v.o weeks, during which time, however, he was able to gt t about and do work. He then took to bed, got weak and feverish, particularly at nigiit. Had chills, and often sweated n great deal. vSIept on the left side as a rule ; when on the right the pain was increa.sed. Had a cough through the wmter ; not much e.xpectoration. Lost flesh rapidly. Has not been confined to bed all the time but got up and went about when he telt able. Latterlv. 3 Ibid,, 1844, I 'V lie has been hnprovine. rongii hasd:';appcarcd, has no fe- ver or sweats, and thinks he is gaining flesh. The history jjoints to some ciirnnic cliest trouble. \''hen stripped for examination lie jTesents an exceed- ingly interesting o])ject tor clinical study. (General in- spection shows a tall. Ijony man, pale and emaciated, and tl, attention is at onc*^- attracted to the lobsided appearance of the body, dne to a marked def)ression of the right shoulder and a decided flattening and shrinkage of the right half of the chest. Ashe breathes (juietly you observe that whi'e the left side expands the right is absolutely immovable, and this is still more marked w hen he takes a full breath the left chest expands to an un- usual degree, the infra-clavicular and mammary regions swelling out in a striking manner, while the right side re- mains fixed. I'rnm behind the same flattening and wr.nt of movcmen'. are noticeable. Closer inspection shows very nairoA' mtercostal spaces on the right side, and in the infra axillary region there are two flat swell ings in the seventh and eighth spaces, and in the latter, also, a fresh cicatrix. 'J'he apex-beat can be seen in tile lifih space close to the edge of 'he sternum. There is a rrotcn-oil rash on th. irom of the chest. Palpitation reveals more distinctly the narrowing of the intercostal spaces : the ribs do not apjiear hyperl -ophied. The smai: flat tumors in the seventh and eighth spaces flu< fuate, and do not appear to communicate with eacli other. He states thai one has already disappeared, and a fourth was opened and discharged about a spoonful of pus. He has noticed them for a couple of months. Tactile fremitus is marked in the upper part of the right side ; below there is no special intensification. The •edge of the liver can be felt at the costal border. Mensuration shows the right half of the chest to be nearly an inch smaller than the left, not as much as you might suppose on inspection, but the eve is in this r )■ ; 1,, I ■ I J. 1 ' k' )• ' • ^ 1 I } ' i ' ■ ■ i *■ 3 ; ' Fff 10 til ( i matter very njit to I'C (U-c eiveil. Percussion u;ives in front, on tiie ri.ulit sicic. a flat somewhat tympanitic note as low as the nipple, flat l)eio\v thi-- and absoUite dul- ness hehintl. I'he lett lung is everywhere resonant. On .lusciiltation, the breath-sounds are absent in the dull regions below, teeble in the supra-scapular and infra- claviruLir regions, and on deep inspiration a lew rales can be iieard. \'ocal resonance is much intensified on ri.nht side. partictiLulv in iiliccs. 'The examination ol" the abdomen reveals nothing special ; the liver is not enlarged. (General londitinn during the three davs he has been in ln'-ipiial has lueii good. I'ats and sleejis well ; h.is n > le\'er ; pulse about .So. A needle was thrust iiuo tiie er;lith interspace behind, but no llu'd was obtained. 'J'lH-re is l;mdable jius in the small flat tuim)rs. He does ii<;t wish them opened, and returns home to- day. With good food, b-esh air, and tonics, he will con- ' tmiie to im|)r(j\e. IT the small abscesses remain, his attending jiliysii ian will open them, but they inavdisap- liear, as one lui . already ilone. He will recover, with a damaged lung aiul a si. -i side ; but with compensatory enlarueineni of ihi. ..rid a gradual inl- ])-(jvement and distention ofthi' upper ])art ol' the right lung the res|)irau>rv area will l>e amply suHicieiit tor the purposes of an or linarv lite As to the diagnosis m this ( ase -could you mistake It for anything ci.se '' The onlv other aflcction which l^roduces a somewhat s-miliar condition is libroid phthisis or cirrhosis of the ' ing, in which there may be the de- pressed shoukier, flattened and contracted chest, with immobility, dulness, and weak breathing, but the historv would be one of long-standiiv; lung trouble, and there wo.il 1 be cough, expectoration, and special aus- cultatory si 4ns. With the loi alabe.-sses perforating the intercostal spaces, the iliagnosis m this case is, at present, casv enough ; but some years hence, when these have tlio retraction, mii^ht not 1)6 so easy ft disa])])enred and notln'ng is IlA hut diilness, and feel)le Ijreatliinj:, it without a full history. The condition of this man's chest illustrates in another way what nature can do in effecting a cure when an empyema is not interfered with. 'I'he effusion has evidently been jirttty copious, and as the weeks and months elnjjsed became more concentrate J and has gradually be.-n absorbed, until now there is probably not more than a few ounces left. W'nh the disapjiearance of the fluid another change has gone on : the flaky membranous exudation covering bf)th layers of the pleura has become organized and converted into a dense fibrous tissue \vhich may have a thickness of from half to one inch. In the process of absorption i)0(kets of ])us may have been left between the thickened jileural membranes, and some- times this ])us becomes caseous or even cretaceous. The angle between .^le costal and dia])hragmatic layers of the ]ilcura may be filled with a wedge of solid fibro- cartilaginous tissue which defies all attempts to sep.arate it from lung or diaphragm. 'I'he firmness of these old pleu- ritic membranes is extraordinarv, and in the removal of the lung, in siicii a case, the only way is to strip off the costal laver and take the attached portion of diaphragm The dulness in front and behind in this patient's r'ight side is due chiefly to these thickened membranes, and corresponding to the se\enth and eighth interspaces there are small jjockets of pus, perha])s isolated, as they often are, and communicating by siiui>es with the small exter- nal tumors, 'i'he lower loJ)e of the lung is condensed and airless, ihe upper and middle lobes, though thickly coated with false membranes, ])robal)lv contain a good deal of normal and functionallv active tissue. What pro- duces the great deformity ? When a sero-fibrinous fluid is alisorlied, or after its withdrawal by asjjiration, the lung expands, and although, as you have had several op- 1 r »■ • ; } ■ 1 f : {■;■ '' )' ■ i , H k T2 f!!i portunitics of observing, for months after there may be basic dullness and defective expansion, there is no re- traction. In chronic pleurisy however, the serous layers are unusually thickened, the false membranes organize, and there is produced a large amount of new connective tissue, which gradually shrinks, prevents the expansion of the lung, and little by little drags in the side, narrows the intercostal spaces, pulls down the shoulder, may curve the spine, and displace contiguous organs, drawing the heart over and the liver up, until there is presented such a typical condition of ritrkissemeiit thoracique as exists in this case. Although the shrinkage and condensation of the organized membranes jjlay the most important part in the process, some share must be attributed to other agencies, such as posture— the patient favoring the affected side— atmospheric pressure, and muscular con- traction. Will this side ever exi)and again ? Not to its full extent or near it. In time the upper regions of the lung will dilate more fully and there will probabb-be some movement in the anterior part, now absolutely quiet, but the deformity will remain and the lower part of the right side will never expand. It is true that oc- casionally a remarkable amount of exjjansion may take place after a pkuritis deformans. Sir 'J'homas Watson refers to two examples of complete re-expansion of the side, contracted alter chronic pleurisy, but such cases are extremely rare. Perforation of the costal pleura and the formation of a subcutaneous abscess constitute the condition known as empyema necessitath, which is not often seen. In this instance the external collections are small, and probably connected with cncapsuled deposits within the pleura. One has already disappeared, and a second, which was opened, healed rapidly, and the two which remain are not connected with each other, and probably not with any large amount inside. There are two or three points c~ 01 .1,. nl,s ,re n|,t 1,, „„ „r and,.,,,,, r.™ , , : tlio Sinuses w 11(1 result run ;„ , " 'L'-o\<.r\. j , year or so a^o in the u^^iC^ ;^) ,^'"^' 'f^r^'^ ^' -Hi at the autopsy wJ,;.„;;;^t^;^^;;^;^^^^^ antero lateral re-ion (,n the Icfr .i,l ,i \ \ '''^ 111 tmhana neasstati^ thr .■v',-,-,i . '^'^' ''^" 'i'i"> svnclironouslv with the he rt .„ , /,""'"!' I'"'^^^^^'^ ane.n-isni. This i the r", I? "!'' ''' ""'"'^^"" '"'•'' «,a.d,acpu,s.t,on:a;;its^s;\,::L^,.:r;;v7;rM^'' ■ Tl.o mistake h,.„ ,.,ri>c„ from . he f,„-t .1,,, Dr UM I , 7 rcnarkallc casus of i,ura-,,:.„ral r,„U„i„ , "''" ''•'■' ''"=''^'•■^1 '"'^ I ■tin. 11 pulsallll^' C-Mipyoiiia. f I i n. n * ) ^- li ■jy: .lii li-"! !!; ii f . / ^^=s fif I I- BRAJ Professor HEAD BE, "CANAD/ I \ R E P O II T ON TUB BRAINS OF HICHARDS AND O'ROIJRKE. BY I I ;l}. WM. OSLER, M.I).. M.R.c.K, Lond Profe.or of .he I„stitu.,s of Medicine in McGiU Unive.i,, and Phy.cian secondary branches. The ascending frontal gyrus was large. The first was typical ; the second was much fissured, and, an- teriorly, was partially divided into two. The third was normal. Orbital fissures and gyri presented nothing notable. Parietal loleH.~lUjhtmle—¥\^ii\nv of Sylvius was partially confluent by a shallow groove with the first temporal, and by a deeper one with the retro central. The ascending branch passed far up into the frontal lobe. The fissure of Rolando was not confluent. From a deeply placed, small convolution in the middle of the parietal lobe, live fissures radiated ; three passed down, of which the anterior formed a short retro-central fissure, which joined the Sylvian ; the m.ddle joined the first temporal ; the posterior had two branches, one could not be traced owin<' to injury of the brain by the saw, and the other passed up and joined a fissure in the situation of the posterior part of a nor- mal interparietal fissure. This lobe was much and irregularly fissured, and the supra-marginal, angular and superior parietal convolutions were greatly intersected. The retro-central gyrus was well developed. Li'ft stV/f.— Sylvian fissure was not con- fluent ; fissure of Rolando normal. The retro-central was marked, and the inter-parietal passed out from it at right angles and back into the occipital lobe, but did not join any of its fissures. It had several secondary branches, which passed into the angu- lar gyrus. The retro-central convolution was not so well marked on this side. A small triangular convolution separated it from the supra-marginal. Teniporo- sphenoidal lobes— In the removal both had suttered, particularly the right. So far as could be traced, the first tem- poral fissure joined the intcr-parictal and also the Sylvian by a narrow groove. The third temporal fissure was marked, and joined the calcarine. The first convolution was large. On the left side, neither the first nor the second fissures were marked anteriorly, but vertical sulci divided the convolutions. The hinder \mvt of the lobe was broken. The third was well marked, and joined the inferior occipital and Wernicke's fissures. Occipital lobes. — The saw had passed through the lateral part of the lobes. On ihl- right side there was a small Wernicke's ';#; n !■ •' -pn- I) r ) ) 1 ■ ' ■• 'i M ' 1 1 Ml j ' 1 Sm 3 ' ] 1 ' < ilj B 1 , 1 r lh.^:i i ^ i .,>. , <~iS3i f 8 fissure, which united with the horizontal occipital and (so far as could be made out) with the second temporal. On the left side Wernicke's fissure was very marked; it joined the third temporal. Median surface. — Left hemisphere — Calloso-marginal fissure normal. Parieto-occipital deep, and extended an inch on the convex surface. The calcarine also passed over the margin. The continuation of these two passed to the scissura hippocampi. The collateral joined the calcarine by a deep fissure. The con- volutions were normal. The precuneus was deeply fissured. On the right hemisphere, the calloso-marginal fissure passed far back, and was separated from the parieto-occipital by a narrow convolution. In its anterior half it was double ; one branch fissured the gyrus fornicatus in the front part. An ascending portinu formed the anterior boundary of the pruecuneua. Parieto- occipital was deep and marked, and curved over the margin. The calcarine was not so well defined. The united fissure ran to the scissura hippocampi, and also joined the collateral by a deep sulcus. The gyrus fornicatus was split into two portions. The precuneus and the cuneus were much fissured. The cere- bellum, pons and medulla presented nothing of note. Sum mar I/. — The two hemispheres presented a marked asym- metry in the convolutions and sulci. There was no special de- gree of confluence of the fissures, with the exception of those of the right parietal lobe. In both frontal lobes there was a partial splitting of the 2na frontal convolutions, and an approach to the type of four frontal convolutions. The secondary sulci and furrows Averc unusually abundant. RE-PRIN REM Prol Gentle-^ the last cl case were to hospital during this to Dispens was 103°F did not pre weeks with all the app( not grave ; were two i having beer while the fe muscles. A course was 1 cure rose to : was a consta quinine in 1. or two. On the highest 1 KK^KO^OMTHK "CA^^MKOJC.. . SHKOXC. .onH.... /.x ..■\ \ ; ili| I. mi ■!■ REMARKS ON CLINICAL CASES. Br WILLIAM OSLER, M.D., Professor of Clinical Medicine, University of ' Pennsylvania. aentlemen,--The case of Typhoid Fever which you saw at the last chn.c died on Monday. The prominent features of the case were: Illness of over three weeks' duration before comin. to hosptal-fever, headache, and diarrhoea ; in bed on and off during this period, but up and about for days at a lime. Came ZoT^ '" '^' ^'^' "'^^ ^'^ ^"^"^^"^d- The temperature jas 103°F. ; pulse 90, dicrotic. He was bright mentally, and did not present the appearance of a man who had been ill three weeks with fever. When you saw him on Thursday last he had all the appearance of a man with typhoid ; the symptoms were no. grave ; temperature not high ; pulse not over 100 There were two unfavorable features in the ca8e,_the fact of his having been neglected for three weeks and allowed to be about while the fever was on him, and the nervous twitchings of the muscles. An unfavorable prognosis was given. The subsequent course was briefly as follows : On Friday evening the tempera- cure rose to 105°P., and throughout Saturday and Sunday there was a constant ^ adency to elevation, kept down but feebly by quimne in 15 and 20 gr. doses, and cold sponging every hour or two. On Saturday the lowest temperature was 101-2° and the highest 105=. On Sunday it rose to 106.2^ He retained \ m'^il r^ f" Nit i'l i I I r i i •I f il III I ii ■ [ U^pIj M I; consciousness in a remarkable and unusual manner. He took stimulants and nourishment every alternate hour. Tlie diarrhoea was never troublesome, but the stomach became a little irritable on Saturday and Sunday, so that the quinine had to be given at times by the bowel. It is exceptional for cases such as these to get well, and when a man walks into your office complaining of fever, headache, and malaise, says he has been ill a couple of weeks and has been fighting against it, and you find his tempera- ture 104° or 105", you may expect a case of severity. As I mentioned at the las*- lecture, there is no worse feature than such a history. The nervous or rather muscular twitchings are also of evil omen, indicating implication of the nerve centres. They may even amount to convulsive jerkings of the head, trunk and extremities, and I remember one case in which the muscular spasms were so prominent that the disease was thought to be spinal meningitis. • Heart Disease : Action of Digitalis. — This old man, aged 75, you also saw at the last clinic, and he is brought in to-day to demonstrate to you the beneficial effects of digitalis and rest. He has mitral disease, which probably followed an attack of rheumatism in 1854. On Thursday last, three days after his admission, he was, as you remember, very short of breath, the feet and abdomen were dropsical, the pulse was small and ex- ceedingly irregular, and the amount of urine was reduced. He has had 10 rri of the tincture of digitalis every four hours, day and night, and has been kept (juiet in bed. The changes are : 1st, The pulse is slower, fuller and only occasionally intermits. Those of you who saw him in the ward-class the day after his admission will recall the extreme feebleness and the irregularity of the pulse. 2nd, The breathing is quite relieved ; he can lie down comfortably, and walking is not an exertion. Crd, The dropsy has disappeared entirely from the legs, and has almost all gone from the abdomen, which, as you see, is relaxed, and only gives indication of a small amount remaining. 4th, The urine has increased from 3 and 3J pints to G and 7 jiints in the 24 hours. He has been taking the digitalis ten days, 5i in tli6 day — not a very large amount, but it has served our purpose. Caisso to Hospiti also — or to which ' liable. 'I Sus(jueha the piers which the Until Sun ence, bey( shall refei feeling all the left le, the hip do home. It ( in it was j evening h( power was again ; w£ the legs ai particular] now quite staggers, i shut. Thi gerated ; i special foa to what th( his imperft often abou cramp of t ments. T always a f with the n leaving the died of th( lyzed in b many casei 8 ■ ^^ Caisson Disease. — The man, J, Farrell, aj;;e(l 80, who ciimo to Hospital yesterday (17th) with a heavy cold in his chest, is also — or rather has been — the subject of an interesting disease to which the workers in the compressed air of the caissons are liable. Two months ago he went to work at Perryville, on the Su8(iuchanna, where they are building a bridge, and in sinking the piers the workmen are in caissons, as they are called, in which the pressure may amount to two or three atmospheres. Until Sunday last (18 th) he had never suffered any inconveni- ence, beyond occasional " bends," as he calls them, to which I shall refer later. At 4 a.m. on Sunday he came up from work feeling all right, but before he could got to his boarding-house the left leg became numb, cold and dead, as he puts it, from the hip down, so that he could not walk, and had to be carried home. It did not appear to be painful, but he says the sensation in it was gone, h remained in this state all day, but towards evening he could move it a little, and on Monday morning the power was quite restored. He did not attempt to go to work again ; was too much scared ! There were some pains about the legs and arms for a day or so, and a feeling of dizziness, particularly if he looked up or looked from a height. He has now (juite recovered, except that on walking, if he looks up, he staggers, and there is a tendency to sway when the eyes are shut. The patellar tendon reflex on both sides is a little exag- gerated ; no ankle clonus ; skin reflexes normal. No oiher special features. He says that the workmen are much subject to what they call " bends," which, so far as I can make out from his imperfect account, are attacks of pain in the arms or legs, often about the joi-its, but whether accompanied by spasm or cramp of the muscle does not appear very clear from his state- ments. These attacks never come on while in the caisson, but always a few hours or less after they have come up. So also witii the more severe attacks ; they invariably come on after leaving the caisson, never in it. He states that two men have died of the affection, and that one man is now in hospital para- lyzed in both legs. In the building of the Brooklyn bridge, many cases of this curious disease occurred, and Dr. Andrew . ]■■'■. .-I ]• ;' ■ ii \ r ., '■■' n ; f!1 4 H. Smith of New York made a special study of it, and was, I believe, the first to j^ive the name by which it is now generally known. According to his description, it is characterized by pain in one or more of the extremities, sometimes with pain in the stomach and vomiting. There is paralysis, local or general, but most often in the lower limbs. Headache, vertigo, and coma may occur. Cases may prove fatal with these symptoms, and, post-mortem, congestion of the brain and cord has been found. In sinking the piers for the bridge at St. Louis, there were raai.y cases, and there were twelve deaths among the 352 men employed. The disease has been known to French observers for many years, and has also been met with in miners working in compressed air, and in sponge divers in the Mediterranean. There appears to be no dihiculty, in the majority of the work- men, in standing a pressure of two or three atmospheres, and, as a rule, no inconvenience is felt further than the temporary pain in the ears, due to the pressure on the drums, which dis- appears gradually. Naturally, there is a tendency for the blood to be driven into the deeper parts, the superficial vessels are compressed, there is less blood in the skin and more in the vis- cera. The brain and cord, enclosed in solid, incompressible cases, will also have an additional amount of blood. But this does not appear to produce any inconvenience, and men can work for hours under a compression of three or even four atmos- pheres. The danger is in the transition from a high to a low pressure, and, as this patient has told us, the men are never affected in the caisson, but always on coming up. The occur- rence of sudden death, or a rapid paralysis, suggest haemorrhage as the cause, but it has been shown by lloppe-Seyler that there may be a sudden development of nitrogen gas in the blood on removal from high to a low pressure atmosphere, and he attri- butes the symptoms and the fatal result to the evolution of this gas, the bubbles of which plug the capillaries in the lungs and ^roduce dilatation and stoppage of the heart. Bert states that in an animal under very high i)ressure, the blood, when with- drawn at low pressure of the atmosphere, will foam from the rapid evolution of nitrogen. The paralysis is probably also due to this cause, and in one case Leyden has found, 15 days after the onset of the jiaraplegia, lacerations in the cord, whicli he attributed to tlie action of the gas bubbles, distending and tear- ing the capillaries. Schultze, in another case— death 2^ montiis after the onset, — could only find disseminated areas of sclerosis. This really seems to give a satisfactory explanation of the cases, and in this man we may suppose that he has had local develop- ment of gas in the lumbar region, limited in extent, probably not destructive, but only expanding the capiliaiies and inducing a monoplegia, which disappeared with the absorption of the gas. Paul Bert found that if the animals which had been exposed to the pressure of several atmospheres were to be kept alive, the transition to the normal atmospheric pressure must be slow and gradual, so as to permit of the gradual diffusion of the super- fluous gas absorbed by the blood under the high pressure. So also it is recommended that, on the first onset of symptoms in men working in caissons, they should be submitted again to the pressure, which should be gradually reduced to the normal standard. Emphysema— Bronchitis.— 'm?, man, J. S., aged 35, came to hospital complaining of great shortness of breath and cough. When stripped, he carries, as you see, the diagnosis in the form of the chest and the peculiar mode of breathing. Inspection shows a short, well-nourished man, with a full, barrel-shaped thorax, into which the head seems set by a very short neck. Watch the peculiar mode of breathing. The inspiratory act is labored, accompanied with more elevation than expansion o?. the chest-walls, but the abdomen rises considerably. Expiration seems still more labored, and is fully twice as long as inspiration. It looks as if the air were forced by muscular exertion out of the chest ; and so it is. With each act there is very audible wheezing, most marked with expiration. The finger tips are a little livid, but there is no cyanosis of the face. On placing the hands upon the chest, ronchial fremitus can everywhere be felt, but most intense at the rig!, apex, in front. Percussion gives a hyper-resonant i, over the vario-.- regions, except the left base and lower axillary regions, where there is >'\ f /■< , ■ II u r I ! I I 1 ' t ^ > II mmmmmmmit^' ) i >'!> IP. U'^ .1 ■ ! In 6 defective resonance. On auacultation, there are innumerable whistling and soiioroua rrdes over the whole chest ; nothing else can be heard with both inspiration and expiration. The high- pitched ones are most prevalent. There are two places where there are special features. At the right apex the sounds are extremely hollow, and there may be here eitlier a cavity or, what is more likely, dilatation of the bronchial tubes ; at the loft base, with the piping rhonchi, there are many liquid riiles, and there is possibly here some infiltration— oedema of the lung. The cough is most distressing, frecjuent, and the sputum is got rid of with difficulty. It is tenacious, thick, and purulent. The area of heart's dulness is covered by lung, and the Hver is dci)ressed. The points in the history are briefly as fodows :— He is a jeweller by trade, and has used the blow-pipe a great deal for 15 or 10 years. He tells us that sometimes he would re(iuire to keep up the flame for 16 or 20 minutes, only inter- mitting enough to catch the breath. The family history is good, and he was always pretty healthy until three years ago, when he was laid up with a severe bronchitic attack for three months, and ever since he has been specially liable to catch cold, and has had four or five spells of shortness of breath and severe cough ; none have been so bad as the present one, which came on a week ago, with fever, cough and dyspnoea. Two conditions are here present : Emphysema, a permanent and irreparable affection of the lungs ; and Bronchitis, a transitory and curable condition, upon which his chief symptoms now depend. Two weeks ago this man could get about satisfactorily, and, if he took it quietly, could go up stairs without difficulty, whereas now he puffs and blows on the slightest exertion. The emphysema has no doubt been caused by the habitual use of the blow-pipe in his occupation, and every such attack as the present one leaves the lung in a worse condition than before. Just now the bronchitis is the main trouble, and the swol^.a state of the mucous membrane retards the access of air to the alveoli, while the loss of elasticity in the lungs renders expectoration very difficult, and the cough is in consequence hard and distressing. On his admission, he was ordered a relaxing expectorant (chloride of aramonni hours, ai poultices much SOI the righ symptom ■4 aramonium grs. x, with ipecacuanha wino "20 n^) every throe hours, and ah-cady, after two days, he is much relieved. Jacket poultices, fraquently changed, are very useful when there is much soreness in the chest. The existence of local trouble at the right apex may delay convalescence, but the bronchitic symptoms should disappear in a few weeks. ■''IP. ^1 t I' :l! I, I m < 1- ^i^:^ r V. ; )■ ■' i 1 I 1 ' \' 1; i i ■C 1 5 tl 1 J' ' f Jp j j;i : J ^ Ma B ( ki' - ■ ^ ' ■ - m I . ■ ; 1 1 rl! ISSrt.] A CoxTurn Clinical A Till', cns( seizures fix certain i'vnt Tlio prcs its origin ir tlie labors c jcot from t science, S corrohoratii study of p knowlcdjje ( tiiis nature oxpcctud ns years ago 1) or spasniodi associated w lie suggeste nature of ai tlieniselves, convulsion ( presidt'd. j reasonable t in each instii Avliicli wlien When OX] irritable, anc of detinite gi was seen in liim to indicj brain, and an bral cases bwi work enables of certain rej to be in tlie i fissure of Rol more or less 1 1 88.-5.] Osi. Kn, .Tacksoninn Kpilcpsy. /wK| 81 ^\>n AllTlt'I.K II. TUK caso hero n-conl.-.l iHnstraN. tl,.- following point. : Epil..p,ilbrm se....n.H ,rom a very li„.i,.„l l..,sio„ ; the situation if tl... l..„ . , " certain feutufes in thu clinical i.istory oC ti.e .lis.a.e " TI.e pn.ont .loctrin. of ccvLral localisation may bo sni.l to i,av. lut.l -.n.,n ,n t c stn.ly of tl. ,.,rcct. of vo.-y lin.itcd cortical IcJ^n the labors o Fntscl, Ilitzi,, Fcricr, un.l otluTs have n-niov.,'! scu n ,t. St.II, as far as man .s concernc.l, wl.ih, admitting the arcat an.l orrol.onu,vc value of observations upon .Io,s and monk:ys, t^ rl st...ly o patho og.cal cases offers the only n.eans wh.L ,y po , " kM wie ,e can he attained. Year by year in the past decade .'i. ,.'^ tins nature has been accumulating, and more important results mav b expected ,. the records become more exact and scientific. Fully Ltv years ago Dr. IIughlings-.Tackson. studying cases of unilaternl con N ,' or spasmodtc secures limited to one member, foun.l that they wen In assocated w.th localized spots of disease on the surface of the brai., , he ^.ggcsted, „. explanation of such cases, that the lesion S. T^ nature of an .rr.tant to the cells of the gray-cortex, whici> disch. d LemseK es, so to speak, in an irregular and explosive manner, c. ' pres.ded As the seizures began either in the arm, leg, or fhce. i, ■ ,s reasonable to conclude that the portion of the cortex atfe^t d was d ,1,., .n each .nstance,-. .., there were actually centres-motor in chan t^- wh.c when „.r,tated in this way caused the convulsive attacks. When experiments on animals den.onstrated that the gray matter wa^ jM^le and ,.at stimulation of limited areas was fallowed l,y co u-Z of dehn.te groups of muscles, Dr. Jackson's suggestion of m'otor t . was seen ,n .ts true light. Ferrier's observations on monkeys enabled urn to .nd.cate approximately the homologous motor centres in the human brajn, and an extraordinarv in.petus was thereby given to the study of e r " b.al eases bearing upon h,calizatio„. The result of the ten or twelve years' work enables us to speak with some degree of positiveness of the fun tions f certain regions of the brain. Thus the motor area has been ascertaiZ to le ,n tlu. nud-rcgion embracing ti>e convolutions on either side of the fissure Rolando. Irritative lesions of these parts issue in .onv.dsio ! more or less limited, destructive lesions cause paralysis, local or generalized ' Read before tlie Medico-Chirurglcal Society of Montreal. § 1 f 1 ., il / 32 O s i> K u , Jacksonian Epile[)sy. [Jan. i j 1 i 1 J according to tlie extent of tlie disease. The otiier areas of tlie cortex cerebri arc silent, quoad motor effects wlien stimulated, and when destroyed do not necessarily induce paralysis. With regard to further specializing of centres in the motor region, as tiir as man is concerned, the analysis of cases would appear to i)lac(; the leg centre in the upper part of the central convolutions, particularly the part extending to the median surface — the paracentral lobule ; tiie arm and hand centre in tiie mid-region of the central gyri, and the centres for the face and tongue at the lower end — a disposition in each instance coinciding more or less closely with the con- clusions arrived at by Ferrier from his observations on monkeys. Dividing cerebral symptoms into those accompanied with loss of func- tion negative, and those characterized by excess of function — positive, the cases of cortical epilepsy may be taken as examples of the latter c-rouj). In Dr. Jackson's phraseology, the proximate cause of the paroxysm is an abnormally highly unstable condition of the cells of the gray matter, resulting in a sudden discharge. "Healthy movement implies a liberation of energy or nervous discharge initially by cerebral cells, at any rate if the movement be a voluntary one. A convulsion, that is to say, a sudden, excessive, rapid, and temi)orary development of movements — many movements ' run uj)' into spasm implies of necessity a corresponding, sudden, etc., discharge." In a local spasm only a few cells are in tiiis highly unstable condition ; in severe seizures the sudden and excessive discharge of the highly unstable cells overcomes, it is sup- posed, the resistance of liealthy cells in physiologic.d connection with those highly unstable. These preliminary remarks will enable the history of the case to be more satisfactorily followed, and I may state too, the main jmints of differ- ence between these epileptiform seizures and true epilepsy ; the slow onset, local in ciiaracter, beginning in, or in mild attacks conlined to, one liml) or a single group of muscles ; the gradual extension until tiie side is involved, o", in severe attacks the entire body; loss of consciousness late, not early and sudden as in true epih.'psy, and lastly, the muscular contrac- tions are clonic, rarely or never tonic. On November 8, 1883, I received from Dr. the brain of his daughter for examination, and with it the following history : — E. L. M., aged If) year.- 9 mo. "When sixteen months old fell on her head from a table and appeared to be very much hurt, as she cried violently for a long time after. She appeared to i)e (juite well for about live montlis, when tiie left hand was noticed to close firmly, and it secMned to pain her a little from the iirnuicss of llie cutili'aclioii. Tills coiitinued to increase in severity and frecjuency for three months, when the left leg became similarly affected, and in two mon ths more she was confined to bed, and the paroxysms had beeome general all over the boily, the moutii being generally tixed open during These spasms lasted in t a spasm, his vioh Mit form for about two months, she having as many as eight or ten m an hour. There never was at any 1885.] time any Then sml ran about She rei in the sati and then and this v after the / and gradu To give describe o Suppose going to h hand.) }i down on t away in a through it place liie c After eii and short! the illness, of tliiU liin ing each i\ Iiecamc pe ciiair and r feeble, and as they woi the positior Last Chi suddenly cf time she be During a very much quence she remarkable. There we the legs beci after they ei During tl foot assumei would rcmo^ of this (lirly i'lu're wai tiie foot was fluxed ill thii Just ;i \ve( incrciising i\ days there v deatli tiie spi gostion of til leiiiperatiire very uuudi ci Just a W(>e No. CL 1885.] OsLKu, Jiicksonian Epilepsy. ^ 33 time flJlV loss of PnTl*:r»innc»i*i^-i 1^1 ' t i Ti,on s,-„i,i,.„iy th TviT ;,;,i,i r "'r,' '""" "'™"'« "i^g^i'". in »» r"';; ":;;;r;.:;r„',';,T :r"™" '" ■■"" '^"'' "•'"■■""°y '«""-« oftli.l ii„, ? "«i''"y*»J"'- years, mul.lnriiu. six weeks 01 tli.il nine ,.he lay ;.neon. ,n In, tcul(,aM.l he joints ot the fm-ers would hen.l nearly as far h^iekwir I fool'Zll^i'l'^tlSi'l^^n ''"'""'' first the n,l,t an,l then the le.t "■'>"M . ' o : n "f^Ml "■ iTI";"""-^' 7 ' ^'l' '"> =nnount of washing ■lays .1.,; ';;;i";:^ ;,r u i:r:;;:::4' ;;:;,,™"'v,r;:' ;-" '»;■ ?- '"7 '■" ;"f «'»' ""'liii"" "f ii„. v,,,«i, „V,i,„ I,, '•' '"'■''"' " No c'rU'vn ■''"; "'"■ '"''■ ""■ "'"■'"•' '•'■' '"" -' •■'" "»• "> JNo. CLXXVII — Jan. 188.5. 3 I P )l (in w / f '•^: 34 OsLEu, Jiicksoniiin Epilepsy. [Jan. liiive a post-mortem, as she know her case was a peculiar one, and that it mitrht h(! of benefit to some one else, and to the medical profession in particular. In rejily to questions, the doctor supplied the following additional infor- mation : " The spasms always began in the left hand and nnver in the leg. For about two months at the beginning of the illness the hand just closed firmly for a few seconds, and there was no twitching, but after the expira- tion of the two months it always twitched from the onset of tlie spasm. Frequently she could be seen standing with the hand closed and jerking before the leg became affected, and she had to lie down. 'Die spasms ' ere never confined to the left leg. When the leg did become involved ilie twitching began in the toes and ran up the limb. At the first the arm alone was affected. When tlie spasms became unilateral, the face would twitcli and the eyes roll to the convulsed side. Tlie left arm though feeble was not stiff, and in the same useless state as tlie leg. Tiie clinical iiistory may be summarized as follows : .lacksonian epilepsy lasting over fourteen years ; the convulsions beginning in the left hand, at first monobrachial, then extending to the leg, afterwards becoming uni- lateral, and finally general, at first without loss of consciousness. For the first nine years of the illness, remarkable intermissions lasting for six or seven months, once an entire year. Six years after the onset the left leg got weak and stifle For four years, the tenth, eleventh, twelfth, and thirteenth of the illness, the seizures frequent, during this period, six weeks' unconsciousness in which the spasms were very freciuent, fifty to eighty in the day. Ten months prior to final attacks freedom from con- vulsions. Intellectual faculties unimpaired. Brain examined on Nov. 9th ; organ large and well formed; dura nat- ural ; iiemispheres symmetrical; no special cloudiness of arachnoid; I'acclii- onian granulations small; large and small vessels of pia mater eniargcil. and gave a very congested appearance to the surface ; no adiiesions of the membrane; no s|)ots of ojiacity or tliickening; the pia mater stripped oil' exposed natural looking convolutions of a deei) [)ink-gray color; motor convolutions looked symmetrical, no puckering or depression; vessels at base iiealthy; right crus badly torn. The cord was cut just at junction with medulla, in the lateral as|iect of which tiiere is also a laceration : tiie organ was sliceil after tlie Pitres method. J-'rc-froittal imd pcdicii/o- frontal sections normal. A section passing 3 centimetres in front of tlie fissure of Rolando shows notiiintr abnormal. In makinji the frontal sec- tion tiie knife met witli increased resistance on the rigiit side, and the section whicii [lassed through the ascending frontal convolution, exactly 2 cm. in front of the fissure of Rolando, exposed a firm fibrous mass occnpying the upper part of this convolution in tht; superior fasciculus of white fibres. It mt'asured 14 mm. in width l)y 1.") nun. in vertical lengtii, was 8 mm. from the surface towards the longitudinal fissure, 10 mm. from the top of the convolution at the margin of the long fissure, and 1 ") mm. from I he external surl'ace. It ran up to the gray matter, but did iiul ap[)ear to involve it except towards the median uirfiice. 1885.] 18B5.] OsLER, Jaeksonian Epilepsy. 35 In a section 7 or 8 mm. beliind tha fronln/ tlie mass was still visible as a small romiil piiekere.l area, sitnatcil" just at tlie ein the upper end of the ase. frontal ^ryrus, bavin;: an antero-posterior extent of about 17 mm., and a vertical diameter of lo or IG mm., almost entirely within the white substance, but bordering on the gray matter at several places. Unfortunately the torn state of the crus and medulla made it impossi- ble to trace any descending sclerosis in these parts. Histologically tin; growth presented the characters of a tirm glioma, consisting of 1st, and chiefly, a dense felt-work of fibres, in places coarse; and devoid of cell elements; 2d, cells of various sizes, branched and fusiform, the processes of which could be directly traced in connection with the fibres. Towards the peripheral part of the growth the cells weri-. more abundant; ;5d, bloodvessels pretty numerous and large considering the amount of fibrous tissue in the mass. The growth shaded into the contiguous tissue in a very characteristic way, and towards the gray matter th(;re was no sharply defined border, although in tiie microscoi)ic sections it was easy to see where the normal tissue began, and there was a zone in wiiich tlnu'e were scattered a number of deeply stained small cells like leucocytes. In most of the sections the ganglion cells of the contiguous gray matter looked normal and their nuclei took the logwood dye as usual. On the side of the convolution towards the fissure of Koiando the growth directly involved the gray cortex. A study of the sections did not appear to bear out Klebs's view tiiat the ganglion cells i)articipate in the growth. The case is unusual in the limitation of the lesion to one conv of muscles in an extremity, or to the entire limb. Thus, in the case of the patient with this disease, wliich I showed at the society some months a2<>, there was braeiiial monospasm, and in the one under consideration, the doctor states that the child might be seen standing while tiie arm wa^ convulsed. The order of spreading is important; it is usually up a limb, but it may be in the opposite direction, and in the event of the monospasm extending it is more common for the face to be involved with tlie arm, or vice rersn, and tlie leg with the arm, than the leg with the face. Herefrom wliat can be gathered the order of inarch of the spasm was up !lie arm, then the leg became affected, and afterwards the face. This is unusual ; it is more com lion for the leg to be affected last. Com[)lete details, liowever, of the precipe secpience of the spasms are wanting. pAidently at first tiiere was brachial monospasm, then extension to the leg, and later hemispasm with rolling of the eyes and affection of the face muscles. "Within six montlis from the origin of the trouble the seizures had become general, but the doctor says there was up to this time no lo.-s of consciousness, such as subsequently took pla(!e. The extension of the convulsions to the other side is explained in one of two ways; either through tiie direct pyramidal fasciculi with which eacli side of the brain is connected in a greater or less degree with the same side of the boily, or more probably, on Broadbent's t'ieory,tliat it is owing to " active conditions of the decussating fibres putting in action the associ- ated nuclei of both sides of the cord, and then the bilaterally acting muscles of both sides of the body." The discharge of the nerve cells of the cortex cerebri excites the motor nuclei of the cord, and the violent impulses p.iss from the spiral ganglia to the muscles. Now it is easy to conceive that when the discharges are excessive and violent, the ganglia of th(! other side of the cord may be excited through the commissural fibres which unite the nerve cells of the anterior horns. 188").] ■€ ■„ ^^ 1885.] Osi, KR, Jiicksonian Epilepsy. 37 The long duration, fourteen years, of a glioma, is not \vitI.ont ..arallel. Dr. .Tackson l.as nM-orde.l two cases, iu one of wl.icl. the fits lasted ten, and m the other twelve years. Cerel.ral glioniata are benign growths, which grow slowly and never produce metastases. _ The other feature of interest in this case is the light it throws on the situation of the leg centre. Ferrier placed this in monkeys at the "vri at the upper end of the fissure of Rolan.h., and the result of patholo-ind in- vestigations in man point to the same situation. Cases of unconu.li<-Mted crural monospasm, or monoplegia are not common, but in the observations analyzed and collected by Ferrier and by Charcot and Pitres, the lesion was in each instance in the upper part of the central gyri, or in their ex- tension on the median surface. When this part is simply irritated, there may be spasms beginning in, or limited to, the foot and leg : when the seat of a destructive lesion there is crural monoplegia. In their latest w.uk,' MM. Charcot and Pitres bring forward additional evidence in support of this view. In tlie case here recorded, the Hbrous mass was situated entirely within the anterior part of the paraeental lobule, limited in ex- tent, confined chiefly to the medullary fibres of the superior frontal fasci- culus, and only touched the gray matter in places. A point to be referred to is the absence of the paralysis of the leg for the first six years— for if the convulsions and monoplegia were ca-sed by the same legion, how ex- plain the late onset of the latter? From the fibroid state of the tunuu-. it migiit reasonably be inferred that it was originally larger, and had shrunk, but the absence of [nickering on the surlkce, and the way in which the margins merged with the contiguous parts, make it probable that the growth was always small—so small, in fact, that at one period of its de- velopment it may have caused sufficient irritation to induce the convul- sions, and yet at the same time not involved the special fasciculi of white fibres to the extent of producing weakness of the leg or monoplegia. In the clinical history, the duration, fourteen years, is the most remark.ible feature; it is rare for cases of cortical epilepsy to run such a prolonged course. The irregularity of the seizures, the long intervals and attacks of coma, which characterize so large a proportion of these cases, are phenomena not less difficult of explanation here where a lesion is present, than in cases of ordinary epilepsy in which coarse alterations are not usually met with. ' Revue de .\Waecfne, Octobre, 1883. ( i-t i!i» (IB :■ : r 1 t' I III i k 1 * r Va n. 15 1 1! n i: n . Intermediate Hospitals for Mental Diseases. [Jan. Ainici.K III. InTI'.KMKKIATK HOSIMTAI.S KOK TlIK TliKATM KNT OK Act'TK ^IkNTAL DisKASKS. By John Van Biiu!i;u, M.D., of Baltimore. TiiK nervous .system lias of late yeai-s claimed the attention and study of till' best medical minds of all countries, and it is now an evidence of a still fiirtlier ])roj,rr(ss in tliis direction, that mental diseases are no longer allowed to remain in the hands of asylum-sujierintendents, but are begin- ning to demand the care and investigation that they undoubtedly deserve from a larger i nd more active class of s[)ecialists. It is by the medium of this development that I have been led at various periods, during the past five vears, to investigate the plan of treatment and the management of insane asylums, both in this country and in Europe. And everywhere, both at liome and abroad, I have, been impressed with the lonely and isol.'ited position which mental diseases hold in the e.stimation of the geiu'ral profession, and I may add, in the opinion of those who devote their lives to the care and treatment of insanity. Indeed, it must seem strange to any one wiio will devott; much thoiiglit to the subject, tiiat acute mental trouble should be segregated like small- pox, or some dreadful contagion, far removed from most humanizing influ- ences, ami immured in more or less tlreary, but always crowded asylums, where each patient, whether irritable, excited, or convalescent, is forced into the companionshi[> with hutatics, and where both patients and physicians sutler the evil effects of a moral and social quarantine. Now, although a man either of sound or unsound mind can endure the enervating and dispiriting effects of life under the blighting influence of a shadow, which makes humanity look hideous, and makes etlbrt seem almost useless, yet it is a question whether the physician or patients are at their best in such an atmos[)here, whetiier tiie one can progress and prosper in his science, or the other derive the best advantages from a delicate and careful treatment. It is, in fact, a curious tradition, which is blindly accepted by most people, that insanity differs entirely from any otiier form of disease, that it must be removed from sight, and, if possible, from remembrance, and treated only by medical men wiio live within the walls of an asylum, and devote tiieir lives to the care of *lils class of patients. No less is it a matter of general belief that the institutions in which this malady is tivated are not hospitals but asylums, tliat their use and purjiose, tlioiigh known, is in some way mysterious, and tlieir existence stands outside and apart from the ordinary ministrations of men. TiiiT uncanny reputation is clearly the result of prejudice, and to some extent the result of the {)resent system of treating and caring for a most unfortunate class of sufferers. It is the remnant of that feeling which. 1882.] to a general lie the onl\ rational and bi-i('lly and, bring us bj' niciliiiitur." 150 Mauiso (»N 1"( iiixo ]M.I!.C.r. Lecturer o Mdiitrciil ( 'riii: accii the dog jiroi affect ion i)re where the h insure easy iincoininoii, to occur dnr in America give an accr in ciiiinectic ami till' (loin I could not 1 ease was coi it is rarely iiistanci's ha The fbllc nnisciuns, jo cast's came i Cask 1. S fur the chiss Faciiltv, in 1 iiionia. No history. 'I'll (ll'tllC I'i^rllt 1( graiiildiiughti Jlfisji'fal JU], Cask 2. ( All Italiiin, a Hotel Dieu v> 1^82.] Osi, i; It, ]'A;liin()C(K'('iis Disciis<' in Amcri.'a. 47.1 to u jrciionil i)ViH'tilinncr, siiu'o the conililidii of llic rvcs iii;iv oftciitiincs Ik- llic only olijcctivc Mniiitoin wliioli will ciialik' liini to arrive at a rational and scifntidc diagnosis. In I'act, .inch consiiliTations as wt-i Iiavc liric'dy and, consciiiirntly, Imt inipcrrfctly >/\\r\\ in llic I'orcuoinu' ]ia>_'(i.H, lirin^ ns liack to ilif linic-iiononrcd maxim, 'M^)ui bciK- distin^tiit, hcno nu'diliitur." 150 Mauisox Avji.Mi:, Nlw Yoik C'iiy. JL x// nu Ainici.r. XII[. On I'.cniNocorcrs Diskask in Amki.ka. I'v Wiri.iA.M Osi.i:!!. ]\I.D., I\r.l!.(M'. Jjiiiid, ; I'rofcssor of file Iiistiliitcs ol' Mciliciiic, .Mcdill l'nivi'rsit\ ; lActnrcr on I Ii!inintliolii;j'y, Montreal Vi'teriiiMry College; P!iysici:ni to the IMontreiil (ieneral Hospital. Till' uocidcntal ingestion of iIk; eggs of the tiny Tcc)i!ii vchhiococciis of the doj: jirodnees the most sei'ious and fatal parasitic disease of man. The atlection prevails extensively in certain conntries, as Iceland and Anstralia, where the liahits of the ])eople or the relations of the canine host to man insure easy means of cominiinication. In Europe the disease is not uncoinnKni, and at any one of the larirer (dinics several examples are sure to occur during the session. So far as I know, {\w facts of its occurrence in America have not becMi investigated, and the object of this paper is to give an account of an inipiirv into its prevalence. I was led to make this in connection with an annual course of lectures on the parasites of man and the domestic aniniids which I give to medical and veterinary students. I could not ascertain, from any writings at my command, whether tht; dis- ease was common on this continent or not. In this si'Ciion of the country it is rari'ly met with, and in the inspection of over 8(10 bodies only three instances have been fouml. The following cases, 01 in nnniher, have be<'n collected fnun the mnseums, journals, transact icuis, ami from private sources. The tirst three cases came under my own observation. Cask 1. Single cyst in liver. Tlie specimen was fouml in a subject ])rn^•i(]e(l fiiv the class in operative surgery (liu'iiig the suiuiiier session ol' .Metiill .Meilieal laciihy, in 1877. The man had been a tramp, and dieij in the hospital of \)\\v\\- nienia. No iiiforniation could be ol)tained from him as to his nationality or past liistuiy.^ 'I'he e\ st was the size of a large oi'ange, and occu))ied the ])r>sterior ])art ot'tlie right lobe, in close contact, with the diajihraufni, 'i'hi'se were dauLditer and gi'anddanghter cyst, and the scolices were well developed. Montrtdl (leiicral Jlosp'tal Jh'portii, vol. i. 1S80, p. ;;] 1. An It vsio 2. Cysts in liver, spleen, stomach, omentinn, mescMitery, and ))el\ Uian, aijed about Hotel Dicu on JNlav 1st, l.s,s(l, al 1 resident ot' the eitv for four vear? ter an illness of about six Died in th The chic ■ ^1 'I7r. OsM. It, Ecliiiiococciis Disraoe in Amorica. [Oct. 1882.] ., ■ i'r. syiniiloiiis wcvcciilMi'iffniciit of liver ;iri(l splci'ii, willi lunliilMr tiinioiii's in aliiloiiiiii, in'ri:iii:ir TcviT, swciits, iiliil ciuMciiition. Autopsy ri'vciilcd tlic tollowinjr : Liver <'iil;n';:i'(| mikI closely liuitted to the stom.ieli and oiiientnin. Spleen projected lieyond tliecr)stid liorderaiul readied nearly to the crest of the iliinn. Allaelied to tilt' root of tlie nu'sentery hy a narrow |)edicle was a lai't'e |)ear-sli;ipe(i cvst the Sizooi'tlie list. ( )nieiiluin contained several small ones and the parietal perilOnenin five or six, one niurli llatteniMl and with four sididivlsions. A lari;ec\st. the sizo of a cocoa-niit. fdled the entire pelvis ami pushed up the Madder to ii level with the ui\\v\ and conipresscil it a^'Min-^t the anterior alidominal wall. The livi'r was p-eatly enlaru'cd lint retained its shape; the nnder surface ami anterior edn-e were closely united (o the stomach and colon. The lel't lohe was as lar^'c as the ri"ht Jiiid 1 tained two cysts, one in the anterior and the other in the posterior part ; lioth contained pus and shreds ot' eciiinococcns mcndii'anc. 'i'he anteiior cvst had l)erforateil ilu' stomach in two jilact's and the dnodemnn in one ; the orilices havinj^ .smooth lirm ed(.'es. There was a lar^'e cyst lit the fnmlns of the stomach, com- pletely within the wall and covered hy a very thin iiiiicosa. The spleen pre- sented tln'ce small vesicles at the hihis, and contained a siiiLde c\st the size ot" a cucoa-nut everywhere inclosed liy spleen tissue. (Unpuhlishcd. ) ("ask;!. Obsolete cyst ill liver. J',iii;lishw(>maii. aL'ed alioiit Ki ; dead of piieu- nionia. Ilooklels in the cri'taceoiis debris, (rnpiiblished. ) CASh: ). Cyst in liver. Xo history. Specimen, with those from Cases 1, 2, ami ;> in tlu' ^luseiim of the Mctiill .Sledical .School. ( rnpublishcd.) Cask ."). Cyst in liver. An Icelandic emi;.'rant woman, patient of Dr. Hu- clian, of Toronto. Cured by a single asiiiratioii. Scolice.s in the lluid. (I'n- pnblished.) Casi'. (I. Cysts in liver and ])elvis. Dissectliiir room snbiect ; female: To- ronto School of ;\Iedicine. Two cysts in the liver, one of which had ruptured into the intestine. A third was atlaclu'd to tlu' walls of the jielvis. (I'npub- lislied. l)r. 1. 11. Cameron.) Cask 7. Cyst of liver. Yoiin and (1. ( Ciipulilished.) Cask S. Obsolete cyst of liver. I'-nglishmnn : inmate of Kingston liisaiui Asylum for 1 7 years, ('uimdiaii .IihuikiI of Mtd. Sciuiices, Aiiif. 1882. Cask !). Suppurating cyst of liver, bursting into lung; cyst in s])leen. J'lnn- lishman, ageil l'!», residi'iit of Canada for live years. Dr. IJlack, of rxbridi:e, Out. (I'npiiblished.) Cask 10. JCeliinoi'Occi in brain. No. .'jCi; Army .Meilical Museum, ^\■asll- ington. Cask 11. Cyst in anterior edge of liver. From a luulatto. No. (;.")! Army ^Medical ^Iiiseiim, Washington. Cask 12. Cysts in lung, spleen, and bladder. Pole, aLre><. Cavity at apex of l,.ft lm,j, ,.o,it.,inin- eel,i,„„.oe,.i. Same eolleeiion, Cask •.'!». Cyst in liver, from a sailor dead of phthisis. Same .•olleetion. No. Cask ;((.. Cyst ..liver. Dr. ,Ia<.,l.i. rrm>sm-li„ns „f \r,r Y„rk I'utlin. Ici/iriif .\)ctil)/, vol. 111. C.\sK ;!1. (V.ts in peritoneum, in -astro-splenie epiploon, attai'lied to spleen and hver, and one in the pelvis. Woman, iut. 2',). Dr. .Metealle. //,/,/. CAsKli-i. Kehhioeneeiis of the eommoi, hile-diK't. Old man, with eiilanr,,! iverand deeply laiindiee.l. Common diiet Moeked with a polvpoid ti.mo,ir7iie Sl/eot thethiiml., wliieli eontained three eeiiinoroeei. Dr. AieCready. /lu,/. _ Cask ;!;f. Cyst of liver. .Alan, a-t. ;)H. Dr. Loomis. Perhaps the'spe.im'en 111 museum ol I nivorsity of New York. //,;,/. I'tinun Cask ;M. Cyst in reirion of liver. An Kiiirlishman, a-e not mven. I'assed our niiarts ot mat.na eontainin^r ..,|,inoeoee„s shreds; also vomitin- some of them. Death Irom e.xhanstion. J)r. Kevs. ////,/. C.vsi: ;(,-,. Cvst of ri^rht l,,!,,. of liver. " Woman, a-ed 2!!. Opened hv eai.sti.. and iiK'ision. Death. J)r. .laeohi. //,/,/. ' ' Cask ;;(i. Two eysts in liver, ri^dit h.l.e. (iernian, sailor. Dr. Cory. //,/,/. Cask ;!7. Cyst of anterior horder of rijrht iolie. J)r. Finnel. //„',/." y/.iVA "'■ ''''■ ^- ''' '" "'''"''■ ^^^""'"''^ ''•^' ''"■i'^i""-r^^<-'Overy. Dr. N'an li.iren. Aion:> claH.'- II;. '''"'■ ''''"'"' ''^' ^''^'''''^ "'"^ i.-sion-reeovery. J,r. C.^.sK 4.1. Kehinoeoeei vomited. A woman, vomited at dilfereiit times ahout .. lit ol eehMi.,roeei, supposed to eome from liver or omentum-reeoverv. J)r. JV1(H1/(I V iJlt'K . Jffiff, Cask 42. Keh 1. A.sK 4_' hei.iiiocom expectorated 7oin the limes. An EiMdisIimaii wh,. .d coiue irom Honolulu. Dv. Jiernays (Sen.), St. Lonis, Mo. cTj.ipuhlishe.t I^i^v" ^'< ^'W'!' I'''''^' ^;'''^''' '""■^t "'fo <•"' I'o^vel. German woman. J)r ISeriiays (Sen.), St. Lonis, Mo. (Uniiuhlished.) Ca.sk 44. iMnltiloenlareyst of liver. A iSavarian. .-ured ;^!i. Dr '«)■*■ M(<1. and .■^tirn. J (J. Jon null, Aiii'iist, Is;; Dr. J>ean. .S'^. Cask 45. Muitiloeular cyst of liver, fro Cask 4(1. Cvst of li of J'/,i/(i(lc/j,/ita, vol. n a nejrro woman. Dr. Dean. I/,;,/. ver. Man, aged 32. Dr. T IV. y.son. Trans. I)/ Path. Societi, rm > 1 1 , J ■ II' iW :! -17.S Osi, i; u, lOcIiiiiiii'di'c'ii.s Disease in America. fOet. issu'.] ('as|.:.17. ICeliiiKicdeci lit' liver , Mild [lelvis. FrenihiiiMii, ;i;.'e(l ,'1:.'. |)r. lliilrh- iiisim. //'((/. Cask is. 'rmiionr in ri;;lit li_v]M)eli(iiiilriiiiii (liver) tur several veiirs. Kxpeetu- ratiiiii of eeliiiKieoeei — reeiivery. Wdiiiuii, a:,'eil ;i"). Dr. Aliiiot. I'msliin Ma/, (iiiil Siirij, ,/i)itriiiil, vol. 111. ('a>4K -I!». ICeliinoeocei jiasseil per reefiitii. Wcniiaii, iiLreil ■_'!!. I)i'. Slieraril (Mi)liile). Mnl. uikI Siiri/. I!i jKnli.r, Is71. (-'asi; .")(». ICeliiiKicdeei passed pel' reelimi. Hov, a;.'ed hi. UidoTiiiiial tiiiiioiir tor siiiiie time. Svinplcans ot' olistriietinii of tlie liowels. i,eeoM'r\ al'ler liie passaj;e ot' a iarfre iimiilier ot' eeliiiidcoei'i. I)r. Siniiiioiis. Pnriiii- Mul. ninl ■'^11 ri/. .liiiniKtl, iMtlt. Cask,")]. t'\st ill (.'astro-liejiatie nineiitiiiii. Woman, in liellevne Hospital. Svm|itoms — pain, janndiee, ami jieritonitis. Ileliiiioeoeiais cyst lav aloiii; ilie eoinmon duct and compressed it. Distension licliiml tlie site of pressnn, and rnpture of the duet. l>r. I'olk. Mul. mid ■'^'urt/. J'ljxiitcr, vol. 42, isso. Casi-; ,">2. I'a'liinococcns of lirain. >.'() liistory. Specimen in Cincinnati. Authority ot' |)r. llyndnian, Meilical ColU'jfc of ()hio. Cask a;). Cvst in liver. No historv. Dr. Ihndman, of Cincimniti. Casi-; ,54.' Cvst in fasei,i ot'iieck, Dr, S AiKtrifiui Ml,/. 'J'iiiics, LsiJl. Cask T),'),' llchinoeoecus of Inng. F. (i. Smilli, Aml/t Aiiitiiian Mtil.-C/iir, J!(ri):ir, l«.").s. Cask ,')(;,' Cyst in liver, J. K, AVeliher. y, w Vor/: Mc. Dr. (iross. ]'(it/iiiliji/icul Andtoinij, 'id edition, liS4."), p. Ijl'r2. Cask ijo. Cvst of liver,' I'haritv Hospital, New Oilcans, Anthoritv, Dr, H. V, Ogden. Cask (II, Cyst in liinu'. cured hy incision, Italian, aged ST. Dr. FenL'er, .i]in. .Iimrnul .Med. ■'^rienci'.i, Oct, ISSl. The distribution of tlic cysts throii^'lioiit the orizans of the body in tiiis series of cases was as follows: Liver II, spleen I, perit(jiieuin, onieiitum, and iiiescntcry 7, pelvis I, hinj? ,'t, iirain 2, abdomiinil wall 2, stoinaeli 1, bladder 1 , sulicntaneous 1, bones 1, in common bile-dnct I , dischar"e(l from intestines o, vomited 2, cxjiectoratcd 2. This list, imperfect in niiiiiy particulars, represents the tivaiiable Ameri- can cases of the disease. Doubtless there are many nnrecorded instances; indeed, tw:dve or more of those here given have not been bel'ore published. It is evident that crhtiiocovcus lioininls 's ti \ery rare affection in this country. Unfortuniitely we cannot say positividy how many of these eases were truly American, /. e., orij^lnated here, and how many were importeil, but in sixteen it is stated tlnit tlus patients were Europeans. In the majority the ntitionality was not given, but in all probability at least one- • Tliose three easci are (luotcd by Cobbolil (Parasites, l«7!t>, but Dr, Hriijluun, uf tlic Boston Medical bibrary, could not fODllrm the references. '■■ I iiiiBluid tlie notes kindly sent by i)r, O^den, but, so fur ae I can remember, it occurred in a wouiuu, a I'oreiffiier. ^■^ 18H-.>.] Osi. r. i;, Ki'liiiioi'dcnis Disciisii in Anii'ricii. •9 thinl of the cmscs wciv ini|i()rl<'.l, Iciiviii-j; (inly al.-.iit t'oHy native ciiscs. Tliis inmumily may !..■ di... liili.T i,. scarcity of tlic a.liilt worm ur u, Hut al)scMci- of conditions tiivouraliir to tl.c intccii,,n of man. Tlic /,i;u'/r rrh- imx'orviis is ciTtaiiily a raiv parasit.-. In -onic scores oC do-s u liicl, I liave examined .im'in- the past lilteen years 1 liavc never met with a siM-cimen nor .io I know of ii,s det.-ction i.y any A rican oliMTver. Kvcn in Knjrlund, ulieiv tiie, diseaM- is loieral.ly common (.ome oi' the meiropoiitan mnsemns liav<' IVoin tweniy-live lo ii,irty s|iecimens <,!' < eii- inocoeci), Col)l)old states lliat tiie only e.\am|,|es ol tins Sj.ecies liiat iit.i knows of iiave l.een reared ex|ierinientally. Tliat it is jircsent in dogs in tills comiliy t(. a .irivaler extent tl.an we mjolit snpi.oso from tin; ahovo fads is shown hy tlie occnrrence of echinococci in ihe lower animals. In casual visits to hatcher stalls and to the shamhhs I have ohluined six or ei-;ht lar-ie cchinococci, and I have the liver of a cat with two larfje cvsls. One of my slnd.'nt^, .Mr. A. W. Clements, ol' Lawrence, .Mass.'! e.xam- ined J7(» iiogs at the .Ahmtrcal ahalloii' and f. 1 III animals alfected. I ilo not km)W of any systematic examinatiim of u iar^a- imndier of aninials, hut Dr. Dean writes that a considerahle proiiortion of the hogs slanghtercd in Si. Louis are infested, and Dr. (iross, in iiis '• Pathoh.gical Anatomy," l«-l,"), slates thai one-lenih of the hogs ji, ('incinnali were at that time aileeted, ami speaks of "whole droves, consisting of three ur iour hundred animals, all of which were diseased in this way." The conditions for the devchipment of celiinococcus disease in man are cerlaiidy present in the coinilry, so far as the existence of the adnli worm is concerned, and the immimiiy which the peoi)le enjoy may reasonahlx- he altrihnted to the existence of sanitary arrangements which reduce "to ii minimum the risk of infection. Inlike the t\, Klt!|iliniitiaHi4, [Oct. jrci CdtjiId^riH' of I.ild'iiry of Siir;.'i'()ii-(icn( Till'- ( Hlic<'. In Dr. N. S. Davi;* (iml l)i'. liiillirlil of Cjiiciij^o, Dr. lii^rlis nl' Diiniii. D"s. All iiihI Diaii ol' Si. KdiiIh, Dr. Ilymlniaii , C'aiiinlii. TllK following: oast', wliicli, with sonic ln'silalion, I have calli'il '' clc'iilian- tia>is," is ill soiin' resi>ects so iiniiiiic, llial I lliink it .slioiilil lu! rc|i(irtiil 1 |iri'-;rrv('(l in sonic journal, tlio projicrty of tlic grciit body of the jiro. an lession. Joiin A., now nearly twenty-one years of i\, of (lenniin ))arentaiic, firtit came uiKJcr my iiotict; soini; eijjjlileeii years w^n. Fallicr iniiiiiirratcd to tills cDiiiitiy wlicii a mere cliild ; inoilier, I think, was iiorii here ; tiicy li\ed all Iheir lives in a healthy rural district, fanners hy occii])atioii, |ierleelly heallliy, and parenlsofa la r;.'c family. The mother showed him to me, sayin;.' that one of his lc;;s was too long. She said that at hirlh he was a lar;:i', wcdi-fonned, heallliy eliild ; that when ahoiit two years old he had the ri;,dit foot slij,ditly hurl, so as to make him lim|) ; that as she knew. or thou'jflit sla/ knew, the cause ot' his lainem he made no suecial ex- amination of the limbs until some four or live months after the injury, when she found the oppositfi leg, the left, to be coiisideraldy the longer. I was at this time away from home, and she had consulted a medical friend. J found the boy was about three years of agi', with the left leg an inch amt a half or two inches longc-r than its fei low. The limbs were ,-m- mctrical as to the thighs; below the knee the right leg was normal in slia|)e liut look<-d small ; the left was much longer, and had a ]Mcidiar loose, tlaliby aiipearance. T lere was no si^rii ol a cal The skill seen to hang loosely, as if too large for the leg, which, larger than its fellow at the head of the tibia, increased in size to the malheoli, where the su|M'r- abundaiit skin and cellular tissue hung over and covered a small and shapely ankh'. 1 was puzzled by the case, but finally concluded that there was an arrest of growth in the right leg, which had been injured so as to cause lameness ten or twelve nionihs bet ore but [l-i to the 'J' leenliar appearance of lluf lel'l leg ] could give no o|)inion. The mother told me that the medical men who had seen the case before nie, gave her the same opinion that 1 had. I saw the child occasionally on my visits to the neighbourhood, or when tllen(iiii I '',} (hf 1 n^Hi r * ) I y 1 ! II 1 } i I I l^ ] ||:>U I THE GULSTONIAN LECTURES, MALIGNANT ENUOCAUIXTIS I., r , "'' ^^'I^^LIAM OSLEi; M D ^"Ml> „l lVm,.-.ylv«,„a, l.i,ila,|,.|i,|„a. LEOTUKE 1. 'l-'ect.on wo nuiy look for T u tf , /vpin !' ""^ ^-^ "«''■■"""' in Xt your ,u.nnis.sion, sir, I iw-, ,t' 'in h" ''■''"','" ^''° '"f'"''- AVitl interesting disease 4n(.inllv,\ f''"' '" '1'" case oC tliif ,nl ^nk.., nnn whoso invo^^u , t"lv;^■'t'"'"^^'>' ^I-e'late D '^^u. Joubtless recall, and reca vf, , "'"' "*''" ^" "'« to-day valvular allections of the 1.^ !'"'';'' '''">' '^'''l «o aldy with ''"»;. '"u« I the past twentv-fiv;.,ri ,":'';'■'"••': '" .^''^'"' "ill «!. w i-ardiao disease, more liartieuk rlv fn ''■''•;'"'"-■ to ^viden our view of 'U'J the association of\alvS i, II " ,nT'''' '",*'"' '•'"'^■^■t^ "'' '■- 1 o J'sorder, and the ,,robahle cSieioo •';'/," T'"' ^"''■' ™"-stit.i.io al f-many, a la.^e au^un oH ;! .il|'] ^^ '""' '^ ''^^ "^ t.^.i ; and w t le .hsease have been fairly" wH '• ''"'/ ="'''t""neal rha arte > f "''o"t as far towards u 11 k^vh'rf '.'!"''' i""' ^l''-'* «« h v ■ . --aus at our dis,,„sal w H ", S" ^ '" '''^;'''°'' ^^ ^he ord na J •y-nptonis a„.l lesions, w r e^h lei.t o 'h''".'" ^''^ -^'-'^''''iptio. of ar^htis; and these, with th/^ i^';!;^!'!' °f "V>'lS"a"t eniH^ tiio General Hosptal at Mn.,f,.,.i '■''Penenee I have in, I ,.f '^on.mvhat more on IS.emiv ' ' ''''I ^'■'^''^' '''^^^^ "'^ to ^''^ yet been attempted/ '''" ''''''"''• >» «"«« respects, tLn has '. ;iituis^?-::a;:!;;";:;rf ^'^^ -■ «- -^ - ^h. o„t.t awite may be ns,.,l ...;. 1: "'^. .■'">' '■lasMIira(i„n. Th ' ■'^^"'^^ <-y I'u used to indicate tl I'loliferation of, and •■'■vudation 1 lose forms wliicl I are :u >!<•'", tlic eiidocaidial "esirriiation "ii)'anied bv surlare, with or if t IMlH .. '^ I I H' I* Without loss of .su1)stiiiice, as opjiosod to cliroiiic, in wliicli tlii'ie aro sci(,'rc)tic cliani,'os witliout vei;otaliuiJs. Sulidivisiuii.s of the acutu I'oriii have bucii arranged on an anatomical basis, as the terms jilastio, lia|iillary, verriieose, I'ungous, uleerative, indicate. On tlu^ other hand, from an etiological point of view, the forms of endocaiditis are as numerous as the tlisi'ases in which it occurs, and we constantly liear the expressions puerperal, rheumatic, scarlatinal, etc. Some speak of primary and secondary forms ; while, from a clinical stand- point, they are arranged in two classes, simple and grave. Ana- tomically, there appear to bo no very essential dilferences in the various forms of aoiito endocarditis, lietween the small capillary excrescence and tlio huge fungating vegetation with destructive changes, all gradations can bo traced, and the last may be the direct outcome of the lirst ; the two extremes, indeed, may be present in the saiue valve. They represent dill'erent degrees of intensity of one and the same process. A classitieation of cases, based on the ordinary macroscopic characters of tiie inllammatory proilucts, into watery or verrucosc and ulcer.itive, will, in many instances, group together cases widely dill'erent in their clinical aspects ; and, contrariwise, a clinical sulidivision into cases of sim|ile and cases of malignant endoeanlitis by no means of necessity iuipiics that tlio lesiinis in the former case are all of tiie plastic or warty variety, and in the latter of the ulcera- tive or destructive. The term ulcerative has come into very general use to describe the grave form, and it expresses well an anatonucal feature ])resent in a large i)ro[iortion of cases ; but in others it is very inajiplicable, as there may be no actual loss ol' .substance, and no more destruction than occurs in the verrucose form : and, on the other hand, there m.iy be gre.it destruction and ulceration trom cause.-i ol an entirely dilferciit nature. 'I'he numerous other terms emjiloycd — seiitic, infectious, di[)litlieritic, mycosis eiidoeardii, arteiial jiyaunia — while eacth expressing some special fciiture, and ,so tai' suitable, have never conic into very geiicial use. On the whole, it seems to mo th:it the names sim|ile luni malignant, wliich we use often ti)separate the mildi^r and severe forms of many diseases, might a]i[iri)priately be employed in desciibing the cases of acute endocardilis ; the simple lieing those with few or slight symjitoms, and which run a favoural)le nour.se ; the malignant, tiu; cases witli severe (MMistitutional disturb- aui'c and extensive valve-lesions, wliether ulcerative or vegetative, the term being more clinical than anatumii'al. JIalignant endocarditis occurs under tiie following conditions : 1, as a primary disense of the lining membrane of tiu; heart or its valves, either att leking persons in )>revioiis good health, or more often attack- ing the debilitated and dissipated, or those with old valve-lesions ; 2, as a secondiiry alfection in connection with many diseases, jiarticu- larly rheumatic fever, pneumonia, scarlet fever, di]iiitlieria, ague, etc.; 3, as an associated condition in se]itic processes, traumatic or puerperal. AVe siiall discuss lirst the anatomical characters, then the clinical features, and lastly tlie etiological and iiathological relation.s. The h-fiiuns of malignant endocarditis are by no nieaii-s uniform, and may be vegetative, ulcerative, or sup[iurativ(^ ; and thi^so various forms may occur alone or in combination. The belief that there is always ulceration has led to some confusion; and we must recognise that there are cases with the clinical history of the malignant form in which, yew^ mortem., the valvular condition has been that of a severe vegetative or verrucose omlocarditis. Such a case was a lad aged 11, a patient of Dr. Molson's, from whom I obtained the s])ecimen which I pass round, lie had chorea in .Inly ISSO, the second attack. Rapid improvement and recovery under l''owlcr's solution, live minims every four hours hypod'rmically, took place. There was a slight murmurish condition of the first sound. Wlnui vcen ag.iin on March 3r(l, 1881, the chorea h.id vet-'irued. liaviug begun ten days before. Th" patient improved •'•regular, .oft, ^ht! vl t. v "., f' '" "?"'-^' '"*^ ' ''''"■''' ^^■>^'-« corpus strmtuMi. rde'St^^""^ ,' 'I'" "^ '■'^'' «"'t^'Mi..^' in th. ri«l,t Illustrate a n.oro advance. .oS T ** ''''' "*' ^-''■- ^^' "■^'^"'■•.s tioas were large., no.^a In i"*^ ^'"' '^'""^ kiml ; the ugeta- substanee was seen. Ev i i H ^V. 'V"""''"'> "" •"'^"''l lo^'^ '>l" < ostruetion of endo ar£ Uis c „n Iv ■ n ^■'"';^''V"? ^'"■'•" '« «"""^ heial hiye,.; while the ',• ", o'nt Im ^ , *'" '•■"^l"t''^'l"'>" ■'»'«1 Miper- valve, or ,„ay invol • tl ;?, ire t^H ,, " "m"""''^ ''^^'I''^" " * '" ^''^ witJiout vegetations t 're ! ,],.•'' V, ^ ■"''" ^""'"""•Iv with or rence of whi,.h h s .'it'n the '"; ^'r? ''''"l"^''"-y ol' the oeei.r- "t endoearditis. 'IV loss < s 1 n '' ""'i" ""''^'■''^■'1 '^' ^'"^ '""" only the endoeardiu n or it n lei " "'"'^ ''? -^"P^'rll^iM, involving l>erforation of a valve' of he ^ f '''' '''..'"^ '''■^"uetiv'e, Lacling tC valves, extensive on ,Vrowt ns ^Z"' °' "'" 'T"'^ '^•^^■"'- <"' "ie '•oneeal the nleer or 7r2. , f, ' "■'■•""l'""y the proeess, and may well illustrated by t is'' co oun. 1 if '"" '"^'f '^ ''■""i its edge, as is I'''Ocessa,,pearssin,Ivtdeeuiv^^ ^" '"'''">• "'-^tant-es, the i" the .slightest fo n onh a s, .r l"^^'^'^^^^^^ •scareely recognisable ; 'in othtTs a' ''"' ''^'•''■''°" '^''^'' r^'>l'»l'.s which half a valve n'lv be h! "O''-'--^''; "' •^^''osion may go on by this drawing) a d.:pe;^avtipvi''!-°'" f''"'" ''""'' ^' (''' ^l'""'" »' ■stroying the mus ^u " ! u^of tl ' b'"' YT"}- "'" "'''^■'■^- -"'^l J'" the septum or of the wal n^t u vl r ' ''''m'" ''^ I'^'-'^'-'-^fion of features, however, ui-on wl ll/l cefn .'tt'" J^T '"'" '''^^ '^""^^•" have seen supertici,/l nee.Sic o ant "S£;;"- „/" '^^ "-'«"«-■ < tions, circumscribed i^atebcs oftlie Sl„I- • "'^''■"^I'on or vegeta- white in colour, r.^s,.nd 1 .%] e , ernH , " "■^'""''' °P^"l"c' yellow- of the lunr' era i.ortinnnf 1 " 'f'ot'o plt-mra, over a pyieiiie infarct uiee. D^K:£tS/;rSehav'r'"Vr'^^^^ condition noted by one or t vo o bs n^.^ /"/stif n^ ' '""' ^''''^ suppurative, in which case the ,b.e, , r r i^', ^^"^ l"'"'"''^'^''* '"■iv be involved, and the en-loc!:;:! m on "'n Xatc° Iv "'' r '^'''"^•'"•■■^' occurrence of small abscesses at the ba ev 1^^ cont.gmty. The uncommon, but there are also nst ' ., . ^-^tensue vegetations is not seems the initial .step. The com in " ,''''"'! *'*" «"Pl'">ation outgrowths is, perhaps t le m ? "* ulcerative and fungating tions vary a good dea in 'u-, , .,, ?" '^°"'"'"o"- The u.g.ta white mLe^ witi" o ihc^^d Se"sm.r"t''''t- .^"'^ ^-^i^''- clot mlheres, are nunuMous o tl e c 'riv be 'i', '''",-,' *'"" '^^'""'■ cences, with deep ]a<"r,a flss ires n, ^^ • ^^ cauJillower-excre.s. titic masses. In tj c"l e. o , ;,? liY "'"'' J""^' l"^"'hilous, stalar- out, the effects of Irie on and s,, 1 n 1 '" '"'' "f "''• ^'°-^"" Poiuted cusp may produ..e. by co'n a e a who r';''"'' "''"",/''"''' '^" ""'•th' along the ventricular w.all The , sure 1l "T^^"' ""^.^™"ths other, and the action of the blood 'tend t,. I ' '"'T? "-'""^^ ^''^'h tations, and one can so, ueti les see w , ' T^ ^'""'^ ^''^ ^•''Kc- oither entire or by T ril ,1 ■'?''"";. T"'"' '"'ve been torn ,?ff ink the force wi h whic h t ', ? ' °* 'h-'utegration. Consi.le .': that the soft veg tatio IS o „ . y 7^ '""':, *°«^^'"-"'-' ** i'^ curious hues of closure, can res t' the entente *'"^ ^"'"^■'■'^">' ''"• ♦!"' are subjected. Some ye'.tuion,;..,? ''"''''''", ^? "•'"'■'' they S-'ey or greenish-yellow cohju ' n " >'emarkalde greenish- 'uaygoon when the -lisease \nu h fV ,/ .^'T'l'^'^'V"': ''''•''^'ti"" n-ay take plaec in the deu't '''"'','■ l''^"'"!'!. iu'iuratiou --U unchanged and necrotic. i^:';£, bLndilljS.rSXr ( ' . w t I )' J 1 h / II, '1 in 1 j i 1 :i j ■li ' uiiii sliiiiilviiij,', Siicli ;v ]iror"s,s I'iiii I)0 seen in tliis siu-ciincti of imii]i'- winlitis fioiii !in ox, in whii-li tlicri' wvk mnst oxtrnsive V(,'j,'i'tiitivf ami desti'iii'tivi' (.'liaii;,'i's. Not uiilVcinn'iitly tliu vcfjutatioiis arc t,'''itty. from till! (lc|i()sit of lime-salts, whiili may take placi! in voiy anuto oasi'S, and is not necessarily an imlication ofa^^'e. It is intiiresHiif; to note how often inor^'anie material is tleposited in the neighbourhood of mi(;ro-or;,'anisms, as hen: on tlie endocardial outgrowths, in the tonsillar crypts, and aliout tlio tufts olactino-myees. Two conditions must he distinguished from the lesions of malignant (niyeotic) endo- carditis : the atheromatous degeneration in sclerotic valves, uhicli loads to ulceration and extensi\X' destruction of segments, a j)roccss which has notiiing in connnon, e.xcoi>t in its ell'ects upon the valves, with the acute ulcerative changes above described, but is similar to the atheromatous iirocesses in the aorta. It must not bo for- gotten, however, *hat an acute mycotic jirocess may be engrafted, and indeed, oftun is, ^'.pon old sclerotic valves, the seat of atheroma- tous changes. The firm white globular thrombi of the auricular ap- pi'ndices, and of the interstices of the columme eariiea' of the ventricles, have sometimes an appearance closely resembling endocardial out- growths, and when softened in the centre and ru]>tured, the re- semblance may be very close indeed. It is possible that the gra.inlar (/I'bris of an atheromatous abscess or a softened thrombus may jiosscs.s irritating jiiojierties when discliarged into the blood. Jlis/.iJiH/iciU C7(.'rmc'(VA'.— The study of a small fresh endocardial vegetation shows it to bo made up of cells derived from the sub- endothelial layer, round and fusiform, which, liy their iiroliferation, have ]>roduced a small nodular pnijection on the surface of the endo- cardium. Varying with the rajiidity of the growth, the mass will jiiesent the characters of a soft granulation-tissue or a tolerably linn lilirous outgrowth. Usually, tiie round cells predominate ; but there may be many elongated sidmlle-formcd cells, with three or four pro- c sse-s. What part the endothelium plays in this growth, lias not been determined. Tiny outgrowths may be seen, in which the process aiipi'ars to bo entirely subendotholial ; but usually, before the mass attains any size, the smooth surface is lost, and there is dejiosited upon it a cap of lilirine in tin; form of a granular, sometimes stratilied, material, of varialde thickness. Though this re.-embli s an oidinary c lagiihiblo .'xudation, it is probably deposited directly from the blood, and is of the nature of a thrombus. Upon ami in this layer may bo found, sometimes in large nmubers, those reniavkablo little bodies which have long been known, when collected together, ,as Schiiltze's granule-ni uses, and wliich have of late become prominent as tho blood-plat - of ISizzozero and tho hieraatohlasts o.f Ilayem. Occasion- ally, they .ire very abundant; and I have seen soft warty vegetations com[)osed .supclicially) in great i)art of them. As their connection with endocardial ami endarterial outgrowths has not, so far as 1 know, been referred to, I may bo permitted to call attention to thiso two drawiii'js, which further illustrate this ])oiiit. The lirst repre- sents the aorta fiMin an old man dead of carcinoma, in which, just above the bifurcation, three irregular masses are shown, one nearly nn inch in length, which projected fully a (piarter of an inch from tho intima of tho vessel. They were attached to atheromatous idcers, were .soft greyish-white in colour, and were eompo.sed exclu.sively of the elements of Schuitzo's granulo-mi'-cs, with lihrinc-libiils, and liero and there a few white corpuscles. The second drawing illus- trates a small aneurysm of tho aorta, which has perforated tlio (esophagn.s.^ On the WiiU of the sac, tho artist has represented a nutnbor of irregular whitish lines, which were nariow elevated rid"e.s, also made u|i microscopically of these small discoid elements, the con- nection of wliirh with librine-formation has been strongly insisted upon by liizzozero. Scatt'ied in ami briwj.Lith the fibrinous txudation »J occur, and may be very abuntlint & 1 ' " i^^'"' ¥''°" ''',''^''' the nucro-organisms stained. Thev varv i anr,A ,1 .,1 • ' ^'^''^"'« '^"'y that i„f„,. ,„„. „ ,,,„,,, ,„„,v;'S"i:s - ''™k;'°:i tip I ! 4 1, i i i * ^ mS j; J } ' ^ ■ ^ {;? /Hm f 1 " » ' K f: '1^ : 1 K' / ( A '-9 \f ^ mm^f^lt e^^\ - ^ 7 i 8 mary disease. Uy culture-experiments alone can we hope to have the (iUustioii st'ttleil. The following figiirts give an ii]i]iro.\ini,itefstiniatPof frequency with which (liirerent imits of the heait are alleeteil. The aortic andniitial valve.s were aflected together in 41 (■as(.'a, tlie aortic valves alone in 53, tlie mitral alono in 77, tlie tricuspid in lil, the pulmonary valves iu 15, and the heart-wall iu 33. The riglit heart is rarely atleeted aloue; this occurred in only 9 iu.stances, in 5 of wiiich tlie tricuspid, ami in ■\ the pulmonary, valves were involved. The valves are most often attacked along the lines of closure, as in tlie simiile endocarditis ; the auricular laces of the mitral liajis and the ventricular surfaces ol the aortic cusps sulleriug most severely. Mural endocarditis is mo.st often seen at the upper jiart of the se|itum of the left ventricle, just h(dow the aortic ring, in which situation some of the most extensive and deep cardiac ulcers ':>ccur, leading to jierforation of the sejitum. Next in order is the endocardium of the left auricle on the postero- external wall, as noted by Lepino {Bull, dc la, Hoc. dc Biuhyii; 1869). Tae local elfects of the ulcerative changes are important. I'erfora- tion of a valvo-segment is extremely common; sometimes there is a clean-cut, ]m_iiched-out hole, with scarcely any irregularity of the edges ; more freiiuently, however, there arc'great fungous vegetations wliich com]iletely close and conceal the perforation. Erosion of the chordai tendime is frecpu-ntly nut with, and an entire grou]) passing to the papilla may be dcstroyeil, the ends curled and encrusted with vege- tations. Ulceration of the heart-muscle, leading to perforation of the septum or of the wall of a chamber is a much less fre(pient occur- rence. I have collected notes of eleven instances ; three of the sep- tum elose to the aortic ring. Ulcers at the aoitic ring perforated the lett auricle in three instances, i' ,■ right auricle in one, and the right ventricle in one. In a rema; :>,ible cafo of Dr. Stephen Mackenzie (i'athological Society's Transactions, vol. xxxiii), the left ventricle was jierforated by an nicer at the apex. In a case cf Dr. Curiiow (Lancet, 18S3, vol. i), the ulceration extended between tlie coats of the acuta, and then jierforated into the lumen of the vessel, and in one of the Montreal cases there was perforation of an aneurv^ni of the aorta by ulceration, an instance of extensive ulcerative enda; ..ritis with the production of multiide aneurysm.s. Another coniiiKiii result of ulcera- tion is the luoduction of valvular aneurysm. The anterior llap of the mitral valve is most frequently atleeted, 'and then the aortic cusps. Iu the records of the cases which I have reviewed, I was suii>rised not to find thiscoiiditioii noted oftener, only in about 12 jier cent, of the cases ; but, in verv many cases, the record of the auatcjinical condition was meagre. I shall not refer further to this interesting pidnt, as Dr. Legg lm.s dealt with it very fully in a recent lecture at this College (iiiMdshau-e Lecture, August, 1882). I may observe, however, that tlie atheromatousulceiation is also a frequent causeof aneurysm of the valves. It was Sir .Tames Paget {Mcdko-Ckirimjicnl Tmnsiictions, vol. xxvii), I think, who first referred to the tVeiiuencv with which sclerotic and malformed valves are attacked by acute disea.se. Chronic valvu- litis is met with in a large numlier of cases of malignant endocarditis. The records which I have examined give only a ])crceiitage of abiuit twenty-live ; but th.e condition of the valves, except as regards ulcera- tion, was often omitted, and thus reiiresents a very much smaller ]ier- cimtage than actually occurs. In" more than three-fourths of the Montreal cases, selenitic changes were jiresent ; and Dr. Goodhart found (Pathological Society's Trinisactions, vol. xxxiii), in a series of sixty-nine eases, that sixty-one presented did thickening of the valves. Ill very many of the cases, the coiiditiun of fusion of two of the aortic cusps was ]iresent. This abnormnlity is almost, invariably accomjianied by .sclerotic changes, and to the existence of these is probably due the fieiiueucy with wlii-h they are attacked by ulceration. In "stvcutceu iiiatouM iiiitiiio " ' °' '-'""'- "' '"' iithuio- I, i"'.'.''' 'T '•«;"'i''k't1.1o instance of ul.vial ^, . , • , V ' i"'i'li'iinl producini' ■sp.rnnen wlu.'l, | laTo .lenion.-strate wu" aniiui'ysnis. »^--l"™i:i-SiS^^^^^^^^^^ and Was known to propose to del very folly wM, ,i,„;,' 1 , o c,ll ,t ™7i',,, f ?' .0.0. .pcrfsl point.: Tl'o ,,,vl f t M ,t, ','■,"' ""'""' ,o.,,tivo, ti,o^. i„ .,,i..i, ti,,.;; :™'l'!r; r ™ ,,:;;;S: S"i: and cases in whiuh sumo of the infants aro si,.,„l,> . i ""'"Lts -tivo. It is renuukable ].ow vSaU: Xr ^ nX' ^;u,.^''r ■ Tliey may he entirely al.sent in well „uu-keid., vol. xix), there may bo witli aortic valvulitis suppurative infarcts in the lungs, and simple ones in the other organs. Tho gastro-intestinal canal may present very remarkable changes, duo to the presence of numerous infarctions, from the size of a pin's head to that of a split pea. They are slightly elevated, greyish-yellow in colour, often surrounded by a zone of deep congestion or extravasation, and on .section may show a suppurative centre. Micrococci are present, as in other miliary abscesses, and in several instances I was able to find small embolic plugs in tho arteries of the .submucosa. Tho abscesses may discharge and leave a small ulcerated surface. In the stomach there may bo similar minute infarcts, and occasionally larger ones. Carrington (Lancet, 1884, vol. i), has described a remarkable case in which there was a gastric ulcer, apparently duo to embolic process, in •^ case of severe endocarditis ; and JMagill (Britisu Medic.\i, JOUKNAL, 1884, vol. ii), a casein which the stomach was inten.scly in- flamed, tho mucous membrane at the greater curvature being black, almost gangrenous. The liver may present minute abscesses, and in a number of cases in which there has been jaundice degeneration of the cells has been observed (Schnitzler, JVkncr Med. I'rcsse, 1865). The serous surfaces are often inflamed, pleurisy and pericarditis being not uncommon complications. The pericardium is most frequently allucted in rheumatic ca.ses, in which endocarditis and pericarditis may occur simultaneousl}'. riourisy is met with cliiefly in connection with the traumatic and puerperal cases, and also with pneumonia, which, as I shall show, plays an important part in tho hisiory of this form of endocarditis. The cerebral lesions are of the substance and of the membranes. Embolic softening, simple or suppurative, is ex- tremely common, and in very many cases head-.symptoms supervene, and there i.s paralysis of one side or tho other. There may be a single embolus, producing extensive suppuration or red softening, or there may bo multiple infarcts in various regions. The meningeal crmpli- cation of endocarditis has not received much attention. Considering the fre(pxency with which it has occurred in tho Jlontreal cases, five in -tances ouv of twenty-three, I was quite prepared to find .such a'largo luimber a.s twenty-five cases ; that is, somewhat over 12 per cent. In tho majority of these cases, it occurred in connection with pneumonia. It is almost ahv.ays cortical, but may extend to the base and involve the nerves, leading in one case, which I saw with Dr. Ross at the Jlontreal Hospital, to straliismus, and also to ulceration of the cornea from involvement of the fifth nerve. In rare instances the siiinal meninges are involved, and the clinical picture may be that of an acute cerebro-spiiial meningitis (WwnoWe, Bull, dc Soc. d'Anatomu; 18(4 ; and lleinoman, Med. Record, New York, 1881, vol. ii). Acute suppurative p.irotitis was noted in three cases. \ >^ LECTURE rr. roSrtri^;"i;;°;;;i::!rii;:? t:iS'''"' ?i -^--«"ti, it is i,„. otiu!)- .lisias,.. •' 'luu.uiy ausiiig m tho course of some endoranlitis/with n-rfoct o. li', ' tlu,,se with .I,ro.uc valvula • tion ocrurs alter an nurv or in I'i '"'"f ""• ^^■'"-■'■'' "'« allk- caus.,W.^hhaveo|i/i:?^,;:^^^SS;,-,J-tly produced ^ 'the syi^pto-uf:^;; ,;"°i:^ ii^'^tX; -^^ -^-i^^-f^y diversity of .sati,sla,.t„ry clinical fct re ' T o In, rn '"'^ ''''""'' *° I"'^'^"^"* a I'ebrile airccti.m of vaVS int. „ 'itf w t..'^''"''\""'' f *'"^'^'' of '^ any acute fever, witli 'i' ors ', i,' t 1 T^ "?''"'''^ '"' ^''^'^ etc.. Arising i.i the ecu," e o'f' e o h d "eat 1^;.;''""' ^'^^!'^^''"'' an mteusilication of the fever ovTlhT •' 1^ 'J"'^ ^"^ ^""I'^y pyrexia is constant, b, v Wa hie in t « fn l'" I'' ^'''^'''''- '^^'^ likely than any otlier synu tZ ti i- 1 V ' • • ""''"■'"ty, an.l more tion of strength, delid ™' ^w atin^ .."ih"'''''^''''^*''*'"'^- ^'"^^''a- stitutional di^tulbance, a"; ^Sl^t:^^""''" '^'g"^ "^ ^'-'-'^'^ -n- tic:;;:t:;;;^f':SLrLS°cs ^-'■^i''' -^«^= i-^n, paipita. been old valvular disea^erbut .?a "oils lerS^n'^'r'''';.*''*^''' ^'' lieart-syniptonis remain in the A, k ",nm , I- \ H"" °* ^^«°« the condition.'and giving o "n cation -or ^ ^"^^'? ^^ ^'^-^ g«»"'al "'iL^'iSi^^'^" "^•tected"^;;'it^i',' ^LSr ''^ ^° ^^'^^'*' *^^* wl^iu ^^^:^t::^Sr:^SnS^:^ 1-a, symptoms, «pleen ; bloody urine and in i the ?/-■"' n"?'^''"'''"* "f ^''^ "eys ; loss of vision fro n „• 1 h mivrt " ""T*'"" °^ ^'"^ l^i''" various o,,ans, or gangren ■'Snl tii^'dSEn^l-lZli'"""" "' siSl^r^f^^he'':; Sr if;:S?i[^?^7r ^^'ttkt a con. ;;Wat,^d;oi:,!KtdiS'^;:';i;t,/S^ UueutlypomtodouUheiact that iullanunation of uie'Sve,^ mSt -.1 frr / / 3 i\u\rr\iir scfiiiiiiit, ,1 j.ati'li, of tlio si/o of a sixiiriiiT, .swollen ami "iwisli wiiitM 111 col.iiir, aiui opjiositp to it, on the auiinilar face, was an lilnT iMj; (.iioiiirli to njiiiaiii a small pea. Tliwv was aiiollicr also on tlio wall III til,. l,.|t aniicln. TliiMv wcir no iiilairts in tlii' arfciial svstfiu In thcso cases ot i.ii,T|M;ial ami tiaiimatic s..|,ti(a.mia, tlui rif,'lit heart Ih iiioruti(i(|iientlyaire,t.Mltlian in aiiv otiier poiip ol'eases. Thus ofthe thiity-seveii eases of this kiml, theiv weiu thiiteou in whilh tho trieiis|iii| or piilmoiiary valves were involvi'il. Ill the aeiite iKvn.sjs of Imi ir aiiite ostoo-myclitis, a secondary omioearilitis may drvelop ; ami in some instani.cs the eliiiieal features iiiaystroiif,'ly resemlih' maliu'iiant emioi'anlitis, as was well illustrated 111 the ease of a lad, aj^'ed 10, who died after an illness of less than a wueksdiiiation, eharaeterised l,y hij,'h fuvet, ri^'ors, sweats, etc. No loeal trouhle was eoiii|daiiied of, and at the jtnsl wortrm. examination there was ulcerative endocarditis of the right side, and a imrulent focus in_ tho septuin ; and it was only after most careful search that the jirimary trouhlo was found in a small spot of a'.iile necrosis of tho tihia. These forms do not strictly coino within tho provinco of tho phy- sician, but they must he taken into account in any description of malignant eiidoraiditis. Thi^ souivo of the poison is very evident in the external wound ; tho metritis, etc., and tho lesion.s, are chiefly in tlie territory ol tlu' venous system and right heart. In the i,y;eniic group of caVes, the clinical features are of a decided )iy:emii' type, and here the .source of infection is at tho heart, and tiio iiictastatK! lesions arc chielly in the territory of tho arterial sv.stem, leiidering very applicahle the name of arterial iiyaniia given by Dr. \\ ilk.s to this class of eases. Wo may recognise two types of tlio pyieiiiic lorni : first, the ca.ses in which the .symptoms resemble closely tho.se ol^ ordinary iiyiemia, with rigors at intervals, sweats, and other signs ol .septic iiilection ; and, secomllv, an important group, in wliic.i intermittent pyrexia is a striking feature, occurring in re-'ular paroxysms like ague, with cold, hot, and sweating stages, fheso (oriiis may (Kividoj. as iiriin.iry indcpcmlent airections, or coim. on in the course of rheumatic fever, imeumonia, etc. In our Montreal cases, thi'V have not been so marked as tho typhoid typo. Tho fol- lowing case, with illustrative chart, is a fair example of pya'mic .sym- ptoms (hie toendiicarditis developing in t'le course of imeumonia. M. W., aged4:j, a well built n, an, w;isn.lmittedunder Dr. Koss, Feb- ruary 'JOtli, 1880. lie. served his lime in th-army ; he had had syphilis and had (|uite recently had .syphilitic ulcers; had also been a hard drinker. In October 1871', he was in hospital with pneumonia, and liad severe cerebral symptoms. On Febrmirv SSrd, he had a .severe ngor, follow, d by f,.ver, cough, and pain in 'the .side. On admis.sion I'cbruuy •2til:;i, tlu-e were signs of coiisoliilation at tho left ba.se. Oil the -JSth, he was deliiiou.s. On Maivli l.st, tho I'lisis .seemed to take l>lace ; t,'mi>eiatur,! fVll to 98', remained low for three days and ho seemed to lie ,h.ing vi^ry well. At 1 I'.M. on the 4th, ho ha'd a severe chill, with vomiting, and tollowed bv .sweating. On the .^.th ho was diihrious; ho lia,l another seveiv chill at 2 P.M., in which the tem- perature ros.' to nearly \0['. He had live stools ; there wero no iiidi- cations [.oiiiting to tho heart. On the (ith, the morning tem).eraturo wis normal ; tho jKitieiit was very lU'ostrate, sweate.l a great deal and there was low wamleiing delirium. From the (ith to the 9th, the toni- perature ros(! a degree each evening, reaching 105.3', its highest point liil.so over 120, and feeble. From this time until the Mtli, ho grailually .sank, remaining uncou.scious. Tho lung-.symptoins di,l not oxLcml, but rather improMMl. The post mortem examination rcvcaleil ext,-nsive ulcerative v. getations on the aortic valves, purulent menin- giHs, and resol vmg pncumoiiia of the base ,>f tho li'ft In The attack iiiiiv be ushered in with a single rigor, or more often a 1 .. ■) ■ ■ ) 14 sonen ofchilU; mid finiii thw outmt tin y may coiiHtitiilr aiiiiiikcil fi'iitiiro, iind, witli tlio HWciitiiiK, |>ii'.Htnition, and iliarrh.ra, ^ivi' a soptic I'liiiractfi- to tlio niHc. A light ,jimiicli;'f may (level"!), uml ntill fiiitlior intensify tlio reseinliliinee. Scmietinies tlin ruse may inn on for a conple ol weeks wi*' niaikitd typhoid .symptoniH, and then pyii'mii: featnre.s develop— li^jors, sweats, ete. Hnt liy far the most rernarkahlo cases of the pyirmie group arc thoso which present a marked interndttent type ol jiyrcxia, simnlating a ipicjtidian or tertian ague. They may occur without any .signs or iiidi cations of iieart-diseaso, or the symptoms may develop in indiviilinds the sulijects of dironic valvulitis. The ea.ses an! not nearly .so fre- .|uent a.s those of the typhoid type ; hut they have been wiiecially .studied hy Drs. W'ilks, Ih'i.stowc, and C'oupland in this country, Lancercaux in France, Leyden and others in (lermany. The paroxysuLs may have the absolutely typical features of interndttcnt ; the chilLs, Iiot utago, and .swi'ating succeeding each other with regu- larity ; ami in the intervals there may be nn entire absence of the fever. The nuotidian type is the most comnujii ; Ihc tertian has occa- sioiially been described ; and in rare instances two paroxysms luive recurred within the twenty-four hours. The cases 7nay be much pro- longed, even lor three or four months. One of the lir.st references I lind to cases of this kiml is in a foot-note to one of Dr. Ormerod's Oulstonian Lectures {MMiml Gir.dlc, IS.'il), in which a case of Dr. IJond of Cambridge is narrated— an instance of chronic valvular dis^ ease, with intennittent fever and diarrlnca, two paroxy.sjns occurrin" in the rales; 187:5), the jiatients had had intermittent fever a short tiiii before ; .so also witli one of Leyden's cases {Zcilsrhri/ljih- A'liii. M ,1., Hd. iv, I'.erlin). Hut the nio.st extra- ordinary case of the kind is recorded bv Dr. liiistowe (liunisii Mkdical JuiiiNAr., 1881). A patient had ague in October, chills onco or twice a day ; she was ill for six weeks ; and, after an interval of two or three weeks, they recurred in the second week of December, and con- tinued until December 23rd. She was well for a few days, and then the attacks ■ecurrcd after sleejung in a cold bed, and persisted until her admi.ssion to hospital on February 12th. For the four weeks pie- vious to entrance, the attacks came "every twelve liours regularly. A murmur was noticed ; but the history of ague was so clear, and the attacks so (diaractenstic, that a suspicion of malignant endocarditis was at first not entertained. It was only alter the failure of ipunine and a variation in the character of the paroxysms, that a diagno.sis was reached. In Dr. Cou]>land's cases {Mnl Timcn and (hi-rttr, 1882, vol. i), the intermittent pyrexia was also well marked. In none of our Montreal cases was the aguish type very pronounced, tliough in one or two cases there were regularly recurring jjaroxysms of chills, fevei', and sweating ; but the conditions under which the attacks de'- velo]ied rendered the clinical features more like orditiary pya'iuia. The maioritj of the.se cases ajipcar to arise independently of other all'ections, and occur among wlnt I liave referred to as the primary class of cases'; though, as already mentioned, sonn' develop in chronic valvular dis- ea.so, and < 'hers appear associated in some way with ague. The tyjihoid tyfie is by far the most common, and the maiority of the e;i^e.s present features which come under this heading. The disease may set in with a single rigor or a series of chills, most frc(|uentlv the Jonuer ; ofleu a ptiiod of maldisi or ill health has preceded the att.K k, tl i\. '5 ^,',l!fi!'"^"Jm"y'r'""''''" *•'" Wnintonis .luvoloi. ir th.. curs., nf son ., rnvvr Th.- ,.l,,.,ra,t..rs of tl,is Lnu an. iiT.^LM.I,ir t. LZZ, The Case of M. W, Inn o'Ti"? 4rM""^^"'ll^ ""^ chief f,.,,turos ol this form. th.. back, loins, and ips S.i 1 fv "T'l'^^'""'! °f ■^''vere pains in '■api.l, tongue ,, 1 S .'lia ... q, ''"'''"^'' ''i' I'">'lti«.s. Pnlso ing fron. tvi.hoi.l fcver N,, ■ .1 n ; i I '™r «"l'l'°'^«^l to bo sutler. be"obtain.,HX biU sKa be.M. o nf ^''^^7' '^""^' "'' r'--'^"""'' '^""''l to the onset of the atta^'k O , n?L/ ■ '^^ f""" '^""'' °'' '^^"'^ '^"^y^ I'^'vious perspiration 32 no e „ntion ,?;^^ '°"' *'""P«''^t"''e 104 ; pulse 110; albumen in u in .On h 6 1,' "n """;'"' ' V^ heart-munnwr ; no turo, 104" ; pulse 120 dicrot o ■ : 7f ^^''^^ ''^stk-ss night. Tempera- passed 18 oLs o wine sS-t I lllnn i ■;'■ "«*«'.«' eJ ; two stools. She menses, whish began to dav^ Woody which might have been from the pulseweak. 120 ^re phat'o^n 54 ./,n' ™°';"'"K-t'"'P'^»'ature 103.27; chest ; bow'els and ^^Z'^^U^^^S ■ "tooTsT '''"'t ?4 coloured ; patient could not be ronse,! Tlf^^ ' ''t^f « *^'^''au«nt. high seemed tender, which cause.l her r,rvn,,fi ^^' and general surface oir by catheter' contain'^rm.iS ^17^'^'"",?^^'^^ -en. and many granular casts. I'upil.^.^;;:^' fej^fc °^^^£ i }ii| 1 I ' n* 1 Is :■ :i 1 Wi S 1 1 1 r-r ! ( p 1* 1 1 I ' i\ 1 6 j'ij^ht. SoniQ rigidity of imisples of arms, most marked on the loft ; increasing coma, and death at 3.o0 i'. M. of tlie 7th, tlie sixth day of \uw serious illness. At neerojisy, no hypertrophy of heart ; mitral valves a trilhi thick, witli small superlieiat losses of sul)staiice on both cnrtnins. Aortic valves normal ; infarcts in spleen. Numerous small liicmorrhngic emboli in kidneys and throughout the intestines. Six or eight suppurating infarcts in brain, chiefly near longitudinal fissure and on median surfaces. The case is a good exam]ile of the primary malignant endocarditis occurring in a health}' individual, and running a rapid course, with symptoms of a tyi)hoid character. The diarrhoia was not profuse, though the intestinal lesions wore well marked. ,-t.<.< ,./<:, .Xt\ 'r :D,:u i 1 1 4 Tt»1Fril»1TWI ftf »■ M lOO lal f»t lt)» 104 ■>)» , ,IM _ 107 _ - "^ 2 ' — — ; — > ' •-■■■■- B "if E M E M E M E E M E E M e M C 'm e" M E M E — — - -— > — - ■ / ... I ,-eC .... i , 1.... — — — — ■ ■— — " — — — — -^ . — 1 M — D — M B M E M . — — M — -- ,:.; ..., 1 iiiiii 1 1 1 1 ^,u^ Ill ^U4. 1 1 1 1 f. The Case of Ann O. In the following instance, occurring in connection with pneumonia, tlie profuse diarrhrea and severe nervous prostration wore very sugges- tive of typhoid fever. J. H., aged 40, drayman, a large well built man, was admitted. May j3tli, with pneumonia. He had been a pretty healthy man, though he had had two jnovious attacks of inilammation of the lungs. He had been in the habit of taking stimulants. His present illness began on the 11th with the usual .signs of pneumonia, for which ho consulted Dr. Blackader. On admission, ho was delirious ; temperature lOfi', respirations fiO, pulse 110, consolidation of lower two-thirds of right lung, with the usual physical signs of hopatisation. On the 6th day, the delirium was less marked and the temperature had fallen to 101.. 'i^ ()n tho 9th day, the fever was 103", and the condition of lung remained about the same. On the l-2tli day, 1 .saw him with Dr. Molson. The dulness iipi)eared to be diminishing at tho right base ; I could detect 110 murmur at either a)iex or base of heart. Tho condition of tho 17 pati..),t rPsomMcl rlosoly oti.or rases of pneumonia in ^yhu■h in ims u stance. 1 he tongue was furred ; no alidoniinal distension • . n spots ; diarrlnea had eonic on in tl,e past few Xys s? K thi^^ (lose (JO grains) of iiuinine, at 4 i'.m. did not iH'opt fl.„ t Tl " ! ^ which at 10 A.M. wa.s 105 0^ On 9fiH, , ^'''^l''''''''*"™' very „,*,„, ,ei„[,o,l constant »ak1,i„s TJ ,„„ ^ ^l^ , .k.' c;: 'Si i rs-.^ fiMiir" ^£r''-« ' "V f rigor; temperature rose to 105" and dcaui took , 1 L If ''" '''!^ ^ of the 11th just a n.onth from tit o2t"?^rdis:as''%'Xl^^ had appeared on the .skin during tlie last few day o w' Hfe split peas, and ai .section present a gim-i^h entil ^s Tf t^^ r a'St "ilf ""t-^ -S--ts f-eri'natu^aMo'ok ng oSe ^T S^"r ;i^"ioTkin?S"o'ri£ ^'^llle^^ "^f ,°^. ^'''^^• auricular faces, .bout 2 formuVifn ires fiS tred^ hatS tto masses. Two perfontrnfex tTbe She ou\^Zv^^^^^^ r1"'^' the size of a crow null ti,„ " "^LHtLu lue outgiowtlis, eacli about to the corpus Arantii. AU of tLse mis .,//'' '" ''^""'''' "P colour greyish-yellow, excep/w£ ^^S Si.^r'^t ICTZ ^ the ones on the anterio- mitral segment mwl on f , 1 • ^'^''°''.-'^'°* ! less, and granular on se(tion. C,W. 1 o^,\''" ''","' "";■ .oft. No ii.l!iction,/Th;f,Z, „r7.1, m'O"-: l™ll' I ' I- ' ■'H "f 5 r'^^ i< ! -as ss I m III I If I i8 f^roy ci'iitio. /a/'-sliiirs. The (l('e[)ly oRoliymotii' patclir.s scrii externally loncspoinlcil with .sinall inf.iret.s sitiuited in tho suh- niucous tissue, anil surroumleil liy a zoiio of ileeply liiuniorrhagic tissue, above whicli tliB jfrcy I'llo {glandular layer could bo distinctly seen. The infarct itself was about the size of a si>lit; pea, a little elevated, on section decii red or greyish red, not in any instance purulent, and surrounded by a ;!one of extravasation from 1 to 3 centimetres in diameter. They were most abundant in the ileum, about 20 in number. Foyer's glands were not swollen. The limrviaa pale, swollen and soft, jlraiii.. Vessels of pia mater full, jiarts at base normal. Thick purulent lymph beneath arachnoid, covering central part of fissures of Sylvius on both sides, over both frontal lobes at anterior i)art, over the left intrapariotal fissure and on upper part of cerebellum, close to great transverse fissure. A good deal of serosity beneath the membranes. No infarcts in substance of brain. In some instances, tho clinical features are mixed ; typhoid and l)yienuc characters may alternate, iis in th3 following case. J. 15., aged 33, admitted January 7th, 1880, had been a Jiealthy man. Ten years atro, he had a .severe attack of pneumonia. On the night of January 4th, he f(dt uneasy, and did not rest well ; got feverish, and in the morning had pain .in tho side and coagh. No rigor. Symptoms continued, and he came to hospital on 7th. On admission, temperature was 103", pulse 128, and resi)iritions 40. .Signs of pneumonia in right lung, lower three-fourths. Characteristic expectoration. During the first week in hospital, nervous .symptoms ap|ieared ; he became delirious, and passed urine and fiices in bed ; tongue dry ; and on tho 9th and 10th there was troublesome vomiting. The temperature was irregular, ranging from 100° to 104'; the evening record usually high, but twice it waslower than the morning. Pulse 120 to 148 ; respirations 32 to 50. During the second week, the in- ten.sity of the symptoms abated ; the temperature tept lower, not once reaching 101°. The nervous prostration continted, with tremor of whole body, and the discharges were passed involuitarily. Tongue very dry. A very disgusting ftctor emanated from tie body. He lay like a patient in tho third week of severe typhoid fever ; took food and stimulants well. On the 19th, a painful swelling appeared in the left parotid region, and he began to have chills, anl sweated a great deal each d<;y. No objective indications of hoart-ti'oublo. The lung cleared very" much in the third week, but tho prostration continued. During tho fourth week, the swelling of the parotil increased, and on February Ist an abscess was opened in this regiin. On 30th, there were severe chills, wit!i blueness of face and the finger-tips. Much sweating, of a profuse drenching character. He Jecame brighter after the abscess was opened, and tho nervous symjitons were le.ss marked. Temin'raturc ranged from 98° to 100°, rising wit\ the chills. In the lilib week, he remained in this state, with bit little change, occa- sional chills and profuse sweats, the picture bing more like severe 1 yiemia. In the sixth week, the prostration ircreased, and he lay in a iii^avy uneonscious state. No chills, but niffit profn.so sweats. On {''ebruary loth and 14th, the tenii)eraturo r(^e very liigh, reaching lO,'')", anil death took place on the lith, after anillness of forty-two days. Th(! necropsy revealed extensive mitral eidocarditis, as the only special lesion. The base of the right lung was a little tinner than the left, but not granular on section. Only oneinfant was found, which WIS in the u]iper i»art of the spleen. Tin intestines were healthy ; tJKtre was no meningitis. The paroti^..< lis 4^ ... 1 — 1--- I _.. — ' :e .-'n 1 9 -/f!, J /'"t■^n'U^. ,. j^ _, ^,^_.._, I ; ■i 'il «' I.' ! li 20 ihangos aro fouml in I'oniiPction witli .sclorotic endocarditis. Many of suuli cases present I'eatnres of the pyuMuie, ty[dioid, or eerobral types, and may bo of tlie most acute character ; but, in others, the process api)ears nnich less intense, and the cause more chronic. In a con- sithn'able series of cases, the history is somewhat as follows. The patient has, perha[is, aortic valve-disease, and is under treatment for failinj^ compensation, wlien he begins to have slight irregular fever, an evening exacerbation of two or three degrees, some increase in cardiac pain, and a sense of restlessness and distress. Embolic phe- nomena may develop ; a .sudden hemiplegia ; pain in the region of the spleen, and signs of enlargement of the organ ; or there is pain in the back, with bloody urine. In other instances, peripheral embolism may take place, with gangrene of the foot or hand. There may bo hebe- tude or a low delirium. Instances such as these aro extremely com- mon ; and while, in some, the process may be very intense, in others it is essentially chronic, and may last for weeks and months, so that the term malignant seems not at all applicable to them ; still, in a large series of cases, all gradations can bo seen between the most .severe and the milder forms. Dr. Green {Lancet, 1884, vol. i) referred to a case which lasted .six month.s, and to another in which, during eighteen months, there were attacks of irregular fever. I have known the febrile symptoms subside for weeks, to recur again with in- creased severity ; and there aro cases which render it probable that the process may subside entirely. The ulcerative destruction, in these cases, may be most extensive ; and I have seen the aortic ring with scarcely a trace of valve-substance loft. The process in the chronic cases is also mycotic, and it is to be carefully distinguished from the atheromatous changes. In very many instances, there is no history of rheumatic fever or of other constitutional disorder ; but the endocarditis appears to attack the sclerotic valves as a primary process, and a very considerable number of the most typical cases are of this kind. A good example was the following case, in which the disease attacked peformed and hardened valves, and the clinical symptoms were pro- longed for nearly three months. H. M., aged 38, was admitted September 8th, under Dr. Ross. Ho had a good family and personal history ; he had always enjoyed excel- lent hea'th. A month ago he had chilly feelings, fever, and sweating, with vomiting. He ke)it about until ten days before admission, when he took to bcii, with pains at the heart, and fever. On admission, there was marked aortic incompetency; temperature 100' Fahr. ; he seemed dull and heavy. On 15th, there was iliac tenderness, and some diarrho'a. For the next two weeks, he remained in same state, tem- perature rising at times to 103° Fahr. During the first week of Octo- ber, the i)rosu'ation increased, and there was slight delirium at night ; temperature not higher than 102° Fahr. On the 14th, there was an cuDtion of [letechiiu. From this time, the tomj)crature kept lower — IdO' to lol' Fahr.— the delirium and prostration increased, and death took ]ilace on the 23rd. Two of the aortic cusps had fused, and there were old sclerotic changes ; there were re.ont soft greyish vegetations ; the spleen jiresented six or eigli'i, infarcts, one suppurative. These are tho cases of ulcerative endocarditis which present fewest dilHotilties in diagnosis. The existence of tho chronic heart-disease ex- cites attention ; and even if compensation has previously been perfect, the ulcerative process may bo the very cause of disturbing the balance and ]iroducing marked symptoms. In my experience, the existence of fever is invarial)le when the ulcerative jjrocesses are due to micro- cocci, whereas most extensive destructi\'o changes may occur in athero- rnaious disca.se without any elevation of temjierature. It may bo pos- sible tliat the granular detritus discharged from atheromatous foci on the valves, or on the aorta, may have irritating properties; yet, in two iiislauccs, I have met witii most exteuaive atheromatous ulcers on 2r W^ais!;!,^';''!' ''"'r n'"'' '^':'"'"l"""fitios of mateml „,„st l.ave (/>rtna< 1884 vol 11, liowi'vur, lias ior..nv, to a cas^e of ulcoiativp ^.te,.ms .„ .,„.U tlK... was no elevation of te-t^S: C7m/./W_ 6Vo«;,.-A con.si,l(.ra],le innnl.ir of cases of mnli-mant end orarduiH come under ol.servation, ikmIku.s, in hospital.,. rn'r or M,e h,st tune, with Mnq.tonis of cerelMal o'r eve I e rH i ' o"; U'd „ ;.' '" •" "* ^''V'^""'''"^' f 'f ^' t''^' "^^'-^"ts were Inoui to .o>pit. 1 uneonscion.s, and presented tlie appearance of profound eerc- iM'al a leetum. One of th,. first .'ases 1 ,'uw was of tl 'is k^ tL l-auent, a woman, a-'d 'Jl», was admitted on O.'tober 2-ind in an u ! .onsco.s state, and no history could he ohl„ined. 0,7 t' ■' si o ^T"ir^^r'T''V'''' -"l''--l "'■ ^-t pain in ije i, deVecte 1 T f' '^-^■''''"'"'i^ "' ■'^'*«''' apex-pnenmonia were Uaected, _ Te. peratnre up to lor. Ou the 2r.th, she passed urine and nuces invo nntarily. There was stral>isu,us of the ri-dit eve an I c-Hnn.encns nlccation of the left cornea. Death tu.,k place" tlu 201 nX Iva '^'cvpnennunua, a patch of endocarditis on the mitidlvahe, and supjiurative meningitis, iuvolvini; chiefly the cortex Another case, almost the counterpart, was admitte.l last\^.r, un l'; i Imfss" n''when"th"""""°"' ''''"• r^'^ '^'"l '^'S''*-" h°'"« ''fte a mission when the necropsy revealed apex-pneumonia, extensive endocanhtis, and suppurative meningitis. ' There may be early ,u- r TnHm r ^''•■'""■•" .Y "'""t .""y "'«»'"Seal impliLtion, af i a im V b i h -^ 7.'^!ocard.tis adnutted June 5th, 1881. The patient n an n '^ 'I'li'ions or unconscious at the first visit of the medical W^ a case narrated by Eberth (Virchow's Archiv, ]5and Ivii) Very many o these cases die within two or three days of a.lmission and the .p.estion of diagnosis has usuallv to be sus,,ended ; indee Tn looking over the records of eleven instances in which these cerebra" oiSZJ"'" '''''' '''"' '''''''' '" '•'^" ■' '"-•" '"l"''! cours^than IIunonr%>»!^'J-''^^^' .'^'''J /''•""' ''"'' '■«>'«l"'o-«I'inal meningitis, llunolle {Lulktm de Sec. d' Anatomic, IsrS) records a case of a lad who was admitted with syn.ptoms at first like those of ty, 1 oid fev and then of a marked cerebro-spinal character. Tln.'e was also a ,u , , ! nary atiecuon and endocarditis. The patient lived five d^t Ate necropsy, there were suppurative meningitis of th.. brain , nd cord ^X^cl^ei""^' ^"^^ extensive^leerativoondocardilS wSl A/.l>.*)^!' v?'/ 'i^'iT'^'!'^"*?'' *' '■?"'"*'''^ byHoineman (Kew York Medical Accord, 1881, u). A boy aged 14, was admitted November l-Hh. eld Is nS' r^'T^y »";.'"^^1 «»"«'«'l with pains in back ami legs r Zn,. ', ^''- "' ''P^'"*""' ^o'"it"'g. and constipation ; he wis of St'::;,ft5n4S^'^ ''''''' ■> *^'"p^^''^"- '''■'' = --'''-» Fi!r:^:!;i^%£i'lS;^:^,5;:™-^. ^03.4- evening, 105.6. Norember21st. A purpuric eruption wasnoticed on the chest thenon thefaceandafterwardsonthelegsandanus. Teniperature 104.V p Is veryfeeb e ; delirium ; l,yperft.sthesia along the spne ; no opisthotonos Su nf r '"'^'''*f • /"^ '■• ''■ °f ^h'« '^^y^ '^'^^^^^ rop of pur.' punc spo s came ou ; temperature 106= ; convulsive movomints. ^ th« 1.. ' m"''' "^ ''•"•' "^'""^^ convulsive seizure, and death. At the necropsy, there was purulent exudation on the brain and the meninges of the spinal cord were congested, opaque, anS' inrtame There was congestion oflower lobe of the lungs There were remit wall of the loft vtutnc ^, a sinul! cavity, ind- tive of probable ''li ■^ 'H . 1 '■ . 1,0.*' ;; il' i. - : ; • ' W I i I'l n If r ! I ' k' n 3it ! i ili' i, I If ^■l: \ - t ^^^mm I ** ^^n K- ^■i t .%- 22 abscess and destruction of ti.ssuo, J'urulent serum was found in the pericardium ; the kidneys presented .mbolic abscesses.^ Certain clinical features may bo specially referred to in a few words. The fever, as will have been gathered from the previous statements, is of a very variable character. Irregularity is the prominent feature ; periods of low may alternate with periods of high temperature, or a remittent may become an intermittent. A remittent typo is most frequently met with, but the remissions do not occiir with any regu- larity. Occasionally there may be a continuous high fever, the ther- mometer not registering below 103° for a week at a time. The pyicmic and aguish types have been sulHciently noted. The occurrence of a rash has been described by many observers, and, in some instances, has led to errors of diagnosis. The most common form is the hivmorrhagic, in tho form of small petechia', dis- tributed over the trunk, particularly tho abdomen, less often in tho face and extremities. They may bo most abundant over the whole body, and at times are large and present small white centres. "When severe nervous symptoms are also present, the resemblance of the cases to cerebro-spinal muninsitis, or typhus, may be very close. In ' one instance, tho case was thought to be liiemorrhagic variola (Duget and Hayem, Comptcs rendiis de la Sue. de Biologic, 1865). An erythe- matous rash lias also been observed. In a ca.so of Dr. Cayley's (Lancet, 1884, 1), there was a mottled red rash on the skin. Colson {Bull. deSoc. d' Anatomic, 1876) describes a casein which tho rash was erythematous, and in spotsdistinctly papular. The mental synqitoms may be of a very varied character. 15y far tho most frecpicnt conditions are low delirium, and a dull, semi-conscious, apathetic state. There may be at the outset active delirium, or even maniacal outbursts. In a case of Dr. llabershoii's { r J. 1, \'; 23 jivroxia, aiipear very prolonf!C(], oven two or tlirco moiiflis. Tho most iai>i(lly fatal case is described by Kberth (Vircliow's yirc/u'r, Ikiul Ivii), ill which a man, who had enjoyed previous good liealth, was attacked on tlie evening of the 25th, with' rigors, foUowed by high fever and rapid unconsciousness. The temperature tliat night, when seen by a physician, was 41° C, and the case seemed like one of typhus with meningitis. On the 27th, he was removed to the hospital, where he died at 5 r.M. The temperature was 42. 4° 0. There were extensive ulcers in tlie aortic valves, and supjmrative infarcts in the brain. The duration in this ciise was scarcely two days. In a considerable number ■of instances, tliu disease terminates within a week or ten days. [.' ' i^il Mil if^ ■ r i I I,' ' 1 k ■■ ^ !■ :ir,^ H ^ 1 ■ ^ i 1 i 1 r LECTURE III. Diafpwsls.—fow discnses present greater difflcultios in tlio wiiy nf diiiKiuwin, ilifficultit'S wliich in iiiaiiy ciisf.s are jiractirally insiuniDUiit- ablu. It is no (lisfiiiiii^'Piiient to tliu luiiiiy Hkilltnl iiiiysiciaiis who have put their cases uiioii record to say tliat, in fully one-half of them, the diai^'no.sis was niaih^ jiost xwrl.cm. In s)iite,' too, of atilo nu'inoirs in the Jo\irnais, the disease has not been niueli known, and it is only of late years that the text-books have eontained eha|itera upon it. The protean character of the niahidy, the latency of tlio cardiac syni[itoins, and the close simulation of other disorders, com- bine to ruiulcr th'3 di^tection iieculiarly dillicult. In the group of cardiac cases in which the disease attacks a patient the subject of chronic valvulitis, the matter is usually easy enough. The existence of fever of an irregular type, and the occurrenco of embolism, generally sutlico to make the case clear. It must be re- membered that simide warty endocarditis not unfrecpiently attacks sclerotic valves, and may be accompanied by slight fever. Of course, in chroiuc heari-discase, irregular pyrexia may arise from other causcH — local sujipuration, cellulitis, etc. — which must be excluded. In rheumati" fever, a disease in whi( h the heart is more systematic- ally examined than in any other, if with the occurrence ol a murmur the symptoms become aggravated, and assume a ty[dioid or (jyiemic type, the recognition of the complication should be ea.sy. The on.set of severe head-symptoms in rheumatism— delirium, with high fever and coma — re<(uires to bo carefully distinguished. Fortunately, the simple endocarditis common in this disease rarely, as I shall have occasion to show, [nisses into the grave form. In pneumonia, a prolongation of the course, with the supervention of typhoid or septic symptoms, should lead to a very careful examina- tion of the heart. The greatest dilRculty is met with in those acute cases resembling the malignant forms of the fevers ; here the atl'ection may simulate typhoid, tyiilius, (-erebro-spinal meningitis, or even hiemorrhagic small- pox. Even witli the detection of a heart-murmur, the judgment may have tobe suspended, and many cases die with the general symptoms of profound blood-poisoning, before the development of any special features upon which a diagnosis could be based. From typhoid fever, with which the cases are most often con- founded, the mode of onset, the pyrexia, and the abdominal symjitoms offer the chief points for discrimination. The onset of severe endo- carditis is more abru]it, not so often preceded by a period of failin" health and progressive weakness. In a large ntnnber of cases, cardiac pain or oppression and shortness of breath are mentioned as early symptoms. The fever rarely ])resents, in the early days of the disease, the regularity of typhoid, and from the outset may be very high. A suilden fall to the normtd, or even below, may occur ; indeed, ir- regular pyrexia is one of the most important diagnostic signs. The combination of diairhcea, abdominal distension, and a rose-coloured eruption, points strongly to typhoid fever. The rash, when present, is 25 usually iietuuhiai, a rare circumstainu in tyi.lioi,! fe^vci. The duvoloi, nont under observation of pronounced nmrnmr.s, i«r icula y Sa ,tir and regurgitant is most suggestive of maligna, t endoca ditis n 1 the occurroneo ol emboli would l)o a positi\e eonfir Zion KiZ rarely occur in typhoid fever, while tluj are eomiZ n Socan litT^ II '«/f -,^^«V'-'r. t" I'ear in n nd that, in many of th 'mosT 'Se cases death may occur, as in any of the infective disor.U,rwithout Many , t the cases pn'scnt the clinical features of iiyremia a condi in tlH vl""^' "'Tf^ exist depeiHlent up.m the \ Ic tiv les^o s ^nfec nn .?'' ' ""'' ^""f "'" '"'^«"°^'^ "«« ''>'^'"=<^^ ^n ordinary Sept c /nEratS'' " """"'' "■ ^"'"■^"'■«^tion from a primary endo^cSal It is interesting to note the similarity of those cases of ncito or,,!. It seenis strange that difliculties should arise in the diagnosis be tween mnlana and malignant endocarditis, but the rLo df of case,' pla.nl;y show that for weeks or mmiths a condition oHnLrmitten? pyrexia may occur, simu ating every tviio of ,uri7„ Ti.„\>„ "* difio'r^' 'r^l^r "'-'l-'-'. --^ S'l- iSpanTin/SSco" ditiona, may fulfil every condition of a (luotidian or tevtinn ,-r,t„^ mitteiit; and the develop- ,e„t of cardiac'sy to"ns! w th bL of the pyrexial type may alone determine the natur^ of the case ^ Etioloyy and J'a//io/,. instances, tho ulcerative process attacked aortic valves, 2 ol v.In, h w.^ro fuse.l, and had undergone the fibroid changes always a_ssoii,ii. d with this nialtorniation. In l'27ol' the cases, the endocarditis was associated with other diseases some o( the most important ol which we shall now iiroceed to consider. ' Uhnunatism.- .Since liouillaud called special attention to the fro- quency ot cardiac complications in this disease, its iini)ortaiico in tho etiology of endocarditis has been universally recognised And as regards the simple form of endocarditi.s, tho general statements 'aro (jiiito true, but, fortunately, the graver and fatal form is much less common, much less, I think, than is usually sujiposcd. In f.3 cases there was a history of rheumatism, past or present. I included every case 111 which there had been the record of an attack, recent or rcmott" In only 21 did the symptoms of severe endocarditis arise during tho progress of the acute or sub-acute disease. In 29 case.s, there wm simply a history of rheumatism, often years before, and no mention of tho occurrence ol joint-troubles at the time of tho development of tho endocarditis. Dr. Ogle called attention to the fact that ulcerative cmlocarditis occurred very often in persons in whom no rheumatic history could be traced. Of 21 cases which he reported, some of which wore m-obably atheromatous, in only 3 was rheumatism mentioned in only J also of tho Montreal cases was the-, any positive history of rheumatism, either before or during the attacks. The following case under the care of Dr. Ross, is a good example of tho mode of onset ' 15. M., aged 22, a healthy girl until three weeks before her admission to hospital, on January 4th. At that time she was attacked with rheumatism of the wrists and ankles, not very severe, and she did not receive any treatment. A week frem the beginning of tho attack, she began to have chills, two or three a day, and she became /everish During tlio next week she became worse, had occasional chills, not de- lirious ; was brought to hospital on the 4tli, in a very low state. On ^r.% there was delirium and incoherence. Pulse 130 ; temperature 100 Double murmur up and down sternum; joint-troubles not evident On the 6th, 7th, and 8th, she remained in the same state, no chills ; temperatiire ranged from 100^ to 102"^. On the 9th, she was more i-estless On the 11th a grey membrane was noticed on the lauces. On the 12th, the membrane in the throat had extended, and covcre, the soft palate. Temperature 103°. On the 13th she died suadeiily. 1 lie necropsy revealed a largo deep ulcer at the aortic rintr nearly destroying one segment, and iienetrating deeply between the auricle and the loft ventricle. There were small infarcts in tho brain extensive recent dqihthoria of fauces. ' In a larger luimber than in any other group, sclerotic valves wore tound, witu the existence of which the i)ast rheumatism could in many instances be connected. A primary rheumatic endocarditis was recognised by Latham, also by Graves and Stokes, and it is quite possible that some of the cases which I have grouped as protopathic represented instances of tho kind in which, if life had been proloii:r»d loint-troubl.-s might have sui)ervened. ' Cases of acute rheumatism sometimes occur in which there may bo multiple miliary abscesses (Fleischhauer, Virchow's Arc/iiv Band Ixxii), and a pyremic condition similar to tho case just narrated, but without tho presence of endocarditis. Micro- cocci have been found in these abscesses, and the cases ivsomblo tliose 'v> 27 raru iusUti<.!.s of idiopathic |.yH.,nia. It is wnrtl.y of obst-rvatinn that a Hl<.n.e,„i,tiou wa. ,nost t,o.,u«ntly noted in co.m.otion with to rhm.,„ati. cases, Koi.crally a., orythc.na. I„ a case of Dr. I irkc« 1 d'hlul 'The o "'"'7" "•"' "^'•;"' •' ^^-^'^ ""^-^^-l on 1,0th ft- a aiian.s 1 he orr.isional presence of a .scarlet rasli in rheumatism duuctys lraimi,ii,ms, vol. xu), has long heeu reco-Miised Inchorfla, with which siniple endoi.arditis is so ol-teii associated tlie malignant form verv r.irely .supervnes associatoa, I'nauaonia a.>i Houiliaua pointed out, is not unfrcquontly coinrdi- cated with endocard>ti,s, hut the important ..art which'it plays h"o etiuo^yof the .naii^-nant disease his not Leen generally reco-Le n the cases I have reviewed, it stands at the head of ho 1st of d seascs ,n whi. li secondary endocarditis of a sever, nature develops 51 instances Imy.ngheen noted, rather more than -T, pe, cent, of t^^.^ total number ot cases. For this 1 was ciuito prepared by our Montreal pneu noma. Ul tlie occurrence ot acute endocarditis in this disease ho s, acments are son.ewhat div, , e. Douillaud thou.'ht tha in 4 h.rd or lourth of the cases in which there was left-si. edpneum.n a there was „,tl.,nn.„t.o„ of the serous men,hrane.s of the iJart ("isl olle, in Ins classical work on pneumonia, states, on the contrary, that It .s a rare comphcU.on, and this would certainly appear to bo ho conclusion o the Committee for Collective Investi^tio 1 for in e report upon l,Oi,o cases, endocarditis is onlyoncen^ntioned 'jly ex notes of 103 necropsies on cases .>f lobar pneumonia, and tho occurrence ot acute endocarditis is not,.! in 16 cases, over 15 p r ce, i Ot these cases, 1 1 were of th.. mali.^Mmnt form. An analysis of these s ...ws that in 6, the l.ft hu..' was involved ; in 5, the right • ii 4 he upper lobe was allected ; in 7, the lower In 9 of the cases was Tn nin^'itis. In the 54 cases which I have reviewed, in W the lune atie..t,., Was mentioned, and in 2.i the atlection was on the iiul)itM't is of tli.i time when Dv. Kirkes nia.li) his nifinonililu invcsti^i*: „. ,v sorioun dilliiMilty cxi.st.s in thoiircuni- Htiin.,. that wo liav • not lo •] il with a Minulo form of diHoawu— an cntiiy— hut rather ,ith a »[,(■(• d innnifeHtation in nniny alhetions ; nlfMaions, too tliu i)a;l!.lo;ry o( .vhi.ii In, in most in.staneo.-i, hy no nieali.N elear. No oi .• , i.; d;.illit i ;at the more HeVuru cases of cndo- cirdllis luesont m a ■'.[■uM nii.e all the features of those diseases whieh we eall mleetiv, ii (;.iii,ve to ho eaused hy the ahsoriition of some poison, till' deve|o| ..eiit of which ill the l.h o 1 and tissues pro- loniidly ilisturlis, and liiially annihilates, fun- tioii. lirielly stated, the tliuoiy of aeiit" oii.luearditis which nt presiMit j.rtivails, aii.l the only ono to which I hjiall refer, is, that it is in all Us lornis, an essentially mycotic process ; tliu loeal and eonstitntioiml ollucts hein« produced hy the growth on the valves, and the trans- teronce to disiant jiarts of inieioheM, whiih varv in character with the disease in whnli it develops. This very attractive theory can bo iidjusted to meet every re.|uircinent of the case, though as yet lai'king certain of those suli.-.taiiti:il data necessary for full acetit- anee, but which, having been lurnished of late years in other di^ease3 we may reasonably hope will in time also bo for'th( ling for this. Ix't us see, first, what has been done, and how far the facts at our disposal seem favourable to this view. The constant presenco of niicro-oi;;anisms seems undoubted; only, in the siniphi acute form, wo nee. 111. .re careful observations with our improved nieth.xls. Some goo.lobseryer.s have not been able to fiml them {Otth, Ichrhuch der .Sp,y iclleu /at/i„/„,,,,rlie>i Anatomie, Lief, i, 1883) ; others declare them to be invariabl.. ciiistituenis of the verrucose outgrowths (Klebs, Airhiu far Krjier I'aUin/o,//,; Han.l iv; Kiistor, Virch.nv's virc/u'y, Hand Ixxii). Ihe careful ai.pli.'atiou of such a satisfactory mode of .stainin.^ as le- commemled by Dramm should rea.lily determine tliis question. A study of the en.locarditis of puerperal and traumatic pyaemia will ho m,)st likely to yield imiiortant information, as here the con.litions are simpler, ami the r.dation ,>f the inicr., -organisms can more readily bo determined. The cardiac complication iu these cases is only part of a general process, excited by a local lesion, and is entirely secondary aiid subsi.liary. Micrococci arranged in chaplets are constant con- stituents ot the \ getations, and, iu tho case of puerperal fever, they have a close resemblance to those found in the [icritoneal exu.lation. Iho well know-n observations of Koch, Ogston, and others have shown the relation of microbes to pya>raia ; and the recent culture-experi- ments of Rosenbach {" Micro-organisms bei den Wund-Infections," AmMcitra drs Mnischm, Wiesba.lon, lS84)go far towar.ls demonstra- ti.m for man what Koch ha.l previously d.uie in tlio case of the pya'mia of the mouse In these cases, a study of the modes of growtirof tho micrococci of the endocarditis, ami of the ellccts of inoculations, and a comparison of those \<-itli similar .)bservati..ns in the organisms of tho original lesion, or of the metastatic foci, should yield results of great value in the interpretation of the phenomena of secondary endocard- itis. •' III rli.'Uiiiatii' fever, we are still too far fiMiuany ol its intimate pathology to dwell on the nossibl. a.'curali' knowledge conue.-'ti.ju of any :'\ r I li: ' *! \ )■ M , ■ ; bA 1 H'^^wi^*! i^ ' !■ IB [^v'ln M^B,i ' 1 iliH ■ l« ^M w m M ■ I ' .j lA l~/M .10 orcraiiism peculiar to it, and tho omlocanlitis ooinmon in its roiirsp K.\ch>i [Archiv far Experiment, rallwloijir, IJaiiil ix) distinguislics tho muTobos OMiirnng 111 rlieumatic cases from those of tho septic forms. Ill iMieuinonia, micrococci uiuloubtedly iiboiiml in the exudation of the air-cells, and tlieir mode of Ki'owtli in gelatine is peculiar, but the numerous experiments on artilicial production arc not yet conclu- sivG. The evidence is accumulating wliicli iilaces pneumonia amon" the infective disorders ; and it certainly is a seductive view to take o? its pathology to regard the local pulmonary lesion as excited by the growth of micrococci in the air-cells, and the various consecutive iiiMammations, the cndo- and peri-car.liti.s, the pleurisy, tho inenin"- itis, the membranous gastritis or colitis, as due to the penetration Sf the organisms to deeper parts, and their local development under con- ditions dependent on the state of the tissues. The procesws are all of the character described as croupous, and have as common features the presence of micrococci in a coagulablo exudation. We have still, however, to settle the identity ot the organisms of the air-cells with those of the consecutive iiillaramations ; but we may reasonably hope ere long to have some positive data from ''nvestigationsin this disease which, more than any other, offers fa/ourable opportunities for the solution of these problems. In diphtheria, as we have seen, mycotic endocarditis rarely occurs • and. 111 the lew instances observed in association with scarlatina' variola, erysipelas, and other affections, we lack positive information with regard to the characters of the micro-organisms. In the way of experimental investigation of the properties of the micrococci, not much has been done of a satisfactory nature HeibertT (Vh-chovi'iArchiv, Band Ivi) placed bits of vegetations from a puerperal case beneath the skin and in the peritoneal cavity of a rabbit without effect. Eberth {Ibid., Band Ivii), Birch-Hirschfeld {Archiv der IMl- kunde, Band xvii), have produced panophthalmos in the rabbit by inoculating the cornea; and I was able to produce well marked mycotic keratitis in the same animals with fresh material from tho valves of two cases. H. Young, of JIanchester, inoculated rabbits with pus from an abscess in ulcerative endocarditis, and was able to detect micrococci in the blood. No conclusive culture-experiments have yet been made. Grancher {Journal dc Medccinc dc Paris, December 20th, 1884) has cultivated a microbe from the blood, taken during life with all necessary precau- tions, but apparently not in series, and no inoculations of animals were made. Cornil {L'AiciUa Medicate, December 22nd, 1884) has made cultures on golatiue, but apparently no special results have been reached. How •uerperal and traumatic septicajiuia, the external lesion is undoubtedly the source of inf(CtK,n which is conveyed through the venous system ; and, in these cases, it will be remembered that the right heart is most often affected. In other instances, where the skin is nnbrokeii, we must suppose them to gain access by the lungs or intestines, most probably the former ; and, m tlie.se instances, ihu left heart is the chief seat of tho mycosis. Whether they reach the valve with the general blood- current as Klebs supposes, or through the coronary arteries, as is oster holds, cannot be considered settled ; but, from the position of the early vegetations in a non-vascular region of tho valves, and from the fact already referred to, that colonics of micrococci can be seen directly upon the eirlocardium, it seems probable that Klebs's view i.s the correct one. He sug-josts, in explanation of the fact that the lines of closure of the valves are the usual seat of the jnocess, that the micrococci, circulating with tin; blood, are here closely pressed into < 'le endothelium by the firm apposition of the flaps. Whether or not 111 any given case endocarditis will arise, dciiciids "rcatly on flie .3' case .suUi as py .niia-in winch wo may sui,p„so iiiuTobes ciivu- ; n^^ u the blood, t,ho cudotlu.liun, of nonnal valves n ay o al ' > ie.i,sl their inva.io,,, or, even if thev ,lo lod^e a.ul penetmte the eo, - afivf l"i ^^' 7':'°"«.'^1'«V"^'''^' ^^■''"•l» '■^■''t''i--''^ i" .so.ne case' to uk r m er o"to t ?k' H °"""' ^^'l'}'"-''- l------- Certah,ly on ■ ?. I ; r ' r^' *''" T'""' "■^"'■'' ^ •'"•^■'^ thus in,i„.rrectlv and 1 nr- o he ea,se fairly well ; but let us, in eoncdusion, f.dlow an 'iniportai 1 le 00 niueh neglected, and «et a definite outli: lor our i ', raS m,,uenc,> of he oceurrenee of n.ierobes in simple endoearditis Are e..ses? Secondly, we want full infoimation of the various fonn of rt'thrnd':;''""'""^ iyoeondary endocarditis, and ^f t£ ^la! An tli dlv T ' '''T'i *,° ^'^ ^'"^ '-''■'"'° "f the primary disease. M.u'no .^r ' '"■' ""-'y ""t *''^ threshold of inquiries relating to the « o V 1 Jit "'•«^"'^"'/!' to the macroscopic' chara. ters ol' tl growtli, and to the possible experimeutal production of eiulocar- tre!aHd,l°H''"^> without thankin. my late colleagues at the Mon- treal Geneial Hospital, by whose kindness I have had command not only of the pathological, but also much of the dinica iZt ri won which these lectures were based; and lastly, sir, you wil alow mrto or su( li an intensely interesting sub ect, and of the distiiHrnisl,,.;? audience which I hav. had the honour of a.Ulressing '''''"'""'^'"^'^ ■ ^Hi' 1 H\ .( ■' » I f f i Mo: Fellow of tlio 1 ^,.' ■V vs Iff ■ i; NOTES 0\ TKl: MORBID ANATOMY OF PNEUMONIA. nv 1 1 m 1 ' : if 1; 1 i i 1 '' it W " ; 1 1 i i ' vmi 1 ■ ? pi| 9b ' ■ j ! i 1 i ' j „i f^mW RE-PRINTED FROM THE "CANADA MEDI ,L Sc SURGICAL JOURNAL," MAY, 1885. NOTES ON THE MORBID ANATOMY OF PNEUMONIA.* hvii ,., ^^ WILLIAM OSLKfi, UD Hoypital, Montreal. Oc„ rl t i *| Z7 ""'"'°™' """"" =" "•» Montreal d,„k fi 'P"" • ,^»f ">« P'TPosea of this article, I shall ex- tne statistical report i -. Tnmaa tj^h j. ^i period of ten .eal^s was so.e,v aT ™ 1^ ^ Z" ^'^ f^ » of the deaths occurring within fort^eilt ho .s " ■;Zi:*"''' As a eonfast, it may be slated that ^he m„ W tv of' hr io'og a period of twenty years, was only 4,8 ' llie statistical details are as follows ■— yoal LaeV I ? 1 t '^''""^ °^'^^"' ^r>*« tl^^ tenth year o cases; between loth and 20th, 6; from 'zO^h to 80tl. 12 ; between 30th and 40th, 18 ; betwee,; lOtL.d h2 ' between 50th and 60th, 12 ; and over 60, 20 cases ' ' 1^ bo h. As to the position of tlic inflamed re-non in the lung the hgures are : in the right, whole organ solidifi^l ^^^^^^^^^^ th(j Moutifial Qonftinl Ho.pita! ] '* Pathological Eepn-t from t Montreal General Hospital Reports. Vol. L Daw«on Bro. 1880. til in m , it f'm I' s .1 r. i • I ! i'r:'-l^ M'* f fc r t im u perhaps, narrow margin at apex and ai'.torior border) in IT ; lower lobe alone, in 18 ; upper aloue, in 7 ; middle and lower, in 3 ; middle i id upper, in 2 ; upper and lower, in 3. In the left lung, entire organ in 10 ; lower lobe in Id ; upper lola in ♦). In the cases oi' double pneii'iioni ■,, it wus most often the lower lobcB which were affected together, but in tiiree i'lstanctts the lowei' lobe of one lung and the upper ol the other were affected ; in three cases both upper lobes ; and in Cme XIJX tho most ex- tC'^riive inflar.imation of both lungs occurred — the left was in a ?tat(.! !.if uniform red-hepatization, with the exception of the anterior ec-rdcr, and the right in the stage oi ,'..;rey-hepatization, except still smaller portions of the corresponding regions. Altogether, in 39 instances a lower lobe was invoivcd, in 19 an entire lun^ and in 10 the upper lobe. Weight of lungs. — To estimate the amountof solid exudation, the lungs were generally weighed. The heaviet^i was mCaae XLVIII, a man aged JO, whose left lung, uniformly solid, weighed 2303 grammes, and the right, very congested and (edematous, 900 grammes. (The normal lung weight is between 600 and 700 grammes.) In eight cases the affected lung weighed about 2000 grammes, representing rather more than three pounds of solid exudate. State of lung tissue affected. — In about one-half the cases, the inflamed area was in a state of red hepatization. In 30 per cent, there were regions of grey hepatization with the red, and in 22 cases there was grey hepatization either dry or passing into the condition of purulent infiltration. State of unimolved portions. — Usually the crepitant parts of the affected lung were greatly congested or intensely oedematous. The latter was invariably the case when he whole organ, except the apex and anterior border, was involv hich then presented a condition of almost gelatinous oedem . Tiio unaffected lung waH 2''"erally congested and oeu' ; -3, particularly at the posterior part. It was not unco' ..i to find the anterior por- tions (juite dry and bloodless, whiK ir. dependent regions were full of blood and serum. No doub;, t'.;' >, largely due to post- mortem subsidence. We do not alwayj- i--' nxtonsivo congestion or oedema in the uninflamed parts. Thu.^ . Jcue XXXII, in which K?^^ ^ ^ Ca.«iW/, a woman age. 50 ti 7 ,■"'"■'■ ^°' »'^°' '" >obe. the „ppe.. lobe 'wa" e^i: "XTt "' '"" '"°" no redness, and no M„„,|. .l.|,„ ,.,° '"''"'"• '"'{ °" '""''on, (except a fibroid onev) drv no J i ""' "'* """P''""' Air pa>ma„ T K ^ "' ""'' ™"'^ "'"o l'l««'- -ro,. Zd?„ To . :, . rf" «°""'^"^ «°"'"=-" » <"«.y. pneumonle expeotor t !;'"™"" '"""" "'"'™"">™eie o reddened, ..a^ .:;;:.• ' ,:X ■7"^™- 7 .-any bronchi verj, „fte„ contained « f °"°"' ""' '"""er stances thes^o were no ed n v TT T """' ""'' '" '"«'"» »- the larger t„bes of t „ " / i'".'"''"';' "'.'" «'="''in8 into of the bronchi '°«'°"' '°™'"S Perfect casts ration. ^ ^^' ^" "° '"'^^•'^"^e was there suppu- The pleurce. — When Hio ;».«„ *e .ung the pieura tU' -t; r.rdTifhr "-^ ™*- »f "■onljr, of a thin shcetin.. of exnd ^ ■ ' ' '■''™"' »'"»- "'at it onl, produces turbidity cftl; "" 7" "' ™°'' '"'"'"""'y instances the pnen,no„"a , a d "'™''™e. I" only two pleura; in eve'ry ole; nraJ!!""'''',""" ^'^ »»' ™* 'he a greater or less dc»ree 1,?,,, """"""r ™ '■"■'>'™J '» was extraordinarily" cu and eT """' "!° "^""""^ '"'".'^"' ".e Hght inng was^nnir:r^;'';„:;^:-^ ^ 'Vfj ^' '" "^=* every portion of the pleuri\.« „ ""-'fe"- '8 ■» lbs. ozs., and layer an inch in thickness • I, ,e T '^ " """""^ '"•™°- exudation, a^onntin/tHhreo' T: ^r '^7 ™ T"' was extensive donbic pleuris, „. " , '^ "" ""*' "«>« "niy- CW ^^illustra dhZ'^l T™:" °" °"' ^""'^ cross the anterior raediastinnl „ i '""""mation could left upper lobe to tUt of rr-iX ''"'' "''' '"' ^'»"'' °'' wefe:r„\"rsres:::zr,:™STr™'"''^ ^ o'tuo'efic, and tibroid induration. • .^Penimen In the museum of McGill College^" U \'- )i f ! ^'l 1. 1 . Vf i-i ,; 'hi • 3 f p- llisi: 6 Abscess.— When a lung in a state of purulent infiltration is examined, wo wonder that softenin;^ and breaking down of the lung tissue is not a more freciuent result of this i)roces3. In four instances there were definite small abscesses. In Case XXXIV, a woman, aged 56, with grey hepatization of the right upper lobe, there was a small abscess cavity, with shreddy walls, the size of a walnut, in the anterior portion of the lobe. The tissue about it was in a state of purulent infiltration. In Case XXXVI, male, aged 00, with grey hepatization of upper half of left lung, there were in the central part of the upper lobe several spots of softening, the size of marbles, irregular, with ragged, uneven walls and purulent contents. Case LXXVII, female, aged 64, with almost uniform consolidation of left lung, the upper lobe was in a state of intense purulent infiltration, and there were in the middle portion several large abscess cavities communicating with each other, with ragged walls and purulent contents. Ganyrene. — In three instances this termination was met with. Case LIV, a woman, aged J];"), a hard drinker, was admitted with pneumonia of the left lung, whicii had existed for some days, during which she had been neglected and much exposed to the cold. The lower lobe presented at its apoi and extreme base signs of consolidation, but in the rest of its extent was repre- sented by a large gangrenous cavity, occupied by shreddy and necrotic lung tissue and blood clots, the whole forming a stinking mass.* The walls were not defined, except at the lower part" where a separation between the sloughing and firmer lung tissue could be plainly seen. In Case LX, male, aged 63, with pneu- monia of the left lung, there was a spot of gangrene at the apex surrounded by dark consolidated tissue. Case LXXIV, male, ag■! PP' caso „ of special intereal, from ll.e fact 12: " ""« "l,08 a,„l ,n a.i oarl» ,., . i 'n.li.ralion «as in laborer, was adm eW.t^lr ,'"''•' '"''''''"' "S"" '^«- '^ ohili Ave days before llf ""' '""» '" "■« *'«• "ad a 100 ; res,„rat,o„ 26. Expectoration no bill PI ', ' ° of pneumonia over rigbt lower mam.uary iXjl' "T" and lufra-seapular rosions I).,,i...Z i, 'T ^- '"■'''"'''"■ patient made „o satisLtZ, pf„ "^ '' "T '™ '^>' '" ''"I""" 99° to 10.3» ; he was heavv a .^. 'n " "'"™ ""'«"' '■'■™ 100 to 120 D,.r,.^H„„ ' '''•'"■'»'" ■■ pulse weak, ri«>.t side ; in '«; rrr^.ttf-?*'' -^""- ™ absolute duluess, feeblo blovC'l rca ,, r Tf '"'1 '' '""'""'' inspiration. The nolo o„ .'» "™'"nig, a few rules ou deep cvpcctoration, muco.,,„rnlenr: „of , J ' rtir^irT 'T baJ a ch,l , aud the temperature went „^p to 10 1" N " in physical signs. Died at noon of the "7(1, ,1, V, , *" 'J'lio right lun.. w,as nnin„.™l , " ^ '''^""' ailmission. serous fluid. ^ 'r , ' ""'"™',"" '-«"". l-atbod with t..- called f„r"a"tt:t "' :';h:"n';:t"rc' '°"™;'""-^' f»- ".0 air-oells could be seen with j^'i :„;;:?:; "' '"^ Opaque white oIn.-,Pf«,. , i • '"'""'^s plugs, of a very oils ted in very s ! ll^ ■'°'°%'"'^ °''""«''- '""" »'»'« localized areas deelvi'firi'T- ■ , "°"'"^' "'"■" «« '"■'"I into deflnite ^^l t t tr f T' """ '?''"« """ of a marble. And thirdlv J *^ , "'' ""' "''°°' ""> ^^''o »'«-M.omo«e„eous:i::z, ::XuS:f"^ "™; connective tissue. In these arei. n fil -T V "^ '''''^"* i-l.e Ions; the alveolar «,;:::" S,'^^^^^ Pini's fillmg the air-cells were under^oin,: ra tXr ' ," ■'7' "■ * giowth of connective tissue. "■anslo,mat,„„ ,nto a •1' ^ • f i" * J ■ ■' ' '^ |i ^ t B. ^. It. ,; •' ■ ■ ^' i -: ! 1 ! ■ • * '^?]:,| J , ft ip "■■' il 11 I :% State of the other Organs — Heart. — Distension of the cliam- bors, particularly the right, with very firm, tenacious coagula, is a very constant foatuio *.* pneumonia autopsies The right auricle is usually very full, and a solid mould, capped usually witli a huffy layer, can generally ho removed with the extension.-; into the cava and many of its branches. 1 have seen a com- plete cast of the branches of the superior cava, even to the smaller vessels, and a mould of the inferior cava includin" the he{iatic and the iliac branches. From the pulmonary artery there can be withdrawn, by careful manipulati"n, a dendritic clot representing the vessels of quite small calibre. In no dis- ease, I think, are we likely to meet with such solid coagula— so firm and fibrinouf ; and on several occasions, when I did not know the nature of the case, the preliminary incisions for the right chambers have ena'led me to make a slirewd guess as to the existence of pneumonia. In many instances the eii'^or"ed state of the right side and condition of general venous stasis suggested the possibility that a copious venesection might have relieved 'Jie overloaded chambers — and I have in several cases acteu witii benefit upon this suggestion. In extensive red hepatization th( circulation in the inflamed area must be very mucl; impeded, and the w a-k of the right ventricle greatly increased. If we may reason from the experiments ot Welch,* the collateral oedema, which wo have so much dreaded under thei!<; ciicumstances, ucis no existence ; for he seems to show very clearly that to produce pulmonary f-dema tl)e hiood pres- sure must be raised t' ., point very much bejond tiiat whioii can be induced ' the cutting otFof certain territories of capil- laries, however 'n ■, in a pneumoi. ... Yet there are dilfi- cultiL's in tlie w.. tf e..; .aining the oedema of the sound portions of the lung on the view which Prof. We' 'i holds, viz,, that the left ventricle is first weakened or paralyzed and the continued action of the right gradually produces the engorgement and oedema. It seems natural to think that the engorged ri'dit ventricle would more quickly fail than the left, which is rarelv •Virchow'a An;iiiv. Ixxil. 9 Si:,;:'.;; ;::;;;;"■■•" '-••"- • 3^1 cases was tlio weight over '00 .... ' "" ^'^"^™"f I" ^n'y r>fl«,^/yyi/ <.-« ^'i-Mmmes— the heaviest in Cje LXXV, was b . grammes. In 12 oases the woi^ht was unrlor the averaire • mC^Bo n/ u , ,. ° "^ unaer n,i L. '"'•'' ^'"^ '''«"§«« '" the tubules. Ojher Diseases and InJuries.~One case occurred in con .;ect.on wuh diabetes and one with erysipelas. T .e c L" ollowed nyunes, one a burn, and one came on a. the '0^^ f incse cases of contusions-j,neumor,ia," as Litton terms this form,* are very interesting, and may come on aft r XL ' «cvere injuries, or after operations. °''^ "' COMPLICATIONS. ^^^^^^o^^^^nnsy^y^-au^ pneumonia. In one there was 'Zcitschrift fur Klin. Medecin., Bd. V. ~ ll'll 1 ;■■ It If r-^-'.':( :f I i ! 10 otidocunlitis as woll. Except in ('ax'' XClll, a portion of lun" contiguous to tlio iioricanlium was involved in ouch case. .KndoearJitix. — 1 have on several occasions called attention to our exceptional cx| ricnco in this respect, though, indoed, a review of the literature shows that the occurrence of this com- plication in pneumonia is by no means infreijuent. In l(! cases there was endocarditis, cither of the simple or malignant ty|)es, most often of the latter. In five instances these were simple warty vegetations, and there were no special cardiac symptoms. In 11 cases the lesions were more extensive, usually of the ulcer- ative form, and the character of the disease was much altered, or even masked by tliis com|)lication. Our cases bear out liouillaud's suggestion that endocarditis most frequently compli- cates left-Bided pneumonia, but in a review of 30 cases of endo- carditis occurring in this disease, and in which the lung atiected was mentioned, I find that in 20 it was in the right side and only 10 in the left, so tliat it seems doubtful if contiguity has any- thing to do with it. MeniuyUis. — In eight cases there was meningeal inflammation, in seven pia-arachnitis, and in one dura-arachnitis. In five of these cases there was also ulcerative endocarditis. Brief details of the cases may be given : — Case II, male, aged 88 ; red he- patization of ujiper lobe of right lung, extensive exudation at base of brain, in longitudinal sinus and along the Sylvian fissure. Case LXVII, woman, aged G4. Grey hepatization of left lung, with small abscess cavity ; the under surface of the duramator of left hemisphere covered by a sheeting of recent lymph, whicli could be detached in Hakes. No lymph beneath the arachnoid or at the base. Case LXXXIV, male, aged oO. Grey hepatization of right uppei' lobe and a spot of gangrene. Intense congestion of cortical meninges and exudation of lym{)h in patches over the frontal and occipital lobes ; none at the base. Tlie following cases were associated with endocarditis : Case XXV HI, female, ag 21). Upper half of right lung liepa- tized. Mitral ulcerative endocarditis. Meningitis of the coitex. A thick fiake in the neighborhood of the left fifth nerve, and a'.i- other about the optic chiasm. ^ 11 Cu.e L, male, a^cl 40. Lower lol.o of ri^I.t lun;,^ Exten- «.vo cn.locani.t.s of ..ufal u.l aortic valvor. Thi^k cnial Ir tt bal ' " '"^ ""'" "'■'^"■' '' "" ''""'^''''^-- ^n« (/a«. Z^V/.V ,nale, a^^e.l 43. Lower half of left lun^' affected Endocanl, ,s, ,n,tral ar.,1 aortic. Meningitis of tl... Idt hlil phore w.tl, exudation of lyni,,I, over the frontal and parietal convolut.on.s. None at the ha.se or on the ri^ht side Case l^XXXm,ma\o. Double pneumonia ; right apex. Ulccr- ::,:er:^r'""^"'"'*^«'- ^->-' -in,L. ^. ,,m;. Vaxr A7 rx, fernale, aged 10. Red hepatizatior. of central part Menuigitis of cortex— both hemispheres The complication of meningitis is one of the most serious that Zrortio' "'/;""'"^"''''^' '""^ '' '''^^'^ "I'f-''^^ i" ■- considerable cardit VV ■ """''^ '" ---^^-1 -th ulcerative endo- carditis We may suppose the inflammation of the heart and the menmges to be induced by a common cause, or, what would appear hkely m many cases, the meningitis is embolic i Ji" for .t also occurs ,n malignant endocarditis, unassociated w" h pneumoma. In :>0 cases of meningitis in this disease, only 5 ocairred wUh pneumonia. The infective material may po slbly bo denved d.rectly from the inHltrated lung tissue, and 'cried off by the pulmormry veins. ^Ve know tlmt occa ionallyl !« omboh may be derived from this source, as in a case of^ e^ inon,a occurnng at the General Hospital in 1879, in w h dunng 1. progress o.f the disease, and not asso iated ^' ndocard.t.s, the., wa. embolism of one femoral artery nd gangrene of the leg, necessitating amputation above the kLe Jho mflammation in these cases is almost always cortical, and tie chief symptoms are initial delirium, then stupor and coma sometimes rigidity of the muscles.* ' melte AbhaudlungU «^<^"^-''""«<^ <" mimical material, Traube's Uosa- M m ;& Si 1 ,1 (f I, i 12 I! ■ Croupous CoUtis.—ln Cases TIT, XXVTII, XLII, X.VA'jrT'and XC/X tliis unusual complication was mot with. InCase III the coecum was covered with a thin layer of adherent Ijmph, and scattered throughout the colon and sigmoid flexure there were numerous elevated patches of lymph, about the size and shape of rupia-crusts, which on section were found firmly attached to the mucosa. In this instance, the process was very extensive and the patches much thicker than in any subscf|uent case. More often there is a thin, Haky exudation^ involving only the surface of the mucous membrane. In none of the cases was there ulceration. CroupomGa^trids.—ln Case /F, the stomach and duodenum were found " greatly distended with gas. The mucosa was pale, except about the fundus, where, just to the left of the cardia,' there was an extensive area of croupous inflammation, repre- sented by a thick, adherent greyish-white exudate, covering an area 12 by 8 cm. Beneath the mucosa the membrane °was deeply injected." This paper is meant to be merely a statement of facts, a record of observations, npon a common and well-known diseis'e • but as opinion is still divided as to the 'ta-y "' 'I- disease. AM i , rf".''' """ ."'« "™« 'W*.^cther, and the intestinal lesions were regarded as lecidenta! occurrences in the course of ordi- nary typhus. Meuiiwhilo Louis' students, returnin;^ to tlicir homes in different countries, had op[iortunitie8 of studying the prevalent fevers in the thorough and systematic manner of their master. Among these were certain young American physicians, to one of whom, Gerhard of Philadelphia,* is due the great honor of having been the first to clearly establish the difference between the two diseases. His papers, published in 1887 {Amer. Jour. Med. iScienoes), are undoubtedly the first in any language to give a full and satisfactory account of the clinical, pathological and anatomical distinctions such as we now reco'^ni^c. No student should fail to read these articles — among the most classi- cal in American medical literature. Louis' influence was eai-ly felt in Boston, to which, in IH:!:}, James Jackson, Jr., had re- turned, and in the same year demonsti'ated in his father's wards at the Massachusetts General IIos|>ital the identity of the com- mon tyi)hus of the country with the typhoid of Louis, lie had already in 18-"j0 noticed the intestinal lesions in New England typhus. Though cut off at tlie very outset of his career, we may reasonably attribute to the inspiration of the ycjunger Jackson tlu; two elaborate memoirs on typhoid fever wliicii, in ISoS and lS;i!), were issued from the Massachusetts General Hospital l)y James Jackson, 8r.,and Enoch Hale. These, witli Gerhard's articles, contributed to make typhoid — as distnict from typhus — widely known to the jK'ofession in America long before the distinctions were recognized in Enghind. The recognition in Paris of a fever distinct from typhoid, and without intestinal lesions, way due largely to the infiuence of the able papers of G. C. «hattuck of Boston and Alfred Stilld of Philadelphia, which were read before the Societe. Med. d'Observation in IHoH. At Louis' retpiest Shatt'Ack went to the London Fever Hospital to study the EngHsIi disease, and quickly saw that there were two distinct alfeetiuns, and brought back a report which must have been very convincin" • rennock was ussociatwl with Gerhard in his Mtudies iipcii Tyiihtis. 8 to the members of the Soeietj. Stills h-nl H , gouig to Paris kmnvin.rthoron.rM,,,,- " ="^^a»tage of for he ha,l been Gerht d's ' ' " •'''"■"'^' ''''^''^^ '^^Vh^s, Hospital, and had stud el to ; J ^^""r '' ''' P^'i'-lolphia of m6. At La Pit 'w ih T f' "" ''"" *■" ^^'« ^Pi^^'^'^ic «on, while in London? ^.th^ dX ''"'f.^ ^"'"^^^"^ '^^- n>scd his old Philadel-hia L ^ L ''"r' l^^'^^ ''« ^eeog- woro given iu an exhaustive n.n^ T !' '^ '"^ «'^'^ervations form the contrasts and di'tin.^; ^ ' T ' "^ ^''''''''''^ "' ^^'^'^'ar tweon typhus and t;;^' tvor'" '"""' ^"^ ^"^^^'^^ '- *Hri:~::d;;™^^^^^ losions as only oecasiori " '■'^'''■''•"^' ^''^ enteric -.0, howeve' ^S: L ^r'^'L "' ^^f'''"^" '^''-o always maintained that Jiridit IT' ^. P^-^coptor, Povell, taught the differoncos T u" e'w " '^'f. '^' ^"^' "^'^^ -'' t'ui«l.od Guy's physician or b ^ r^''''''^ ^" ^''« ^^'^^in- delineations^f ^be . ^ i^;':^ ^ b'"'"^ ''''''^''^^ ^-^ h.^. Reports of Medical CaLT v3^ I t'f"'"^' '^^'^"^ '" article of the first vohune of T ' ' rr ' """'' '" *'''' ^^''^ pIeaded,fromthefactsol,.K-,^^' ""'^''"' ^^I'^^^s be -^''odinthetreat:^t" ^••ation of irritatin.. ran-.at- 7 '"V^"""""^^''^ '^'^ adminis- tinal disorder; butli:;;;:^^,;::';:^';;;;^ ^7 up the in^^^^ '^'^'a of two forms of fever Jo >, . ' '''^'" ''^"'^ '''"^^^'^t J-ions. lJ,,,bt, how V r ■'''' '"" ••'''^''- ^^'^''^'ut enteric »i treat,,,,.,,! i„ fevc,_„ „,,„ ,' ""'V ,"' "'" riiiSit,vc |,la„ 5 ■i-'i. /i. 1. btewart Ipiipiiii >J ■ I I'} ' r > i I I' 1 ii !ii ■ S S «| :ii n ( 111- ;: studied the continued fever. The results of liis observations were jjublished in 1840, and his memoir has been reprinted (1884) by the New Sydenham Society. In the decade which followed many important works were issued and the more cor- rect views gradually gained acceptance, but it was not until the publication of Jenner's observations, 1849-50-51, that the question was finally settled in England. The Irish physicians, to whom wo owe so much on the [lathology and trearhiOiit of fever, were among the last to abandon the old views, and even as late as 1801 the identity of the diseases was maintained among them. The extraordinary difficulty of establishing on an incontro- vertible basis any great truth in medicine, is nowhere better illustrated than in the history of the subject which I have out- lined in this imperfect and sketchy manner. Too often a truth has to grow to acknowledgment with the genei'ation which announced it. After the intellectual climacteric— Zti crist'. de qaarante am — wo assimilate new truths slowly,* and some by training become incapable of their reception. This was the case with many an ardent student of Fever, whose cducatioi) had unfitted him to see a truth which the untram- melled mind readily grasped. Dwelling now in the clearer light and with fuller knowledge and looking back o'-or the half century of doubt, dispute and discus.iioi) upon ^he (|uestion we have just 'considered, what lesson may we learn? Surely to see in it a picture of our own times — a picture the counterpart of which we can find any day in our current journals. The mists of doubt hang over many problems, disputes rage with the old intensity, discussion wa.xes hot, but by the light of his- tory wo can read with faith and trust the larger hope — in no faint manner — that a similar hap[)y solution awaits many of the (juestions in pathology which to-day ve.x the mind of the profession. Of the workers who were actively engaged in defining the distinctions between typhus and typhoid fevers three only, so far as I know, remain with us— Shattuck of Boston, Still(; of Philadelphia and Jenner of London. They, with their fellow- * True to-day as iu the timo of Harvey. (ieepeu. ^'^" "°^ «ttacc but will rather * * * * »ve.a, occasion,, e.ooode,! ^ '„ ? ? "7''- ''-' »» en.lmg May lat 1x7., .„,,•, ''""""".y. For the te„ „ea.s rate was a Httlo^vo; iC r ^r^'"'"^'"^"^' ^'^^ ^^^'^ 8ies, which are arranged i,. tlh'u r "'*'' "^' ^'^ ^"^op- article. " '" *''^"''^'" ^^^-^ at the end of the Thirty-six of the cases were in males and 17 • p Dr. James Bell's statistical renortT ' '" ^''"'^'^- ^' are admitted to the hospita w ' , '"'^ '"^"^ '"«'•« ^^n t'^e-" is sh-ghtlyloweXniH "''"''" ^'^^^-'-^^^ ^-^ou^ .1 o J' '""I'l man ui tne wompn /ic i- . " t'le age was given, 20 occurrod J ^^'^' '" ^^'^'^I* ^^^^_ occurred m persons under 25 years of In 10 cases there w.-e no special complications. theie had been hjemorrha-e from H,« i , ^'-- were diphtheritic tffetL'or' membranes. '^'^'^ct.ons of mucous there was thrombosis of veins pyaemia. affections of the rpqr,;>.nf-> lut respu-atory organs. Anatomical LEsroivq w„ i, n cl'ieflj- occur, ' "°'' "'" 'P^iS" ""-Ai.l chanj-c, Germany ulcers in J ^''" ^'^^^' ^^^ «ases. I„ common^ the : ly'Ltn.? "^ "^" ^^ ^^^ -«^^ -' -<1 Vienna post-mor e. o Is 2T ^"" ^" ^'^^ ^^-•"» '■are in England. Necroiro f h! " '''^''' '' '^''^ ^^ thyroid which were ou" Jun bf '""? '' ''' ^^* «^" ^f- ;:"«:^"i "P ^^ ^ convalescent from typhoid, " 11 " 9 (( (I 2 8 9 a ■ Montreal Oeoe,.,Uospi^,«oporH'vo.: I., ,«eo. I I i tm > I' ■s. ii ■' h I If'" t ■: il||*f no' ■ J ( 'I ■ 4 1 i* \ I: 5 r \ I 6 and I have recently had a patient with acute perichronditis which fortunately terminated in reaohition. There were no special alterations noted in oaHophaym or sto- mach. The lesions of the intestines wore all distinctive. The atYection of Peycr's glands may he considered under the four stages recognized by all writers : IstStaok. 8wclUn(j and Il/jperphisia. — No matter at which period of the disease a patient dies, some of the patches will be found in this condition. It is rare, however, for death to take place before necrosis or sloughing has occurred. In Oase XVII., a, jdrl, agivl 24, died al)()ut the end of the first week with severe nerv(jus symptoms. The patches of Peyer were much swollen, pitted and cribrilorm, lint no sloughing had taken place. Oase XXXIL, a man aged (io ; there was great hyperplasia of the glands, particularly ol the isolated follicles, but neither necrosis nor ulceration. The usual condition met with is sloughing or ulceration of the lower |)atches and swelling of the upper ones. In the early invk in -1.0 Lt Lo,.o IC'; . 1:™; 1-7 «'- on. E.cn "Pr»™o.,,„;„»;, ,": 7^"°';.-'» ""' often at.ack the '«'.>y 3„„si.los witi:., •*;':;-- ">o swelling p,.„. ■n.'J occnr while the A„,u ° e "i,, "'" , '""''• " «"»! ^ult int=«.it^„r.|,efeve,.:; ^,,"„ '■ '" ""? ''»=<'. -'- '» 'Lo "'« l>a -PKii. t„a„ the .n,'™! :/7ir:r': ""V"™^™- u-ai, I tt,i„k, .H„ ,,,„„,„, ai'j :: 'i; . :■ : "' ", ™™ plasm, become nerrnHp n,, j i- •. " '"tense hyper- mark .heir plloe" sl , . "2 "ff "' ''""">S ""!« p' to f™n the ru ,. ,; of 'r 1, T; ™' ''""'""•'■»"- ™y -"it 'taea ..on i„a„ niee ^ ^''^r'' ' ""» -era, ao fuaion of several of .he,ell«To,ite " "'■■S'™'"'' fom feome have thoujrht thi^- th„ • »l>ii El I 11 i 8 children, and Brans* discusses the various conditions under which it has hecn found. While there is nothing specific and distinctive about the swelling of Peyer's patches in typhoid, yet in adults wo raKcly meet with affection of these glands, associated with fever, in any other condition. Cases of typhoid occur in which death takes place rapidly before any distinctive symptoms are mani- fested, and insjiection of the small bowel alone reveals the true nature of the disease. Such a case I saw not long since with l)v. Sinkler. A lady came to town, a distance of several hundred miles, to see a specialist about her eyes, arriving on Thursday morning feeling apparently well. On Friday and Saturday she was seriously ill, high fever, temperature reached 10") '^, diarrhoea and semi-euma. Death took place on Sunday, less than sixty hours from the first visit of the attending physician. The nature of the case was demonstrated by Dr. Longstretii, who made the autojjsy, and found swelling with commencing ulceration of Peyer's patches. No doubt before she left her home she must have had slight fever, and we had been dealing with a case of ambulatory typhoid, with sudden accession of fever and head symptoms. 2nd Sta»jk. Necrosis and SlougMnff. —When the hyperplasia of tl'e lymph cells reaches a certain grade resolution can no longer take place, the vessels become choked, a state of ans^mic necrosis is induced, and a slough forms, which must be separated and thrown off. The process may be (juite superficial, affecting only the mucous tissue of the patch or even only a part of it, but usually it extends to and involves the submucosa. In Case XXVI. there were many thin sloughs adhering to the patches, in which the follicles and pitted appearance could be distinctly seen. It is always more intense towards the valve, and in severe cases the greater part of the mucous membrane of the last foot of the ileum may be represented by a dirty brownish-black eschar. The solitary glands may also be capped with small sloughs. They have a yellow-brown color from the bile pigments. The depth to which the necrosis extends depends ' Vol. X TninsftttidiiK of I'athulQjii'jal Society o! Fhil.isli^ipiiia, on the intensity of the iyrnj,hoi,l infliltration ; it ,„ay he ot om of clean, tlnn-walled ulcers Ca.e. 1 the fatal uJt could he d„.c.tly traced to an ir.di.s.,retion in diet nearly ooks aftc. the temperature had l.en norn.:.l. f,. ,, „,,,L' tl.o sloughs were still partially adherent ahout the site of ^.f" ration. _ A majority of the cases were in small, deep ulcers 1 ontorufs was present in every case ; in two it was localized 111 "7 f ''""""'^' ="'• ''^'^'« -"'«"- i" --eral instances the base of u cers was formed, wholly or in part, of thir., .rev- jsh pentoneal fssue, evidently necrot.c, and ,reat care Imd 'to 1)0 e.xerc.se.1 to prevent t.-arin^' in removal of the bowel I have o,.ce o,. twi.e seen the serous coating covered with thin flakes of lymph m the vicinity of s.ich patches. //.m.n-V,. occurred in nine cases, and contributed directly • 'Hl-c ly to the fatal result. In two, perforation also occu' • .. five there was blood mure or less altered in the c.ccun. and colon ; n, one case in the ileuu. itself. In most of the eases c b eedn.g see.ned to result directly from the separation of the Ploughs, but u. no .nstance was the bloeding vessel found, not cwenm r... .LLriV//,, i. .hich only one ;tch had slou./hed a«'' i\ iV «bV^", -!^\ W^ u '^^:.. %^ i/.A t^ \ :/-? 1 1 i ,. 1 :^ 1. 12 Sfh'i'n. — Moderate enlargement of this organ constantly takes place in tvplioid. It is rare — in my experience — to be able to jtalpate the anterior edge under the left costal cartilages. Of 35 instances in which the weight was accurately noted, in only one case did the organ weigh over 20 gzs. ; in three about 19 ozs. In four cases the weight was below the average. Complications — Puhnonarij. — The hypostatic congestion is almost always uiot with when death occurs slowly. In 6 instances there was actual pneumonia, in 2 siuii)le {)leurisy, and in 1 empyema. Pjiaimia. — In '^(ue XlT/Z/the'-e were suppurating infarcts in the lungs, and in t'ase X.VXl 1 1 infarcts in spleen and kidneys. In neither ease could any disease other than the intestinal be discovered. Thrombosis. — In C^ase IX, the right circi'mflex iliac veins were distended and fdled with linn thrombi. The superficial veins on the right side of the abdomen were enlarged and |)romi- nent. In Case XXIX, in the 6th week, a thrombus formed in the left femoral and iliac veins, and in the former proceeded to suppuration, with intense phlebitis and involvement of tiie inguiiial glands. Diphtheritic affectijm. — Secondary membranous inflammation of the mucous surfaces is .arc in typhoid fever. Louis mentions three cases in which diphtheria arose us a complication, and Murchison states that he has had several examples. Six of the cases I have dissected presented more or less extensive inHammation of a croupous or diphtheritic character. (\itic I (No. 12), female, aged 2o. No special clinical features. Mucous membrane of pelvis of left kidney covered with a firm, greyish-white membrane, which could be stripped off in th'; form of a mould of the parts ; deep congestion ot subjacent tisPues. Case II, woman aged -55, admitted Nov. 25th. Had been ill for about two weeks. The case was tolerably severe, and lasted over eight weeks. Temperature-range during the first fortnight in Hospital was lO^*^ to 104.5'^. On December Hist it became 13 normal There was a good deal of nervous depression through- out. She had retention of urine, and was eatheterized on several occasions, the first time on Dec. 4th. On the 14th there was a bloody discharge from the vagina ; on the 2;3rd, l.loody urine and from this time shreddy matter was passed from the bladder' ihore was great pain on the passage of the catheter. Urine' not dimuushed in amount. Death on Jar., .".rd. Tcmr.erature normal for four days before the end. At the autopsy hoalin. u cers were fo.nd in ileum. Spleeu 9r> g,ammes. The co.niitio;; ot the gen.to-urmary organs was as follows : Kidneus not en- larged substance pale. On section, the pelvis and calyces were covered with a th.ck greyish -yellow exudation, in the left organ nvolvrng the entire membrane, in the right only the upper third. .The surface of the exudation was rough, and on secUon it was een to extend deeply, in some places 3 m. in thickness. It ould not e hfted off the mucosa, but infiltrated it. The papill. ir/ I "fr" "''' ^^'' '''''''^- '-The ureters were not miter !i n J T'"'''''^ ' ^^"^""^^ '^ greyish, shreddv mtenal and a membranous cast of the upper pari of the organ, which had separated. It was about 2 m. in thickness, and wa begmmng to d.su.tegrate. The p^ . ts about the neck were covered with a th.ck grey.sh exudation,which was with difficulty detached In the cen ral zone, there were many isolated patches nrojecti,.: j-4 m. Ihe wall was of a dirty greenish colour, and was', in the greater part of its extent, denuded of mucous memb.-ane. The onfice of the urethra was free, but the tissue about it was h>Bm- orrhagic Fayma-Mucosa in the laterp.l walls covered with a. greyish membrane, which, in the right side extended, to the OS, covering part of its margin. Towards the vulva the mem- brane surrounded the entire canal. It cou'd be stripped off in nakes. Ihe uterus was normal ; no exudation in its cavity. am r/Z (No. 3(j), male (young), admitted Feb. 22nd, with well-marked typhoid fever. All symptoms mild, except the diarrhoea which was difficult to control. Pain and tympanites were troublesome. He was doing well, temperature had not once reached 108°, when on March 4th he complained of sore- ness ,n the caruncles beneath the tongue, and there was swelling 'I I m^^ 3 i ■ I'i ! 5 A J Ilk I! ! U:i ■ • il ! : H 14 beneatli the cliin at a corresponding point. The sore part was touched with nitrate of silver. 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O — ' s o U, rf3 > ■<" H O a tt ^ '■'. -r ^ ^ it iJ ,„ c; cc 5 U) a,o X' ol .0) <^ ^ lO T*< »0 '-' H . » , ^ ■ • b. b .s • O m (d 'E • ^(^ 1) J! u ►J -M *l S as; a Ci, fa o 5 M 00 • fe fa S e — iM 50 5z; lO la lO 1 Her Ui >i ii. 'f'lt- CONTKNLS. .Sarcoma of Jcft frontal l„l,e l^-boii«m of left antoWoreorobral artery PAOI 3 Three cases of abscess of the liver ■''••• 4 Two cases of cancer of the stomach '''■•■ '"^ Hernia of cfecum and an.jenrJIv .."'*••» p.o-,>..eu,„„..„.,.,„ „„x:,t:: ."°''"™'-™ <"• '-- .-i'»"i«. .0 Retroperitoneal spindle-reJl,. ' " * • • • 12 changes . . _ '^"'"'^ '^'^'> extensive thrombotic "^ Cirrhosis of liver fifnJ k • " ' " • . 13 Aneurisms of the Wer cerobrnl . • A . " ^'^^'^' '"'Series ; twelve c'.so« Aneiir'"'" "^ ^' ■' "^'vc cases 'J-isni of the thoracic c aorta ; perforation into left pleura . 19 Small aneurism of arch of anrh, ' ' ^'^ ^"'''"''' ' ' 25 trachea . ^'''' ' ««'»Pres«ion and perforation of Aneurism of the nrfl, . , ^ . **'*•■ H.^..reofJ::lr:"^"!^^-^^--^-pbagus . posterior papillary muscle of left ventricle I ^:^'" ^'"«^« «f ^--r pulmonary valves . 26 27 30 Lai 'cuspid pulmonary valve ■ge phlebolith of long sapl: lenoug vein 31 32 32 N 1 1 'I! l|: I ,N 1 1.^ Ci r I^B f * ' )^B - ' I > ' I '1 H: /P* ■!''' I CONTENTS. On the morbid anatomy ol" pnenmonia . Aspergillus from tlio lung ... Case of Addison's disease (with Dr. J. C. Wilson) PAoa . 41 . 42 The hicmatozou of malaria . . . . . . Intestine of dog with ticnia echinococcus in sihi . , . Cysticercus cellulosio in heart, brain, and muscles of pig Calfilication and dilatation of the bile-ducts ; the effect of flukes Hydatids passed with the urine 45 6(5 G7 07 08 !■§ u J k ^''"•''^^^ of the left frontal lobe. Unknown man, ad„,iK„, Deron.bor K,l ,r '"'•' «''«''t fbvor, l,„t no local , In ' "'"■'' ''"' '''H'lM-iatc.s. He I''»- on tl,o third day. '^'''^"^" ^■""''' ''« J^'^^-otcl. Death took "-Late Iv ahovo the left olll.e , - ,* ; ':"^'^'"''''^' "--• '•''ia.sn.. !,„. j obnun substance beneath f^ '^r ""?•''""""' '■""^-^"'• dollar was ecchymosed. Vessel. o^'liMv'-,?' '" '^'^^ ''' '^ quarter «t."g the longitudinal sinus the nl I ' ^^''"'^ "'"''""'• 0" «'Par- -^^"-; "0 extravasation. T Z^T '''''^ -"'^-'ed an.l .!;de. -e- unusually distended with llood n' T ""^' •^"'"'^' ^* ^^- base ve-ns were very full. The J^:^^:J^ ^ ""'"'^ ^^' '''' ^•-» ^''e prominent. The left fronfd Z '"'' "''^'' ^''e convolutions were verv by Puros' method, the,':; l^::;-;-''^;'- ^"the ft-ontal i:^ "g the anterior extrenutv of^l fl "m " '''''''''' ^^^-'^ ^^^m- apox ; at its lower part it M-as cvstic -in /'!'"\'^-^^^"'''-ng close to he «ocon,l section, cut at a distunrof- two "??'"' " ■^"'"""•'■^'' «"!^'- The 0^1 olando, expose,! an infi t"!^^^^^^ "'; ' ''^^'^''''^''es fron. the fissure no.ghborhood was n.uch swt^\l": '""«'• ^''^ "'"'--'^tter i„ tl e '"""-iatoly through the bas f th T^T'' "^'^ ^'''••<' -^^-n 7';'"'^' "^"^« -atter. Thissect at "'"''"'"'""'""' '""'''''^ ^ 0/ the corpus striatum. Sectio tl .m • """^ '''"^''■'"'- ^^'^''^'^i^V ; -ved no change. Section 1 ^.^"^'^^ ^^"tal convolution « oaths swollen ; no neuritis. eTJ ' tio 'T °'': '^'' '''' ^^^^^'^^l the gbosarcoma, with cells of larger s^ri';""'/'^ ^""^^" ^'^ ^^ ^ I'suai Jan liar)/ 27, 1887. 7.He::L ;-s:^ri;-j;7 thighando,,." ' ^^^t- admission with syn.ptoms of co„f''^^^^' P^^^ ^^-t ten days ! t r > 1 I I' 1 1 J M i 1 „t i ■ / l*>| ': Ih-aiii: The left frontal lobe tore on removal, and a soft i)urifbrm flnid exuded. This lobe looked flatter and was softer than the otlier. At tlie liase vessels looked natural, a few thin i)lates of atheroma. On tracing anterior cerebrals, the left vessel, three-cjuarters of an inch beyond anterior communicating artery, was swollen, became tortuous, and was closely united to the inner face of the iirst frontal convolution. At thirj i)oint the vessel walls were thin, looked infiltrated, and of a grayish color. At the region of softening on the walls of the artery tlie two anterior cerel)rals were 'ulherent together. The vessel was ])lugged for the lengtii of three-(juarters of an incii, lirra except at the spot above referred to, where the walls were quite soft. The first frontal convolution, as far as its base, was softened. On section, there was a distinct puriform softening at the apex of the left lobe. In the white matter this extended back to the anterior horn, gradually becoming less. Superficially it involved the anterior part of the third, the gray matter oi the anterior portions of the first and second convolutions not much involved. Small foci of softening in the inner section of the left lenticular nucleus just above anterior i)erf'orated space. No further change noticed in brain. There were no thrombi in the femoral veins. Heart normal. There was suppuration at the seat of the fracture. June 9, 1887. Hemorrhagic pancreatitis, n'ith swelling of the semiltniar ganglia, and Pacinian corpuscles. The specimens were removed from the body of a man, tct. 58 years, whose lungs were emj)hysemat()us to a remarkable degree, and whose body presented slight axleina, accompanying the heart trouble due to emi:>hysema. Tlie Pacinian corpuscles, about forty in number, were found in the connective tissue behind the duodenum and pancreas, showing as bluish-white, translucent, rounded, ovoid, or reniform bodies, with a central white axis. They varied in size from the largest, G nun. long by 4 mm. thick, to some not larger than normal. They were all plainly attached to nerve filaments, most of them scattered and single, a few in groups of three or more. The increase in size was due to an oMlcmatous condition of the concentric sheaths. Tliis form of en- largement of the Pacinian corpuscles seems to have almost completely escaped observation, for it is not referred to in any of the text-books on morbid anatomy; but Dr. E. Przewoski, in Wrchow's Archiv, Bd. Ixiii., describes five cases yi which tliese bodies were atfectcd in this way. In two the subjects were (edematous, and it is probable that, if looked for, they would not infrequently be met with. The semilunar ganglia. Hi - ;; " "'-lines and in.li.tin.tn " ^^ ' "'""?'• "^" «-'" --'-I coJJa, i''« pancreas presented an ;, ^"""''"" '^^'"«- -tivo .i..,e.J fined"-re :;::;; tr- ^^••TwHoretheeon. the ease toward i|,e tail wl.ore ""''"' ^'""^^^ E«peciallv was this ^-'y<'^tl.o gland the aci,„'::,7'-^ ""'• ^^^"'^' ^'"^^ J" ^o - |.'--h.white areas, .ur...u:;^t72Z Ti"'"'' ""' ^^^^^^^ ■0' • il.e loose tiss„e in the nei^hbL ' , '^■"""•'"'tnc exuda- K ;^l's g.ves a ,.,od aeeonnt of h n ' "^ ''"'' "''''^''''t^^'I "ith serum col eeted several cases in whi.! '"\^ 7" ^'^ Pancreas, an' ^'-^'^ ti„,e ^ ■« ;-o co„.p,ai„ed f;>r several o ronsod, but the pul^ , ,• "'"•'r"^' ^^^ F- A. Packard? he -'^ t'-e was typical Chev ^^ ^: ^'J ';!'i--ptible at the wH^ PO"o,Is of apncea. I„ this" .f.te L ''T '"'' "'"' "»"«"a]lv lon^ took place Tl.,w.i i '° contnnied till 1 I '^n ,. i " / ^ IMce i he chambers of the hea,.f ,..,,,• , ^^••^«. when death ■^^■. wore fb.Hui to bo dilated. Ti « k!. • ''"''"•'•^- ^''^^ "^' ^I- Hght 'posted in these cases that the r , >1, " "'' '"•'•'"^^'- ^^ has b^en ">" or the heart, induced bv f :"'' ^'7 '? '"' ^" '•*'"- -''i^i- "'ay be supposed to occur when he " ' '" "'"^ ^"''"- I''«-^"-^. which «".cr., of Uvcr. Cask I. Cln-onir. dmcntcn, ■ // , ""^''^^'"'-'^''''''-^-p^-AugSt^^r-,^^ ^•^ iiau typiioid ';f:,M L^ ■! ■^ I I il Will 'TM il 11 if if ti.Ji m Ml - I 6 fever when lilleen years of age. Two years ago tlie present t/ouble began witli pain in abdomen, vomiting, and diarrluca. At times lie would be better, but not for long. Tliej-e was blood in the stools at first, and he had nuieh burning pain in the rectum during defecation. At time of admission he had four or live soft stools daily, not containing blood. He had slight fever at first, but subsequently the temperature was nor- mal. He had lost flesh, and had a sallow, cachectic appearance. He had chills and fever shortly after the trouble began, but none during his stay in the hospital. On September 18th, the following note was made: Abdomen flat, veins not distended ; epigastrium prominent, and on pal- pation a firm, smooth mass is felt, occupying the entire region from the navel to the steriH;m. An indistinct edge can be felt a little to the right of, and also below, the navel. To the right the mass does not reach the nipple line, and here the fingers can be placed beneath the costal border. The nui?s is extremely tender ; it moves with inspiration. In the sternal and right parasternal lines the liver dulness is dii'ectly continuous with that of the nuiss in the epigastrium. In the nipple and mid-axillary lines there are four and five inches of liver dulne?s. On October llth, the note was: Mass above the navel rather more promi- nent, still very tender ; it cannot be separated from the left lobe of liver; right lobe certainly not enlarged. The vomiting was variable and latterly was not so troublesome. He continued to have two or three soft motions daily. The enmciatioii and weakness became most profound, and he died on Novend)er 10th. rost-morteni notes as follows: Body extremely emaciated ; abdomen de])ressed. On incising the abdominal wall, an abscess was opened, which is between the j)eritoneum and right lobe of liver, and extends for an inch from ensiform cartilage to navel ; this communicates directly with an abscess cavity in tlie right lobe of the liver. There is no peritonitis. Omentum is adherent at the rij;lit lobe. The right lobe of the liver does not extend beyond the costal border. The left lobe extends three inches below the ensiform cartilage. Stomach : A little distended ; contains a quantity of semi-digested food. The ])ylorus is free, nnicous membrane soft and congested. In the opsophagus just above the cardiac orifice, there is an oval tumor, about the size of a bean, which is subnuicous, freely movable, and on section is firm, grayish-white in color; looks like a sarcoma. The duodenum is normal. Orifice of the bile-duct pervious ; a clear bile fh)ws out. The duodenum, one inch below pylorus, is closely adherent to the hilus of the liver, and on s jueeziug this organ pus flows from two orifices through which a leil iiencil could be passed. The tissues in gastro- abscess cavity l.as porfbruted fn>,„ f ] "r s .1, f' "'""""' "•'^^'' ^^ externally. This abscess is the sixe of 1 ' ''"''' '''"* ^^'"^ ^^''^'ent P"s ; it is lined by a thick m b 'l it '""'" '"' ^"'^"'^ '-^ «--»y duodenum; it is confined toZ^Z:^ ZT'''''^''' ^''''''y '''''^ ^ The right lobe of the liver is fin ?d t :"^"l'!"-- I-« of the Jobe. TJie colon is thickened thl T ^^^''^ '" ^"''^''^etion. places ulcerated^ •;; ;^ rri:::f '•"^^'' T''^'-' -^' "^ --y The prominence of H.n " 7 ''^^^"^eric condition. ^ P-gressiveemaciation, leltTr;i;:;nf t.c'"T f"'"^^' «-' ^^^ this case. On two occasions a carefid IV "^ ^^'" ^^omach in of deciding whether the „ Zf «-^?""'f ^lon was made with a view ;- fonnd practicable. sXi Tr: ::f ^ !'"-' ^^ '^ - tinal symptoms, which had. however nl! T ^ '''^' "P"" ^''« "'^es- treme sensitiveness of the n^s a .oi 'T . T'' '''"'^'- '^'- ^x- n'ore than tiie ordinarv p.in ' ,^ t ^ '"^^ ''^""*^' ^' ^' "'as much Case II. Aente .^.^ / m" '""r'"'^^'»"""^ ^^'■--^• McB.. .et. 50 years. ZlJl^ ^ ^^ I t^^ V!. f"- - ^"^^ ten days with diarrhoea and great n in i^ , , f ; ^^"^ '^^^'^ ^" ^^I^o^t about and tried to work untilal v d V) f '^:'""'"- ^^^ '^'^^ kept been healthy, but had heen^^Z^! ^^efore admission. Had always i7th, appeared to be in co " " L 'Ze ?"'? ''^^"'^ ^^^ ^ ^^e and .ry; respiration 50; pni^i^^l^lZ^^''^^'' ^"^^^"^ ''^'•'•'' tended, tense, and drum-like and evh. Abdomen greatly dis- tynipany everywhere; live mlht, ''"'^'' '^"^^'•- *>» Pe'-cussion, There had been vomiting h^ I; T, 1" '"'"" '^'"""-'-d continued ; the stools sn^dl ; m c .u f'"' ''''' '''''-''^^^^ «*"! perature was 102^ on the ev en f " ' ^'^ ^'""^- ^b. tem- •ng of the 17th, and rose to 100^ ^n T"' ""' '" ''^ '^" ^''^^ »'«- ^ B-lv that of a nuddle-a!ed e 1 h7V"^' '^'"" '^'^ ^^^•'^^^>- tended. Right inguinal henda S " f ; '"'"• ^^^'''^'""^ ^is- and here and there flakes o IvnS ov ; "l'"" ''"""''y '''''^'^^' enornK,nsly distended, the transver fn '" '™- ^'''^' ""^"^^^ine partof ,u-m In ^, / , ''^''"^^ei^e portion equal in «\ye to (h; 1 , I - .11 Ml. in sjjots the Dcritonenl a,„.f 'o inickcst and the wall of g,t had iV , n^ ''''^'''.'' ''''' covered with lymph f,'-l I' . E ■ /•■ i (^«',\ ^. ^t I ' i I I' ^ ' !l . I i 1 ^ ;■ •: M" 1 f i: :iij' K 1 ■ i ! 1 / ^^ // 8 Larr/c intestine: Caecum was tliickencd and inflamed. The membrane was in enormous folds transversely placed, blackish in color outside, and sphacelated in places to a depth of from three to five lines. This condi- tion extended up the ascending colon and was very marked, also, in transverse and descending portions. Some of these necrotic areas were isolated and ranged from a (juarter to half an inch in size, and presented a cap of dark gangrenous tissue suiTounded by a zone of grayish-white tissue from a (puirter to half an inch in diameter. The necrosis in some of these spots extended through to the peritoneal coat. On the right side a knuckle of the lower portion of the sigmoid flexure was nipped in the inguinal ring, projecting about an inch beyond the level of Poupart's ligament. The hernial sac, when opened, was about the size of a small orange, contained lymph and serous fluid, and at its upi)er part the knuckle of intestine was thickly covered with lymph. The orifice of the ring was large ; the portion of gut was adherent only to the inner and lower aspect. On slitting open the sigmoid flexure and rectum, a knuckle of bowel was adherent to ring as above described. From within, the mucous membrane was dark and gangrenous ; the gut for a distance of three or four inches above and below this part was greatly thickened ; mucous membrane sphacelated. Stomach (ohI ihiodennm presented no special changes. The small in- testine was swollen and presented no lesion of the mucous membrane. Liver looked normal. In the right lobe were two spots, the size of large marbles, of a grayish-brown color, well defined from liver substance, yet without a linnting capsule. These spots represented the commencement of a hepatic abscess. On further incision of organ there were three recent abscesses, the size of oranges, softening at centre and presenting fragile necrotic liver tissue at periphery. Cask III. Chronic phthi-l, imi Fu.nilv and .u.-son . ' U,.ivc>rsity Hospital in -••ko,nc,„exte„clin,-tothV . e "i "' " ''""' ^'"'"'^ ^"'nor in «^ ^i'o ."ass was about anin. a,!: ,:,"';'•'''' "''^ "-''''-•■ Tl.ooentre 1-cns.on linn, tln-oo inches in L^ ' "1"^ '" '""■'' ""'' ^^ ''''d a f'"""^ tl,e .toniach. The live,- ''^'''•Mvas n.o.lenitc dilata- -■•'-!^- "--^ained in ti^ :;,£:;;:; ;"^^ '""-- c^ans ..:! -n.tn,,. was very troubleson.e, I, o^^^^ ^-n- months. At first the ^'■-luent. The vonn-ted n.atter el .1 ""' " ''^■^•'""^' »'"^'l' iess the .surcina ventrienli D„ t ' "' "^ "» -^traonlina.-y nunU.er oJ --- He enn.ciate., .api,,;;^. ^ S ^ly'^f'"' ''' '^^^^^^ -« ilie stoniaei, was ]ar ^'^ "^ture of his ilh.:^ -"'very nKKlerate wasting. u'r^'^T ''"'' 'r' '""^''""•' -'-"-^. TJ.0 genera] and local svmpton s v / ^ ^''* "^^^ *'^'^!'-'- ^^ '>-lilated. :;'T" f^'"-"f ^'•-to.nal.h iZr,, ;r'^'':,^"«^-"t to indicate t'-/a.^t the small mass in the epi- ns 1 "•"" '^'''^ '"-^---« and on -'the eon-lition had in.prove l^l^t J'^" ^;'f ^^'" '"«- distinct. "'ore of the case for fb, pi'esent at the somewhat. Idid not h - -"ths, when Dr. iiolling ask l--t-nc at tlie autopsy. TJie .(>,. 7 ' pronounced and thf^ LL • , *^»"'aoh symptoms ' the emaciatioii extreme. Tiie disea lear anything ig asked nic to be liad become more ise was found limited p. Off. ) f : ',W |J: il^ m ■m '»>; .iM. iiJI kiL_ p;' • . i'^ 1 • '^ • 10 to the stomach, in I lie pyloric region. The sections lioro shown iliiistrivte its characters. The i)yh)rns was involved with the (liiodenuin for an inch, and the stomach for at least two inches, forming a uniform annular mass. The little finger could he passed into the pylorus, but, as the sec- tions show, the lumen was much narrowed by the projection of irregular masses, which gave ii sinuous outline to the cross sections. December \}, IS.m. Henna of em-ton and appendix ; perforation, of liitter ; old peritijp/ditio ahseeM; recent larger one; (jeneral peritonitis. C. J., tot. 50 years ; cook. Admitted to University Hospital, March 4, 1887. ' On Sunday niglit, February 27th, after having taken a walk, was suddenly seized with intense i)ain in the hypogastric region. Immediately took to his bed, vomited two or three times, and on the following day noticed that his abdomen began to swell. On Wednesday night Imd forty stools. Dr. Wharton gave him a hypodermic of morphine, which relieved the i)ain for that night. On Friday was admitted to hospital. Abdomen greatly distended and tympanitic. Breathing rajjid and difh- cult. Pulse 112. Complained of great pain, chiefly in hypogastric region. Temperature 100''. Was given enemas of turpentine with sweet oil ; whiskey every two hours ; poultice over abdomen. March o. Dr Wharton gave history of the existence of right inguinal hernia. Temp, to-day, 99^ J'eels much relieved, but still comphuns of j)ain and difliculty in breathing. Vomited this morning twice; dark- green in color, but no fecal odor. Bowels have not been opened. (Uh. Complains this morning of intense ])ain. Is vomiting constantlv. Was given a lialf grain of morphine in two hours, which relieved him for a short time. Iloirmann's anodyne and rectal tube gave no result in relieving tymimnites. Punctured three times witliout relief Died that night at 1 1 p. ^r. ^HCo/wy.— Well-built man ; abdomen distended. In nipple line !iot more than two finger's-breadth of liver dulness. Three punctures of ab- dominal wall, (me in right lumbar region and two in epigastric. On opening peritcmeum gas escaped; moderate amount of fluid, chiefly in flakes, sero-purulent. Coils of small intestine greatly distended, "one crossing at the level of navel as large as arm above wrist; toward pelvis not so large. The general surface of intestines was injected. Peritoneum n coated in j)lacos witli recent lv>,.nl, .< i "'"' '"'^"'"mg colon containe( eon«iV(>nt fof.na fi. • !■ verv dry. Ciucuni wi^ ..,ll„... . . i .,""•"'" ""^ "'f^'s. tlio.so in former P.."I.V fcn„c,l by fold, of ,; ,; :?"■■■ «"™"f ■■"«»l. -'I >™lls P""d,. I! ,,; contract IP ■„ ""'",' """'"'"'' """ """"1»»'' .«.t,„„„,,c„c,l, nope «„",,''";'';'"«-'• ««"-»"' ll.-„-c „„.l inci,« of .fe,,,„id ,,i„o ;■':;::;: r,:;s "■- «-"';''j>y ■- I«a.l.K the |,r„.,i„,„l orifice «■„., fi.nn.l .„ , »«;'''""g *»r ap. into ab,lo,„c„ innood . I ' ;,l ' T "'"'" "-"■•"• I'"*'"' ■""■'l' ;;...ot,,„,o,ut.,.,„d::c'L:;l;;;::,;T:;;i;rr^^ ^rec ; terminal tliree-(,uarters of .„; • , '^ , '' " ^'"^ ^"'"''" ^^"^ cii-otly into a sn^nller dr ums il " l"^-' ''"'»'""»' '""' '•l-"'->d one. Ti.e ^^oundaries i; ^ :;,^;t. •;::::: r'^'' f r^'>' -^" '^^>^- ^'^'"'» "' ^ro"t, sign,oid flexure nndei . T ' '""'^"^^''^ '-^"^^ ^vas along tl>e.i.nu>i/... large 1^1^ "'"^ ^'"^ abscess passed into Douglass pouch. Klihunj.'^ somewhat swollen. Ihin-t valves normal. Lnng.i normal. tion of the ap„e,„l V ■ ' r ?"l>I>'"-"«'». the rcM.lt of porfin,,. e«.>.od f ,r »,ne ti,n .', , I n , "'T'"'" ">"■""'• '""' '''""'"■^- sya.„ton„. The fr ,', , h hM '" '';.'";""^'.'""- «oUed serio,,, a".i i. took both ,■:; X : , ,r ' m °""" "•■■• "'""■""■ the parts. "" °"' "'" V"""' «lalionshij, of I I''* i I*. L i i! ) f Mf ^ . . „-; 1 ' 'bkI ■'■ ? * ': ' '■ B \''}' fM 1 1h If ^ ! • S^ 1 1 '" ' I 11 n :liH::i. i' 12 The fact tlmt he hail an old hernia, which Dr. Wharton had at one tinio reduced, siijrgested the pos^sihility of the troidjie oriirinatiiii!; about it. J^uparotoniy was advifcnl, and Dr. Ashhiir.st eanie out one evenini; for the purpose, but the patient refused his consent. Februanj 2-i,]SH7. ilii • Pi/o-pneumo-fhcmtx mbphrenicus. W. S., £et. 24 years, was admitted to the surgical wards of the University Hospital on November l-'j, 1885, having fallen under the wheels of an engine. The left arm wascrusiied and he had a deep scalp wound. The arm was amputated at the upper third. For a week he had lu-ematuria and he comphiined of a pain in his left side. Subsecjuently erysipelas developed in both arm and face. About three weeks after admission, signs of inflammation appeared in the left infra-scapular region, indicated by a rise of temperature, dulness and feeble, blowing breathing, and he was transferred to the medical ward. The stump at this time had almost healed. Ivxamination of the chest revealed circumscribed dul- ness at the left base, extending nearly as high as the angle of the scapula, and, laterally, to the midaxillary line. Tactile fremitus was diminished; on auscultation, feeble, blowing breathing, and on deep inspiration rales. Slight cough, very little expectoration. A se])tic pleurisy was susfjccted. The condition remained practically unchanged for several weeks, during wliich there was irregular septic fever. He complained at times of pain in the ilium and left side, particularly when he drew a deep breath. He soon began to spit up fetid pus, and in twenty-four liours brought up several ounces. It was concluded that a localized em|)yema had perforated the lung. On examination, tympan- itic resonance, amphoric breathing, and metallic rales were found low down in the postero-latcral region, beneath the ninth, tenth, and eleventh ribs, indicating pnenmo-thorax. The autopsy showed the existence of a large abscess behind the left kidn'v and descending colon, extending from the diaphragm to the crest of the ilium. The chief part of the abscess lay above tiie kidnov, beneath the ribs, and in this region there was a distinct cavity, part inliy occupied by dirty-brown pus, siuiilar to that which the patient had ex- pectorated during the last two days of his life. Part of the diaphragm was in a sloughy condition, and two orifices, through each of which the, point of the index finger could be pjissed, communicated directly with an abscess cavity in the lower lobe of the left lung. The pleural membrane of this part wero I'rciitlv fl,;,.!.,.., i i , '^t i''^ "Pper part a .li.tinct"cicmid Lt I'T U "' """' ""' '•'•*'^^'"^'^'^ tissues were strongly ndhJuL " '"'''"^^ ""^' '^<'j"-^-'»t The seqiioiice of evi'iif^^ in fi,;. or ki.l„oy with hruiJ ^ hI^^ Z^T "^'^'^:^'"^'' "^ ^'^"'>- ^ ^V"u„d '-•^^>-'i'-'5-^ii' ^h.^^^^^^^ -U,,oitywith ..bphreni. al.co. i of a subphrenic aiUomain . ' ^^ ^ f "'"^ ^1" '"'^ ' ''-^'"P-.t ^.^P^ets orthc le. side, the .^l^pll'ltSir ''' '''''' "''' ^"^^^ ..e;^r:;ih :rZ:r.sr:r:r''"'-- '- '- - - i" ^irc/ur der HeUhnulc for 187 ' "^^ '"'' '' ""'""' '"'^ '^'"^"<^'-. one, followin. injury. The liter Unr'T'H' '"'' ™'''' ""' ""'"^'^ ^""'^ occrri,., with linlyphlit' ^g : ' ^Dr V'f ''^ ''^^"'-'^ "^=^ ^'- Canada J/. J/../ ,„/ ^s'..^/.;/ j!^Z ' "'"f' '" ^"^^ '''■ '' *''^ • -^"""ar?/ 28, 1886. A <-a.e of retroperitoneal ^^i^dle-eeiU sareor.a .Uk e.ten,re tkro.,,ie ^nd hemorrhagic changes. ^omuofic In addition to features of general pIIm;,..,! • . is worthy of record fron, the r r v \v T"""'' '^'' ^""""■'".'? ^"^« ronn large ulKlonnnal t„lr 2 i nl "'^'r'""''^' ^'"•^•"'-^^- hemorrhagic destruction which "^ ^2^1 Z '"';' f" '"^"''^'•'-•^'^ undergone. ^''-*'^'^' I^'*^'^'"" o^ t'le growth had -th a tu„,or of abdon/en H d " '"';^' ■'^^^'^'"'^^^- 2'^' 1884, tohacco to excess. Had b en tit" " '"'7^'^ ^'''^''' ''^^ "-'^ ill"e,«s. Fannly history good W ' 'T'"'; "f' '' '^''^ " ""^'^ P'-^'«^"t -nths ago he notic.l 1,!'!; d """ "'''' ''''''''''■ ^^'-'^ -•- inconvenience, and it wa "ot , t"" "r.' ""'''''' '''^'' ^"^ ^""'^ - uncon,fortable after oatin"! . ""T^'V'T ''''' '" '^»''^" ^'^ ^^^ iost about eighteen poundJ' ii; we g " H ri^el^' ^'•^"^'" ''-' ravenous, -mhI the thirst excessive " /'"/ ^ '"' '^^ *""^'^' l^''"» ' i flf- : f:if. I j i 1 i £ , I !■>■; P 1 I '.; 1 :: M Mi 14 clean ; a|)potito good, but ho ciiiinot take large meals on ac-eonnt of sen- sation of iiihios.s. Says he is in good health, only weak. Passes about seven pints of palo urine of a specific i^ravity of about 1004, with a trace of albuiuen; no casts, no sugar. Exauiiuation of thoracic or^^aiis negative. Abdomen presents a symmetrical prominenco in the neighbor- hood of the umbilicus, rather wide and Hat. Superficial veins not dis- tended. On palpation a solid tumor is felt, occupying the hypogastric and umbilical regions, aiul extending laterally into the Hanks. It is irregularly nodular on the surface, slightly movable, and the n)unded out- lines above and laterally can be distinctly felt. Eelow, the outline is not clear and cannot be defined, ({rasped firmly, it can be moved as a solid uniform mass, occujiyiug a median position. Xo one part is softer than another, and there is no sense of tluctuation. Percussion gives a dull note over the tumor, tymi)anitic above in the e])igastric regi(Mi and in the lateral part of the und)ilical. From splc(>n and liver the nuiss can be easily separated both by percussion and palpation. There is no pain in handling. Measurement round umbilicus thirty and three-quarters inches. Glands in groin not enlarged, feet not swollen. He stayed in hospital until Novendier 11th, the condition remaining unchanged, except that he gained three or lour pounds in weight, and his general health had improved. The condition of the urine was oj' interest : ibr several weeks he continued to pass more than seven pints daily of i)ale urine of a low specific gravity, with a trace of albumen, but in the last three weeks in hospital the amount fell to about three and a half iiints. On October 18th he was made the subject of a clinic, when the diagnosis of Lobstein's retroperitoneal sarcoma was made. The l)olyuria was attributed to irritation of the renal nerves caused by the pressure of the tumor. On the loth of November he went home. Subsetiuently he was admitted to St. Mary's Hospital, under Dr. O'Hara, and the upper \x\xl of the mass, which had become soft, was aspirated by Dr. Moars, and a couple of ([uarts of bloody fluid removed. lie was taken to his home, where he died in April, and I have to thank Dr. Miller, under whose care he was, for an invitation to be present at tiie autoi)sy, and for per- mission to utilize the specimens. Ai(fo/).-• ".'«'■" «»- (•arefiilly removed- tlioro u-„u i li '^'""'^•'^'- ^'"-' I'ltostincH were ;-l into the Icavh-'m ',:':;: ^a ^'^ '''^''''\ ^"""""• 1""' "oadl.csions. Jk.|ow -.nd t. V '■'"'•'"'' ^he tumor >"•■•... <'f tho pelvis r/eio V ■ " ''"^'^ """^■l'"H.,t was to the I«-tion; tho t p 3 H d li^l ; "■ ^""""^ ""^ '"^^"■••-' i" tl.c tumor. Tl.oadu iZ hi, ,\T'» '"'^^'^"^ the syn.physi.s and we^i. was estimated a;:c:x;:fpL:;r'^"'-^''^'''^^^ ^''- a iow:;:;Hi:;r t!.:^ :;;:;.:;:';^' "" t" -'''-' '-'^' ^'-^"- -^^ pint an ^ which also ]ine,l the wa . ii ' "' "^ VcnowLsh-hrowu n.atorial, -ovedattheta,pi„:h;;d'::ii:;ur::ri;'::^ by cxtrava.ated bio o -^ !^ , ' ' " '!'^'' "'"^ everywhere surrounded i" son.e plaees ex^o^u;. 7 ' P'-t.onjust within tho eapsule, and nothin. n^-^estive •; " ""!"''''• ^" ''""=* ■^^•^•^'"" ^hero was -ten^s o^^n :;m 1::^:^:;; ;-xr"''^''' .''^ tiwi of tlio luivc- „.„-l .,(• ,1 '^ " ""' "" Ini'iiii-itiou. Scc- *".iy of. i.c„,„„eo:r:,:t a " ;::'z ;;;.,;;;. ""'■™™—<' -i. «m( l«n-t of 11,0 ontiro nms, ' ' "™'' " '■"■''■■'• "'»«"'«• a. '^l. s i l:'(, ) r > ) 1 ' k' in tieiiliirly llic rif,'lit ; dno, doiihtloss, to pivsaure. Tli(« Ii.«urt sliowcd niodcintt! liyiHM-trophy of tlu! lott vt'iUriflc. Aurtii sukioiIi. Lmi^s iiuu'li ciirlxiiiizoil, and Hoiiu'wliat (•mphyscniatoiis. IJraiii not cxainiiied. lfinfo/i)f/lriil iwiinlifflion: TcaHcd portions sliowod that I)otli |)riniarv and secondary growths wtTo conijjosod of l;ir;:,'o spindle cells, closely packed toK,.tiier. 'Plio reninantH of the original growth .situated at the lower part of tlui tumor were (jiiite distinctive, and hail not undergone degeneration. There were also, in .some places, portions of sarcomatous tissue just within the capsule, separated from the central dry thiomhus by freshly cxtravasaled blood, Sections of hardened portions showed a typical spindle-celled growth. The thi'ondnis presented a finely granular basis-substance, between .strands of translucent, hyaline m.itcrial. All traces of cell structure wore gone. JieiiKid-K.—Thu points of interest about this case nuiy be brielly eon- sidered under the following heads. T/ie r/Kinirfcrof t/ir f/roirt/i : Sjiiudle-celled sarcomata rarely form huye abdominal tunuirs. In the examination of a considerable nund)er of new growths of all sorts, removed from the peritoneal cavity, I have not met with a similar one. T/ir ^itmilloii of oi-iijiii was unusual. 1 fully anticipated that wc should find it springing from the Iund)ar retro])eritoneum, the common i)oinl of origin for large abdominal sarconuita. Here the growth seems to have begun in the subserous connective tissue in front of the symphysis, not, from the peritoneum, for it was ipiile loo.sely attached. Jt is interesting to note that spindle celled sarcoma not infrequently originates in the connective tissue of .'-icari)a's space, a tissue directly continuous with tliat from which the tumor in question grew. The looseness of the attachment and the readir'..--; v"'; Inch the tumor could be lifted out of the abdominal cavity, made us rcirret that we had not yielded to the patient's urgent solicitation to have the abdo. men opened. The charudrr of the rrr)rcs.->ive rJunxjrs: So soon as a tumor obtains any •fo expect to find in it areas «)f degeneration, fatty, caseous, or cuh a- re >,. , V. . if '• apidly growing neoplasm, hemorrhages. Sarconuita . 'ire pa it-.-, 'a'-'y prone to hemorrhage; indeed, when growing actively, it is i<>.n:r... CO find foci i extravasation in them. The effu.sod blood not unfrequciitly becomes encysted, and the dark contents appear to result from the liipiefaction of the coagulum. In a large tumor several su(;h cy.'-.ts may exist. Snudl scattered hemorrhages are more common, and the blood gradually undergoes changes without materially altering the appearance of the growth. «i» 17 I ho coiKJitioii ill (I. 1 ^^•'"'' " c.o...si,loral,lo portion w,.; ; , '"" ", :'''>; ''"•'•' ^'"•■""'n... "•"""•'•'"f ^' ^'-'-..ion or a :. ": ' 'rf • ''■"'■ ^---i .een prolon^cl, tl.o l.loo.I llnj]l 't, I'.V »«P'niHon. Ha. life l->.no inspi.atc' -''^"''^ ''"^•'■^•a^^o in ,he ^1' to nonnal ,.f,re uXZ^^l^T W T"''''' "^ ^'^ ''"'-- ci.se con,lition,s under which thi.ocZ r '^" ""^ ^^*' '^"""- ^''o ,„e- need carefi.l observations o '^^^^f r'""^ ^^ '^ "^ --• -'" '>i' the nerves ^•f J; 'i ^"iijd t^^ir :c::; :r ^- ^ — . -ou,h I^'-- Tyson wo;,|<| Uk, ,,, ,,,,^ ^';' f' ^^'t'' «on,e hen.orrha^e. ^'•^^^tof; thron.bo.icde,ene; ,^;.r;V;'f '."Vt ""'"'-• "^ ^he "".''.••'^■=""> in it possible for clots t t Tf ^''"'"-""^-^ "^ ^""'o^-s. -^;'>uItun.o, as is assorted bvU;,'; '"""■^^' '"^^' ^'^ ^'-'-f thj i'le 1 resident remarked th-if flw, :'",""'■ t""''"™'. i" view ,',:;:„;;•" °'; "■'■'•'' '"-est «,,„» "" "*"1 Dr. 0,1c.,. „.|,c.l,e,. the ,,1'' ', "';='"'' "■•«'*'-o..cc. > r ) I i c ii i..'i ^ .( li 1 ( ! if .}■! Ij m 18 from a similar growth occupying the more usual position in the lumbar region. Dr. 'l\son, in connection with the clinical history, called attention to a retroperitoneal sarcoma, ])resente(l by him to the Society last winter, which had been mistaken by liim and others for a tumor of the kidney. Dr. Osier, in re|ily to Dr. Tyson's first (juestion, stated that the only remnants of sarcomatous tissue were two or three small, but very dis- tinct, portions of the lower attached part of the tumor; the remainder had wholly undergone this throml)otic cliange, and in tlie upper part had become converted into a blood cyst. This change was, no doubt, slow, with first a destruction of the sarcomatous elements by the blood-clot, and then a slow process of necrosis. There was no evidence in any part of the tumor of an invasion of tlie coagulum by the sarcomatous ele- ments, as is not infrequent in thrombi in other regions, as he had seen in the portal and renal veins. The chief interest in the specimen lies in the remarkable extent of the thrombotic change. Looking at the clinical aspect, he had diagnosed the case as one of retroi)eritoneal sarcoma from its large size, the central position, the slight movability, the dis- tinct separation from liver, kidney, and spleen, not being placed more on one side than on the other, and from the fact that palpation in the lumbar region gave no pain or other evidence of kidney lesion. It was firmer above the brim of the pelvis than any other tumor he had ever examined. One remarkable feature about these tumors is their painless character; this jiatient complained of no pain, and in two other similar growths, which he described at length, pain was not a symptom. Jdiiuarij 14, 1886. (Jirrlio.-ii.'i of liver ; ftital hrmorvhagc from m-iopharjeal wirix. David M., set. 44 years, white, admitted to Philadelphia Hospital Surgical Wards .,n October *2(i, 1886, with an ulcer of the leg. Had been a hard drinker, but up to the jjresent time had not been unwell for many years. He had had syj)hilis. Patient was very pale and trenui- lous. On the morning of the 27th he complained of nausea, and at 1 o'clock P.M. vomited a large quantity of blood. Tlie vomiting continued at intervals through the afternoon and night, and he lost .several pounds of blood. I saw him for the first time at noon on the 'ISth, when lie was in a semicomatose state, could not be moved, was breathing deeply, and was evidently failing fast. The examination of the thoracic viscera was negative. In the abdomen there was notable diminution in the area 19 :? lir;™,',;;:::;;:" -rMrf *:ri T-r -r ,"■»' "-^^ -- «■« '-- ke|.., u„.l „» tUcldv c ,« ;, '■? '""' '""» ™'""«l. '""I been .tool, wi,ic.h i,t i>J,e ^u . ;. ;r r""",""' ""•■' "'''"" ''"'"«'■• a contracted. The diu ,l,r,.ni,.it;. "'»''" '''''« ^■^■'■^' '»"«'> covered the kidneys, and the no J 1 , ''' ""^"'"''^ "^' ^'^'^^els did not contain hLd : ^ : ;! ^le ■ "" '" ^"'""- ^'^^ ^^"-^^ tl.o canliac en»orrhage. ni^od event in .i::!^!7Z Z"T 'T ' ^ '■^^^' ^"^ ^^^ --^- f>n'l the veins of the gnlJet .n-ontlv r , \ ■"" "'""'' ""common to anastomosis with the ^/^X ''"'"' '" ''''' ^''^^-«' - their portant channel by which t e ' L I'T' ?''''''^ '^^'"^''^ ""^' ""- l=>tion. In cases oVfata Le nt i '""^T-"'" ^'" ^""^^^•''^' -"-- agus should always be nu^^ h" wi^ H^^ I>e overlooked. ' " " "" ^''^ "'^"^^ «f the bleeding may I'^chruary 24. 18(S7. i"; I i i.i f:. > i r ) ::': ■ 1 ■s ' p 1 r- ■ ,1 1 Aneurisms of the branches of the circle of \V\m- i part ... the historv of cerebral hon, , ''"''^ ''" nnportant anouris„,s of the nutritive t'l^"^'"^^' ""^'"» "^t to n.iliary tl'an the state.nents of text-bool-s w 17- 'T' '"■"""'^'' '"'"'« ^'^"""on 'li-ction is n.ade the a • ^^ unless a careful two... cases are .,,J.^:.:X;.^^Xl7::^'; "^'"'^^^ «^ iIosi..tal,Mont.-eal. !„ oi.rht th. "nn • ff '''*^ ''^ "'^' ^«"oral l-nor,.hage ; in fl.„r. th ^"^ ' ""r '"'"? "^^ ^"^^ -^' -"-1 fatal 'l""ed any syn.pton.s. ' ""' ^'^^''"'^''tally, and had not pro- '% U ' 20 A majority of the patients were youiii,' or middle-aged individuals. One was a child of 6, another a lad of 17, and a third a man of 20. In live the age was about 40. The early age at which they occur has been noted by several writei-s. Thus, of seventy-nine cases collected by Coats,' there were forty-two between the ages of 10 and 40. The case here re[)ortcd, occurring in a boy of G, is the youngest of which I can find any note. Eight were males and four females. The arteries involved were: Left internal carotid. Case I. ; right Svlvian, Cases II. and V. ; left Sylvian, Cases III., V., IX., and XI. ; basilar. Cases IV., VII., and Vlir. ; anterior communicating, Cases VI. and X.; and anterior cerebral, C'ase XII. The aneurisms ranged in size from a small pea to a large cherry. With the exception of Case IV., they were sac- culated, and communicated with the lumen of the vessel by an orifice smaller than the circumference of the sac. In Case V. there were two aneurisms, one on either Sylvian artery. In Case III. the aneurism was surrounded by thickened meningeal tissue ; in the others the sac was free. In seven cases the hemorrhage was chiefly meningeal, and the laceration of brain substance was slight. In Case III. the hemorrhage was altogether into the substance, which, from Coats's account, seems not uncommon. The extravasation was usually basic, and beneath the arachnoid ; the amount of blood considerable, except in Case I. In Case X. the hemorrhage extended along the right optic nerve and appeared as a subconjunctival ecchymosis. In Cases III., VII., VIII., and IX. tliere was heart disease; in Case VIII., ulcerative endocarditis. In Cases I., V., VI., VII., IX., and XI. there were atheromatous changes in the branches of the circle of AViliis. Embolism, endarteritis, and atheroma are the chief causes of aneu- rism, and the cases in this series afford illustration of each. Although it was suggested by Ogle," Ciuirch,'' and others that embolism played an important part in the production of aneurism, the evidence was not very conclusive until the i)ublication of Ponfick's observations in 187.'>.* In several of his cases, the connection of the eiid)olus with the aneurism was very clearly demonstrated. Of the cases here recorded, four were associated with heart disease, but in only one. Case III., was the condi- tion suggestive of the previous occurrence of embolism. In this patient, a lad of '20, with aortic valve disease, the aneurism projected directly into an oval cyst witli reddish-brown contents, and there can be nil Iff I I ( , . I • • ! 1 filiisgow Mcilic'iil .Iimrniil, l«-:i 3 St. Uiirtholumew'n llii.iiiital llciJurU, vol vi. = Mfdicii! Thiipsiind Giixcttc, IHCI < ViiTliuw'3 Aroliiv, lid. Iviii. 21 ulcc-ativc ™,l,„:,„,|itis ,,,,1 a r 1 , . ^''"■'•"'""- There were ,v:'--- "■^"' - '^■''^^':::::2:'::"i; ""' ■", ■"". -''■" this part «as obli^e„,tc tiliroid i„ ,1, . '■™' S"'"S '» ancri.,,,,,. Tl,e wails we ^ ' w, r,"';, .'''"r™ '' "",'"''"«' ""<■ vel.licJ on the proximal si,l,. .,(• ,1 • "'° """'■''■sm lia.i de- ctly, of in.erfele„:: r , e at:.; ::':ni "" ■" '°"7"™-' "l">- I" .l.e other eases associated ier,'!,:'"t? '" ' "j "^«"- •.. >» -y .raee of previoas embolic le r 'w „ S t' . 7' T"=!" cases there were athoroiivifnM . ..I, • '"'"^"^'-ted \ cssels. In six Willis, and I tIdaU i: :^^:::jr '" "«'/■«* of the circle of .1.0 fcmmtio,, of these a, r .l p', ""7 "''"™' """°"'"" "'"' in II.C intitaa, is verv com, , T n ,1 ' ""■'"""• "''"' «'«.v changes I'avc n,ct wit ins lees h hi h " \'°" ,"""■'" °' "'° '"■""■-• »«i I arteries were chieH;, , al , n ,1 ^l "n '"' ""^ ""'''"' '"""-' tl.ose eases under the a.-o of 40 , " ,"»""-<»"-o of so ntan.v of tkcory, bnt „„„,.„„„ par ictd. rle ' ":"° '" *'""■ °'' ">° ""bolic .vo-g. A weak .pi in ;';,: ;:f ""' 'rS'""-' ""="'■ ■•■ "- S|«iaily liable to yield as la, ■ '" «« "robral vessels w,„dd be co,a,n,,,,ie„ted fro.n t^l'e a^;'! ' "" """" '"'"'"'"' '" » •'"■«ly Fn Case IV. tile dilatation was due fo I,.,,.,! i |.ossibly „«,cia.e,l with recent, v, I ' T ""''"•■";"'"■ "I"-'. ! 22 p!|[f"-fiiHi would answer intelligently. Urine alhnniinous. She remained in this state nearly five weeks. On January 'iolh the right arm was flaccid. Insensibility supervened, and death about si.t weeks after admission. The post-mortem examination showed atheromatous arteries at the base of the brain, and on the left internal carotid artery, just before its division, a sacculated aneurism the size of a hazel-nut, which communicated with the lumen of the vessel by an orifice one by one and one-half lines in diameter. The sac contained a firm decolorized clot. In the course of the middle cerebral artery there was recently effused blood, beneath which the brain substance was lacerated to a slight extent. There was an atheromatous patch on the anterior segment of the mitral valve; otherwi.se the heart was healthy. CJasr ir. Aiieurixm of rigid middle ccrelmtl arlenj. — IMrs. R., let. 40 years, married, five children, patient of Dr. John Bell, was i nd speech- less in her bed on May 29th. She had been a healthy woman, but had suffered with vertigo, and of late her memory had failed. There was left-sided hemi[)legia, gradually deei)ening insensibility, and death oc- curred on the night of the 30th. At the autopsy, slight meningeal hemorrhage was found at the base and over the convoluti(ms of the right side. The right Sylvian fissure contained a large clot, and the convolu- tions bounding it were considerably lacerated. At the main bifurcation of the right middle cerebral arteiy was an aneurism the size of a bean, about half an inch in length and a quarter of an inch in breadth. At its under surface was a rupture with a ragged orifice. There was no athero- matous change in the vessels at the base. No heart disease. Case III, Aneurism of left middle cerehml artenj. — A. R., ret. 20 years, a small, but well-built man, died suddenly on the evening of the 25th of March, and tlie body was brought to the hospital. No history could be obtained of any previous illness. Brain, on section, presented a large clot on the left side, which involved the lenticular nucleus, internal capsule and part of the thalamus, and reached almost to the convolutions of the insula. On carefully tracing the vessels in the left Sylvian fi.ssure, one of the vessels was closely adherent in the angle between the insula and the parietal convolutions. The artery appeared to enter an oval mass the size of a large cherry, which, intcrnallv, was in direct contact with the clot, and on slitting up the vessel it expanded into a small aneurism the size of a pea, which occupied abjut one-third of the oval mass above referred to. The wall of the aneurism presented a rupture four millimotros in length. The chief part nf the oval nin.'w was nride up of a cyst with firm walls and reddish-brown, pulpy contents. No communication existed between this and the aneurism, but at one 5 \ 28 point tlie connection of the aneurism •nu) tl.o filM-ons. A branch was ,ivcn o i "J '''' '''' "^^^ -"«'> ""^1 ^ as if it ha^I been forn.e.r.tt the l, ". '"""'"'"' "■'''^•'' '"'>ked * of NVilii. were not a e InJ^ n"^ ? I'""'' ""^'^^'^^ <'f the circle of the aortic eusp«; ^ZtaZj ''^'l-^^P^-d ; fhsion of two Ca.sk IV. Aneurismal dilafation nf L.fi .. , i , i-i.«i. Eisi„oe„ ,„„„ti,., iK.f„,' d t:ito ;,C;'? r'',"' 'r;'" ■" sivc coagiiliini at biwo of l)ril„ f, ,■ ''"""''"■' s)'l>l"Ils. JJxteu- tl.o latter vosKl close to K „ ,. ""= I'"*''"'' ""'<=li P-e.,teU o,.„,,„„ a.l,e,.:: :■„,.", ;;:r ;;- -7". -' in l>i-« basila,., very materially redoced the 1 , ™ t' "■.», «""'° "*' "«> vessels i,„„„a|. Heart l,e,I hv No H ""'"'"'" '""' ^J '""" Male. tet. 65 years, patfen Jt Art ,/a B, "'n,''"/ "'*"■'"'- ."onths ,.itl, obscure brai„ sym,Ho,t Vetb' .T; , '"' """"°"=" ;™.o-,a„d jost beyond the fl'rst ' "'"■= an old apoplectic eyst 1 . ,e S^^^ '" ':°,'°" l>™'«Pl»ie there was a„e„ris,ns.' No valUa; dt,:: "JhL:! "'' -"■—- -'-y Pifa No history ';rev;, ill', : "cl '™>"'" '" "'» «»■«" «»»■ fasnre, and „ nniforn, sheetZ a he I,/ f '" ,''.'''°" °'' '""S""'""al entirely beneath the „ n< 2d <^ " °""'='°''-'' '»'"« "> "<»■''. basilar and ndddle reb^l the^'c:!;?,-'""'^ "' ""'"'""" ^ Willis revealed a .mail .,„e,, . li "' ''"^""^tion of the circle of »n,m„nica.i„g arte an T '","" ^T"'"'^ ^""'' ""^ ""'«"<>■• tniMin,e.res in lengl'' T Z :'lf ,T M '1 '"'"'"= '■""'"- ''^ -;.«! a spot ..f°atherom:::: -r:- c:™'St:r'"'''v''"V''^^ atheromatous. Kidncv^ ■, IJtH. """ce. lleait normal. Aorta r \rrr . ^'"^^^ '^ ""le granular. V-Msio VII. Aneiiri.vn of basilar nrtp,;j~ J « Death from thrombotic « 'ft..,:.. :. '.! '^ '^•. ^V «^'^'- 7'> .vears of age. at the base atheromatous. A nected with the basilar arte iiig in left hemisphere of b 11 aneurism the size of a lai ram. T r :1s iry, a ■gc pea was con- ^^ I: h '■ 1 V: i' 'k 1 !■ . "( V. 1 'f Ij ll^ ] , , -«" J-.-11 iliio ui nd lay imbedded in a shallow fossa in H - I -"il 24 tlie pons. The wjills wore tliiolc, and did not contain tiirondii. Heart liypertnipliied. Aortic valves ineoinpetcnt. Perieardiiun adlierent. Casio VIII. Aiifiin'mn of Ixisilur ((rtn\i/.—'M. W., male, a't. 4.') vears. Had had syphilis. Admitted with pneumonia, and developed ulcerative * endocarditis. An aneurism six by five millimetres projected from the upper wall of the basilar artery, about its centre, and had formed a hod for itself in the pons. It did not contain clots, branches of circle of Willis not atheromatou.*. Heart a little hyperlrophied. Recent ulcer- ations on aortic and mitral valves. Cask IX. Anenrium of left middle vcrehnd artet-ij. — Female, ict. 40 years. Died of pneumonia. Vessels of circle of Willis slightly ather,)- matous. A i)atch in the basilar narrowed its lumen considerabiy. Just beibre the first bifurcation of the left Sylvian artery there was a saccu- lated aneurism the size of a pea. The wall of vessel about it not athero- matous; no clots in interior. Heart hypertrophied ; vegetations on aortic valves. Casio X. Auciiri.'Oii - ^™- ^;.. »o„ o„ .1,0 H„. »*,„,;j':„f;;;-,.i;;T „ * ;:Er ti,o c„„t,,.,„„„ |„„,i„„ „,.„,„ ,„,_.,, ^^^,_^^^^ „„: , : Mlior„„mto„s, and the heart „a» healthy eerel,r,'rhr'""'i" "•■•''""'"*'" »'' "'<= <«'V «rt^'™» i-s » lre,,no„t c«,.e of coub.al he„,or,-hase .., person, „„,h,- Cofty ve„,, ot„,.e; n the e„li cnee of .,on,e |,„,h„h,,tas, the „,«it common cause. '"«- "Lm- J% i;5, ],s8(). V '■ Ancurls>n of thoracic aorta ; perforation into left pleura. Miibel W., ;ct. 22 yours, was a.lnutted to the Phil-ulelnhi., U . > i ,|m, ,„ the c,„g„st..i, .„,, left sijc. I ,„„<,e „ e„,.cf„ Z ' „ of and in a few minutes fell dead on the bed ' Autop.j.-On opening the thorax, the mediastinum with the heart V: M' t|-9 f , ii r ) i I c 1 if i : I if II 26 WHS pushed to the right by an extansivo hemorrhagic effii.sion into the left ploiini, iimoiinting to several pounds. The lung wiis colliipsed. When the pericardium was opened, it was noted that the apex of the heart was not pushed beyond the middle line, and the oblique position of the organ was retained in si)ite of the dislocation of the mediastinum by the large effusion. Ilcnvt: Right auricle contained about =j of blood and clot. Left auricle and ventricle empty. On further dissection valves normal, the arch of aorta smooth, muscle substance pale and flabby. ^^Aurta: The arch was small, and the lining membrane healthy. Thoracic aorta looked normal until level of the nintli vertel)ra ; here there was an opening on the posterior wall an inch and a qmirter in lengtii by a half inch wide. The contiguous parts of the aorta looked infiltrated and swollen. This orifice communicated with a sac full of clots, whicli lay immediately in front of the tenth and eleventh vertebne, and projected into the left pleura, where it was closely united to the diaphragm. At the point of greatest prominence, there was a transverse laceration a half inch in length. Tlie sac was about the size of an orange. The bodies of the nintli and tenth vertebne were eroded, the latter most deeply. The cartilages were not involved. No changes of November 11, 188G. note in the other organs ^ t ■M \St :■ Small (Dieiirisms of arch of aorta ; compression and perforation of trachea; death from suffocation. Dr. Osier exhibited the specimen, and gave the following account of the case. Patient, an Englishman, let. 32 years, had come to Phila- delphia on his way to Colorado, as he had been advised to winter there by his English physicians, wlio suspected the existence of lung disease. He had been in Australia, where he had lived a very active life. Had had a chancroid, and had taken alcohol in excess. For nine months before leaving England he had a cough, much worse at times. He came to the hospital August 31st, complaining of weakness and severe cough. Examination of the chest revealed no special areas of dulness, but many rales, mucous and sibilant, in front and toward the bases. At times the cough was very rough and hard, and there was much wheezing. Tiiere was irregular fever; the temperature on 14th reaching 102\ Remedies had very little influence on the cough. On the 17th he was foun-' in a condition of stupor, and it was thought that he possibly had taken morphia, but the next wius attacko.l with coiigli and thomcic tronhh', po.ssiblv pul- monary, whicli kept him in tho house and in hed for several inonths. It was not until May of last year that he was able to work. Since July be has had at limes attacks of shortness of breath, with whce/.in-r, and often at nij-ht he has to sit np in bed. Within the past three weeks the pains in tiie shoulder and down the left arm have become very severe and the couali and shortness of i)reath have increased. Note on admission was as follows: Well-built man, face thi-i. f,'eneral musculature ^^ocxl. In.spiration rough and noisy, expiration long .,iid harsh and often accompanied by a bra/en, laryngeal cough. Respira- tions 1« per minute. Can rest in tlic recumbent jmsition. On inspec- tion, the left side of the neck is much flattened, especially above the clavicle, and the sterno-mastoid muscle on this side is evidently atro- phied. Ajiex beat visible in normal positicm. no abnormal imlsatitm ; slight visible pulsation in vessels of neck. Paiputlon in the ordinary way negative, but on firm pressure with one palm on the upper bone of sternum, and the other on the back, a decided impulse can be felt, and the second sound is accentuated; deep pressure reveals pulsation above sternum and behind the left sterno-clavicular joint. Percussion reveals a slight area of dulncss in the left half of the manubrium sterni and beneath the leit sterno-clavicular joint. Heart's ana m a^tate ot fatty degeneration and broxvn atroDliv e ponus of ,ntcre.t in this case were the repeated blee i .. extend t . !?'■ r > ! ! I,' C \ hi i ■I:i IP ijl^ ;. !' ^i 1 .■^, If '■' ii i-i ^•i I: 1 80 indication that erosion of tlie trachea had occurred, but Nuhsc(|U(peiidcd, as no careful dissection was made of the nerves in that region. Possibly the sympathetic was affected, but there were no diflerences in t''^ l>iipik Ajyrtr.), LSS,"). »' ' Jinpfara of the posterior papillary muscle of the Ivjl vcutride of the heart. li. l\, ;et. about 70 years, a hir<,'e-framed negro, was in Ward (> of the Philadelphia Hospital, tour months, with .symptoms of mitral valve disease and heart fiiilure. When I first saw him, about a month before his death, the legs were swollen, and the urine scanty. There was orthopncea, and slight effusion existed at right base. The apex beat was outside the nipple Hue; impulse forcible; and a systolic thrill ccjuld be felt in the apex region. There was a loud, rough systolic murmur heard well into the axilla. The pulse was irregular; superficial arteries verv atheromatous. Ilis history was not very clear. He had been a hard worker up to a few months before his admission to the hospital. His symptoms appear to have come on gradually, and throughout were tho.se of mitral insufficiency. Three weeks prior to his death Cheyne-Stokcs breathing came on, and persisted without intermi.^sion. During this time he was well enough to get out of bed for his dinner, and at this time he was repeatedly seen to wait for the urgency of the respiratory move- ments to pass away before taking a mouthful. Body that of an elderly, well-built man. (Edema of legs, back of thigh. Abdomen contained a small amount of serous fluid. In thorax effiision into both pleural sacs. Pericardium contained a moderate amount of fluid. The pulmonary veins, arteries, and also the aorta, were filled with dark, firm clots. Right auricular appendix filled with an ante-mortem clot softened in the centre; several globular concretions in the neighborhood. The right auricle was much dilated. ricus] lid nng. \v\ 4.' ■f ''^^ i-i ..„., r:1 1 ' J?,;;:: ;;;;i;'-''. ■■-•■"'«■ > » lari. .t.'m,..,.,l. I,,i v,.„u Ml,' ^,"'"'^"^■* ■'■'"" "' I- ""I ■■■•■"" "f rnurni ,i,i„ „„ , , ;„„;;"■":;■ 7-'^"'"i-. A-'-i-- »«■ III., i,„»ti.noi- »,.t„,„,M „-,„ „„„„,| „( ,. „ „ '" '" ""« "' 'I'l" "CgiiK.iu. nvooi„„,,„p„.,„, „' ; ,„.';,|:: ;•';"■: ""pi"...,- ,„„,dc «„„.,„. «»II ..f 11,0 vent," I, ;,„ '"■" "" >•<'»«'»"■■"»■ <)" ll,c |,..,lc.,i„r Wall, „n,,c left „:, ,e ttr^ , :, :;■;:.■" ''™"-"'' ^'°°'' »'-■ .o:;:;:;:t:t:::;;;':;;;::i;r:?t:::;r™r™'''-"'T-"'" uiKloiililcdIv tlie til, „f , ill '"'"'V ^"1™ "'TO nctached, to be » I-- " n-w- fii„-c c«:i t; , 1 1 ;; " ''""''»""• "'- """v experience, an.l I do not re.Ln . ^l ' '"'" " ""''^"^ literature. Ti.e absence o v 1 r . ''''' ""■'^' '"^ '»^^""^'« "> absence of ^egetatIons on the torn surfaces is interesting. iVrt/-t'/( 10, 1887. Trvo cases of four leaflets to the pulmonary valve. «'"'|,ii'il liva fourth .„„„„„„ , ■''" "''j-'<^™' '■»!« » I I i< f I' i(: I I S :; i I 32 Case. I. — Between two cusps there is a space 3-7 nun. in wicltli, wliich is occupied by a small semilunar valve. It has a well-marked curvi- linear l)ase of attachment, the free nniri,nn is H mm. in length, presents no corpus Arantii,and is anchored to the artery wall by a small narrow tag. The depth of the valve is N mm. The lateral attachments are to the adjacent cusps, not directly to the artery. Two or three fenestra- tions of the large cusps communicate directly with the pouch of the small one. The three segments are of eipial size, and normal. Cask II. — Between two normal looking segments there is placed a small cusp 7 mm. in width, 8 mm. in depth, with a distinct crcscentic margin of attachment and a curved free border. The lateral edges are united to the contiguous valve. The sinus is distinct and does not com- municate with the adjacent ones. The adjacent cusps look a little smaller than the third. November 11, 1886. Bicuspid jmhnonary valve. In a case of carcinoma ventriculi, with enormous secondary mediastinal growth, the i)ulmonary valve presented the following peculiarities. The orifice was guarded, by two segments. The smaller measured So mm. along the free border, was M mm. across the face, presented two fenes- trations, and there was no distinct corj)us Arantii. The other segment measured o() mm. and across the face 1") mm. The free border was thickened, presented no distinct corpus Arantii. The body of the leaflet was also a little thickened. At the attached margin there was a sli'dit indication of separation into two segments. On the arterial face there was a small median raphe which jjassed from the arterial wall to the base of the segment. Here it expanded into a seri'- of radiating fibres which extended along the inner surface. This in .^au raphe separated Iwo sinuses of about equal size. Decey/iier 9, 1880. Large phlebolith of l())if/ tiajjhoioas vein. The specimen was obtained from G. H., an elderly man, who died in the Philadelphia Hosi)ital of fatty and dilated heart. The tumor was noticed during life, but there is no note as to how long it had existed. There was no sign of a wound or of external injury, though the .size and situation suggest that it may have resulted from traumatism. *• 83 ati:^:!;";;^^;:-^:::::^^-'^; f^'-'^-^^ '--'- ^'-^-^ relations o,. ,lis.ection werel X„o,^ ^r? '' T '''"'"• ^^^ di.-cctlybe„oathit.ndwas„ottvS F^ f '"'''"'' '^'"'^ of tlie long saphenous vein oecl 1 'l, T '"'" ''"'' ^'''■'- ^'•"'^« on«-. The occlusion u^a tl t / T ' ''""'"" "' "^ '"'^'' ^-■- Pi^^'l the upper end of th Ion . . , T ■" '"^^'^^'""^^^l- ^^^hich occu- ^7 heio!.; ana ente.:;^!:!:^^^:' at J';;; r ^% '--'-- and a ,,uarter fron. the ie.noral vein If . '\*^f '"''^^ "^ ''» ■'"ch funor by three or four sn.all n s. - O "• ? '"""'"'^^'^ '" ^''^ nally a dense fihro-calcare s ' i T" ! ''""""' '' ^^'■'^■^^'"^^^'' --^or- ably consistent, altered bZl ' ''" ^""^'^"^^ l^'-ownish, toler- Febmanj 10, 1887. ^" '^'^ '"'''•^'■'^ ""«'«'»y o/-;;„«,,„„,.,-„. My post-niorte.n records include 105 cases of Inh ^vluch, with one or two exconHn.. , "" pneumonia, all of Hospital. For the V^:,Z!^^ ^^rt Tt 'iT'^' ^^"^^'^^ -''K'l> the data are incomplete s i o ' '"'''"'' "^'^ ^^»^^«' '" tl>e death-rate fron, this dsete is hi 1'! ' '""f ^"'^^ ''"^'''^'''^' ••"'^^""ly the severer casesTre b "^^^^ fact that, as a siderable proportion of le cat ' '" ' ^^"'^' «^««"''. that a con- Paupors, who\.apidIy l:!;:,! :::j;':;;-;;;f^;!'^^' "»<• ^Hssipated In the statistical re,)ort of Dr T... n '? '»"^^ction as pneumonia, ten years was aon.ewl 0.^2.^1^' ''^rT'"'' '''' "' "^'""^ «^' ring within fortv-ei.d.t hou s . , " ""' "'^ "^^''^ ''^'^^''^ "^''^•r- «ta.ed that the nun-tali v ,' c l'"'?"- ^^ ' ''''''''''' '' '^^-^ »^« P'-of R. P. Howard, of^A „t ^ Z-i'.; '""""T'^ " ^'" J"'''^'^'™ "^ onl.v 4.8 per cent. ' '"""= "^ P''^""^ «^ twenty years, was The statistical details are as follows • ^-.--Of the 100 cases, 70 were iu n.ales, and :)0 in fon.ales ■K^tl.. 18; between 40t and -0 T\ I V'' '''''''''' ^^^'^ -'d over 60, 20 cases, ' '^ ' ^'''''''' ^«^'' '">J 60th, 12 ; and lung alfhrted.-Jn M case., th As to the j)osition of tlie infl 'e right; in 32 c; ises, the left; in 17 Montreal Genenil Hospital Iloports, amed region in the lung the % ures vol. i. Daw- son Uros., 1880. f • ( . ■ t r )■ i I I c ■ ( 1 .1 •■ » .!i i m II ^ ■ ii :{!■ -^H I ^f : M ! 1 / 34 •; :l h. ; ! 4 .1 a are : in the right, whole organ solidified (except, perhaps, narrow margin at apex and anterior border) in 17; lower lobe alone, in 18; upper alone, in 7 ; middle and lower, in 3; middle and upper, in 2 ; up])er and lower, in 8. In the left lung, entire organ in 10 ; lower lobe, in 10 ; upper lobe, in 6. In the cases of double pneumonia, it was most often the lower lobes whicli were affected together, but in three instances the lower lobe of one lung and the upper of the other were affected; in three cases both u])per lobes; and iii Case LXIX. the most extensive inflammation of both lungs occurred — the left was in a state of uniform red hepatization, with the exception of the anterior border, and the right iu the stage of gray hepatization, excei)t still smaller portions of the corresponding regions. Altogether, in 159 instances a lower lobe was involved, in 19 an entire lung, and in 16 the upper lobe. Weight of lungs. — To estimate the amount of solid exudation, the lungs were generally weighed. The heaviest was in Case XLVIIL, a i.ian ret. 40 years, whose left lung, uniformly solid, Aveighed 230)> grammes, and the right, very congested and (edematous, 900 grammes. (The normal lung weight is between (iOO and 700 grammes.) In eight ca-^os the affected lung weighed about 2000 grammes, representing rather more than three pounds of solid exudate. State of lung tissue affected. — In about one-half the cases, the inflamed area was in a state of red hepatization. In oO per cent, there were regions of gray hepatization with the red, and in 22 cases there was gray hepati- zation, cither dry or passing into the condition of purulent infiltration. State of uninvolved portions. — Usually the crepitant parts of the affected lung were greatly congested or intensely cederaatous. The latter was invariably the case when the whole organ was involved, except the apex and anterior border, which then presented a condition of almost gelatinous ivdema. Tlie unaffected lung was generally con- gested and (edematous, particularly at the posterior part. It was not uncommon to find the anterior portions quite dry and bloodless, while the dependent regions were full of blood and serum. No doubt tliis is largely due to post-mortem subsidence. We do not always find exten- sive congestion or oedema in the uninllamed parts. Thus, in Case XXXIL, in which the lower lobe of the right lung was hepatized, the upper and middle lobes were noted as " very dry and bloodless," whereas the left lung was a'denuitous, except at its anterior borders. So, also, in Case LVIIL, a woman, tet. .W years, with" red hepatizaiion of the left lower lobe, the upper lobe was crepitant throughout, dry on section, no redness, and no blood. The right lung was also crepitant (except a fibroid apex), dry, no (edema, and very little blood. i II I "^m 35 The „.ncoas n.en.brane v uZw^u /""""""^ -'P-torution. a«oete' «^^'''"o»« exudation amounting to tliree or four 'in t'' 'f '''•''"' '"^'"'^ ■^^''""^ extensive double pleurisv w.Vh n„ • *" " ^'"^ ^'"^^^^ there was il'-trated how reLlil S^ nt X" " 7, ''''' ""^ ^'^'^^^ ^'^^ ^ V. -;:a-p-.omthepCr;;-^^ - wonder that^hJif ;^;Y;:'i:!jT""'"V"f '"^"" ^^ ^^'-"-^^ -ore freciuent result o7 this p ^ ;? ^77 ^'l^ ^""-^ ^-- - "ot a definite small abscesses. In cL Yvv v" "''^"""^^ ^here were ^vith gray hepatization of the right uppetlobe T. '™"'""' '''• '^ ^'''''' cavity, the size of a walnut wiM. . / ' '"'''' ''''*' ''^ ■-'"^11 abscess of the lobe. The tiC Ij .th a's^f ^' ^" ''' ''''^''^ ^-^•- n Case XXXVL, male, .t. 69 v"; I "'/"''"^^"^ '"^'^^-tion. half of left lung, there were in the m ;, ?'^. ^^P'-^^'^''^'"" «f upper «pots of softening, the size o i ^1^1 '".l'''''^'- ^'''^^ ^^^'^^^ -:• 13 and purulent contents. In (^.se Lxxvrr' T ' r^^'"'' ""'^^^'^ '■ -bnost uniform nnn...i:.,.-.:., f f f^'^^VlI., female, let. 64 vears. .«tate of intense purulent 'd.'Uion of loft lung, the infiltration, and the "Pper lobe w re were in the middle Slieciiiieii in tl. as in a por- '' iiinsoum of MoOill Coll, i-'gf. ■i^i 'm- ' ' m. - i ■ P. h r i 1 1 !:^ ■ «£: .j"! f ! ^ ii! I j ■ i f |i! fii 36 tion several large abscess cavities coiniminicating with each other, with ragged walls au'l purulent contents. Gangrene. — In three instances this termination was met with. Case LIV., female, ret. 35 years, a hard drinker, was admitted with pneu- monia of the left lung, which had existed for some days, during which she had been neglected and much exposed to cold. The lower lobe presented at its apex and extreme base signs of consolidation, but in the rest of its extent was represented by a large gangrenous cavity, occupied by shreddy and necrotic lung tissue and blood ch)ts, the whole forming a stinking mass.' The walls were not defined, except at the lower part, where a separation between the sloughing and firmer lung tissue could be plainly seen. In Case LX., male, a!t. 63 years, with pneumonia of the left lung, there was a spot of gangrene at the apex surrounded by dark consolidated tissue. Case LXXIV., male, set. 50 years, a hard drinker for twenty years, was adr;\itted supposed to be suflfering with delirium tremens ; had had convulsions before admission. Rigidity of muscles of arms, coma, and death thirty-six hours after admission. At apex of right lung was a gangrenous mass the size of a hen's egg, surrounded by greenish-black consolidated tissue. Suppurative menin- gitis of cortex. Fibroid indurufion. — The production of a chronic — so-called inter- stitial — pneumonia from the ordinary croupous form is, perhaps, the most rare termination of the disease. The following case is of special interest, from the fact that the man was under observation almost from the outset, and the induration was in patches and in an early stage : Louis Phillippe, xt. 58 years, a laborer, was admitted with cough am! pain in the side. Had a chill five days before admission. Temperatui'o 101*^ F.; pulse 106 ; lespiration 26. Expectoration not bloody. Phys- ical signs of pneumonia over right lower mammary, infra-axillary, scapular, and infra-scapular regions. During the first ten days in hos- jf/ital patient made no satisfactory progress ; temperature ranged from 99° to 103°; he was heavy and dull, not delirious; pulse weak, 100 to 120. Defective resonance in infra-clavicular regions on right side; in mammary region, a flat tympanitic note ; beliind, absolute dulness, feeble blowing-breathing ; a few rales on deep 'ns])iration. The note over right mammary was markedly tympanitic. Patient emaciating. No heart murmur; very little expectoration, nuico-purulent, not bloody. On the twenty-sixth day ho had a chill, and the temperature went up to 104^^. No change in ])hynical signs. Died at noon on the twenty-seventh 1 Specimen in museum of McGill Medical Faculty. 87 bathed with sero«3 luid On ; ' ■'"' ''''. ^"••^■"'^' ^^ -<'"-' -as fbaturos called .fattentio^ i e^,:r!r'"^ ^"^ ^^'^ ^^^''••"' ^^"- a.r-cells could be .seen Mith thoi,. fi , "' '" ''''^'''" "^'^''™^ the character, u„do>.,„i„; IZ ^ .'''T ' l^^^S^, of a very opa.ue white able areas, ^e.^^^^;, tlZt^^J^' « ate existed in very consider- -itb Pu., and break „„.^;;, l:":;''^'^^ "^-« ^'-'-^y '""Ifated tbese was about the si Jo T, , ^^ il^^^' ^'^ 'arrest of the lung there were .pots wh b 1 "'''-''' '" ''""''"''^ '^'''^^ ^f finn, smooth, hon,o,e,;^: : : t.-': j.;;. ^^ ^'^TT^r '•^^'^^^' -- connective tissue. In the.; areas a fi. '^ "" ^"''^ '^^ '''^^' b.ng; the alveolar wall ";.X,l'r f?""^:/"^ S^ing on in the the air-cells were underVoi u! f ' ''•"' ''"' "^'"'"'^"^ P'"g^ «Jli"g nective tissue. ""''"'S'^'"^' transformation into a nc.v growth of con ^=^"thf;:r;;iu;^::^r'L^;r Mature in pneun.onia autopsie TI 'w . ''^- ,"' •" '" '''^ ^""^^'-^"^ and a solid .ould, capped 'I^^Hy'^^.'fXh: '^ ""''"^' '''' ^"• ronu.ved with the extensions into the cav^ a ^ ' \'- " ,'""''"""^' ^" have seen a complete cast of f 1 I . '"'^' ''^ '^' branches. I the smaller vesii:^::r:'n 1 T hJ tf • -^-•-.— -" to hepatic and the iliac branche Fro.n T''"' '^'^^'"' '"^^"'1'"^' the be witlulrawn by carefnl n.l > P"l.nonary artery there can vessels of n^^ii!:iz:':iz:T:' :^::::f:, 'r '-''^-'-^ '- meet with such solid coagula-s fi^ ^^'^ ' '''"'^' ^''V^''^ '''^^'^' ^« occasions, when I di- ulcerative endocarditis. Bnef deuil, „ ,. e e alVZ b"' ""' *° Case II., ma e, ;ct. 38 veara K„,l I '"".'^^ ">»)' M given : lung, extensive ixudatio^ Tl,„ „ f?'""^"!""' °'' "I'P'''- '»'« »' rieM along the Svlvian C'e """' '" '""-■"■di'-a' »i.."S ,fnd wiS'::„a,fi!;eir;'i:;.-"?e' 't "'^^ '■°"»«'-""™ °f '«" i-s. hemisphere c„ e id ^^^ e," " /""'"""f "'° """' '""'-'"•'«" delacLed in flakes. /„ Ivn „l, 7 ,1 7°"' '™^^- "'''"■•I' «""W be Case LXXXIV., ™,e ":" ' 7e /"X:";'"'" 7 °^ "'° '"'*• »P|.or lobe and a spot of mmle jj ' l>epat,.ahon of right meninges and exudation of ifmT , ,,, e,e ' °T'!'°" '''" ~'""»' Pital loLos ■ none „t the b.nse ' *"""■ ""= '"'""' »»'l »«* .i-.i. Mitral „i;:: ; : • ; ,«aS- Sf " '■;-"'1."°"'" '"■■« ''''- Endocarditis, n^tl- ' d'^t'it 'T ' v'"',''f "' ''"'' '""'^ '"f-"-'''- exudation of i,,nph otrr'tLfar rS" "' "'° '* '"""■^^'--- -"' Ht the base or on the right side Case LXXXVII ni parietal convolutions. None iile. Double pneumonia; right apex. Ulcer- I i -F ^ i ' ' III it j^ if 40 ative ondocanlitis of mitral. Cortical nioiiingilis-. No lymph at the base. Case XCIX., female, ret. 19 years. Red hepati/ation of central part of right huiy. Endocarditis of anterior segment of mitral valve. Menin- gitis of corte.K — both hemispheres. The comj)lieation of meningitis is one of the mo.st serious that can occur in pneumonia, and it would ap})car, in a considerable proportion of the cases, to be associated with ulcerative endocarditis. We may suppose the intlammation of the heart and the meninges to be induccil by a common cause, or, what would apjjcar likely in nnmy cases, the nicniugitis is embolic in origin, for it also occurs in malignant endocar- ditis, unassociated with ])neumonia. In twenty cases of meningitis in this disease, only fiftecMi occurred with i)neumonia. The infective material may po.fsibly be derived directly i'rom the infiltrated lung- tissue, and carried off by the pulmonary veins. We know that occa- sionally large cnd)oli may be derived from this source, as in a case of pneumonia occurring at the (ieneral Hospital in 1879, in which, during the progress of the disease, and not associated with endocarditis, there was embolism of one femoral artery and gangrene of the leg, necessitat- ing amputation above the knee. The inilannnation in these cases is almost always cortical, and the chief symptoms are initial delirium, then stui)or and coma, sometimes rigiditv of the muscles. Croupous colilh: In Cases HI., XX VIII., XLIL, LXXXV., and XCIX., this unusual com])lication was met with. In Case III. the csecum was covered with a thin layer of adherent lynij)h, and scattered throughout the colon and sigmoid flexure there were numerous elevated patches of lymph, about the size and shape of rupia-crusts, "which on section were found firmly attached to the nuieosa. In this instance, the process was very extensive and the ]iatches much thicker than in any subscfjuent case. iNIore often there is a thin, flaky exudation, involving only the surface of the mucous membrane. In none of the cases w..s there ulceration. Croupous f/adrUis: In Case IV. the stomach and duodenum were found " greatly distended with gas. The mucosa was pale, except about the fundus, where, just to the left of the cardia, there was an extensive area of croupous intlamnuition, represented by a thick, adherent, grayish- white exudate, covering an area 12 by 8 cm. Beneath the mucosa the membrane was deeply injected." This paper is meant to be merely a statement of facts, a record of observations upon a common and well-known disease. As opinion is still :^. I 41 still divided as to the ,c,cnoml or local nature of pncuruonia, it is intor- s.„g to note how strongly the evidence iron, n'orbid anaton.y t L tonard the fonuer view. The frequenoy of the occurrence of various «ut.ve .nfianunutions finds a parallel only in some of the specific AVhile this paper has but a trifling value as a pathological contribu- tion, to he writer, as d<,ubtles3 to the students wlu, perfor.^ed the a - s.es un. er lus d.rect.on, the careful study and observation of the eas s "Pon winch .t has been based have been of ,he greatest service. 1,1 .nvesfga ,on of disease a knowledge of the M,orI,id phenon.ena observe.l dunng , e .u,d of the organic alterations found altJr death are inseri:;: . )lc.. I he teaching of the post-niorteni roon. must supplement and : ustrate the lessons of the wanl, and, as Bichat says, it il neither fCn f ' yir ' ' '■"" '''''' '''''' " '" ^-^^'^'^^"^ l-^'-''>«- " -" April 23, 1885. !• I ■I' } i H H 2. Asperr/i/f lis from (he lung. The specimen was sent l>y Dr. Rogers, of Denver, Col., with the folio w- ... history : "Mrs. H., .t. 2!) years. In Colorado for tw; years. Mo h^ iK^o^ phthisis when patient was eight n.onths old. She i a robust and ugoious woman, and states that she has always enjoyed good health When seventeen years old she began to cough up bodies shnilar to tl e aocoinpanyng one, but smaller, at intervals'of about three months-nev ..K>.-e than one at a time, an.l it was generally unbroken. The bo.lies live gradually increased in si.e, and the intervals have become si o er .•nt.I now the attacks recur every two or three weeks. The bodies ^ you may see fron. this one, are now of the size and shape of a sma 1 '.i can, and present a soft downy outgrowth on all sidc^ but one, wh a little ca ity 1 he color is of a light gray, but dark on the attached side On examination, I found it to be a v,,getable fungus, and send it o ^^^^ for more accurate determination. Mrs. H. has no ou-h, except from o..e to three days before one of these bodies is expelled,;^! t fii X broug^it up by a very violent cough, and she descJibes i as comin. wi h ome force into the larynx against the vocal cords, where it som^t me odges unti another cough expels it. Shortlv before it conges she has a 'husky,' obstructed sensation on taking a deep bre h b no hoarseness or marked discomfort of any kind! For a short time she expenences a disagreeable, musty taste. ^After its expul im , "Is no I! f ) \ ) 1 l' ] p 1' ^ '!. ^ ., i . H^-%- 1 1 i <1 U it m" J^ ll V^HB f ^ ' 4j| ^HH M ^^B 1E| IjuH w' 42 furtlior symptoms until tie next attack. Ilor luisl)and, who is a physi- cian, has examined the Iiin;,'s repeatedly, and can (ind nothing ab- normal." The specimen contbrn;> to the txcellcnc description of Dr. Rogers, and on examination is seen to be made up almost exclusively of the myce- lium and spores of an aspcrgiHiis, most probably A. (jlaucm. There is no portion of lung or bronchial tissue with it, or any mucus or adherent cells. Cases of so-called i)neumonomycosis aspergillina are rare, not more than eight or ten cases having been reported. The literature is fully given by Furbringcr, in Virchow's Archlv, Ixvi. The majority of the specimens have been discovered post-mortem, in old cavities or spots of hemorrhagic infarction. The points of special interest in this case are : (1) the occurrence in a woman in ai)i)arently good health ; (2) the re- markable duration of the atiection ; and (3) tiie recurring attacks of coughing which result in the expulsion of the fungus. October 8, 1885. Specimen from a case of tuberculosis of both lunrjs, with implication of the suprarenal bodies and tuberculous ulceration of the colon— symptoms of Addison's disease. The speo-'nens exhibited were removed from the body of a gentleman 38 years of age, married, and by occupation a piiysician. Family his- tory bad ; his mother, his paternal grandfather, and two uncles, having died of pulmonary consumption. The patient's health was fairly good until about two years ago, when he had well-characterized mild enteric fever, from which he made what was regarded by his physician as a good recovery. He did not, however, fully regain his strength, and an occasional cough, from which he had suffered for some years, began to be persistent and annoying. He was able, however, to resume his usual occupation. During the spring and summer of 1885 he began to lose flesh and strength, his appetite became irregular and capricious, his cough more troublesome. The cough was especially annoyir.g on assum- ing a recumbent position and during the early hours of the night. Ex- pectoration was rare and always mucoid in character. He suffered from occasional irregular chills which were regarded as malarial ; night sweats from time to time annoyed him. After a cold f^ontrartcd while driviii'-'- m September, all the symptoms were aggravated and the patient began to experience more or less constant deep pain in the epigastric region. 48 I llus pan, he dcvsonhnl a.s of a toari„g or clrag.in.i; kin.I not af,,rravato,l .V iood and l.able to parox y.sinal cxacerhationH of considerable inte..sitv lie now noticed that his complexion, ahvayn dark, wan l.ocn.in.^ deeolv and somewhat irregularly pigmented. About ibis time he be-an to Bufler from occasional vomiting, f,,,- which no cause c.Mild be ascribed At intervals of five or six days the contents of the stomach were thrown up without pain or distress, and e-jually without relief to the ordinarv sympton.s of his mahuly. The bowels were moved with renmrkable regularity once a mucous n.enibranc of the mouth was but slightly afiected, the hands were much discolored, the finger-tips clubbe.l, the nails ineurvated, the bo.lv and imibs wore also much discolored, especially about the flexures ' The pigmentation over the site of a former blist'er and in the neighborhood of an old injury near the left knee, was peculiarly intense Aiuemia was of moderate .legree, the numbe;- of red corpuscles, as counted by Dr. Osier, being 4,200,000. The patient suHered from a sense of great Aveakness, which was in- creased an.l accompanied by dyspna., and faintness upon exertion His mental ondition was clear. The clinical phenomena relating to the digestive system remaine.l the same, with the exception that the appetite curiously increased during the last weeks of the patient's life. ^ The imlmonary symptoms grew rapidly worse. Physical examination vealed du ness ,)ver the upper lobe of both lungs, more marked and more extended on the left side. There were also feeble bronchial respira- tion and occasional crepitant and subcrepitant rales. The heart's action M-as regular, 90-110 per minute, very feeble- there were no adventitious sounds. The area of liver dulness was somewhat increased; that of splenic duliiess \vas normal. hp'^nc The abdomen was neither distended nor retracted ; it was resonant w :),i V<' ■• 1- i ■'. i r i i ! I ' 1 i I ':'» II:: J 1 ! * ■ i WM .? W'' ^^KSjtge^ ' m ■HHH|j L I i^^^i; .i 1 m 1,''. IP :j 1 1 1 If f r ': 44 upon |)orciis.^i()n, witb tho cxcoptiun of ii Ilmitod area in tlie left iliac region, wliorc there was dinunislud tympany iiinl Home ohseiire resist- ance on palpation. These signs were atterwanl ioiind to orrespond t„ thiekening ,d' the colon und enlargement of the glanduhe epiplcicio in the reiiion of an nleer. TiK're was slight epigastric tenderness upon pressure. Death took pluee May '22, l.s,S(5. A i(l<>/<.v/, ih!rty-»lx hours after i.— The finger pad from which the blood drop is taken should be thoroughly cleansed, and if the examination is made during a paroxysm, the sweat which may exude after the friction and drying should be removed. Attention to these, apparently trivial, details will secure specimens of blood free from small particles of dirt, and facilitate considerably the search for pigmented bodies. The layer of blood beneath the top cover should be very thin and uniform, the corpuscles, as far as possible, isolated and not aggregated in clumps or in rouleaux. It is well to surround the cover with paraffin if the exumination is pro- longed. No reagent of any kind should be added. Cover-glass jjrepara- tions may be made and stained in methyl-blue or fuchsin, and mounted in balsam. Osmic acid preparations may also be employed. Although these bodies may be seen with a power of 500 or (JOO diameters, it is essential for the satisfactory study of the changes to use higher powers. I have unifoii.ily worked with the j\ homo, immersion of Zeiss, and the yV im. of Ri'ichert. Strieker's warm stage wOl be found useful. Desciui'tion of the Bouriis. 1. The forms which exid wilhin the red corpuscle— (a) The most common alteratioiF in the blood of malarial patients is presented by a pigmented structure inside the red corpuscle. ' Tniito (los Fii'vres Piilustres, Piifie, 1884. 2 CuMipti'sliciiiliis, 1N«2. 3 Kortschritto dor Modicin, Nos. 14 and 24, 1885. < l'u|icr rend iii'fDie tlin Associiition of Anic-iciiM Pliyslciiina, June, 1880, 6 Coiiucilniiin and^bliul: Ainoiicau Journal of the Medical Scionoea, April, 1885, ^i\'- 47 The attention of the observer will most likely be first attracted by the presence of a few dark grains in the stroma, and a careful study of a suitable specimen will soon lead to the conviction that the?o are not scattered loosely, but are enclosed in a finely granular or hyaline body m the interior of the corpuscle (Fig. 1). The red disks in which they FlQ. 1. ■i. 1 ifMI- ! Ameboid body in red blood-corpuscle.. Th. .K-tchoB were n.ade at intervals of five minutes. occur are usually larger, look flat, and are verv often paler than normal • they may indeed, exist only as colorless shells. The number of corpuscles so afTectcd varies extremely in different cases. In some instances they are readily found after a search of a moment or two, but, in other cases a prolonged examination may be necessary. Only one is usually present 111 each corpuscle, out two or three, or even four, may occupv the stroma, lliey vary greatly in size, the smaller ones not occupying a fourth of the corpuscle, while the larger ones may almost fill it. A delicate con- tour line can usually be seen separating the body from the stroma; at imes this ,s very indistinct, particularly if the illumination is very briglit. I he substance appears hyaline, or very finely granular, and the pigment grains are scattered irregularly in it. They may be very numerous, and give a dark aspect to the body, or they'niay be scanty, lliey fre(,uently present rapid Brownian moven)ents. Occasionally a yacuole may be seen in the interior of the body. In several instances the bodies appeared to be enclosed in a clear space-vacuole-in the sroma. When first seen they are more or less spherical, but, as already stated, the outline may be indistinct. The pigment granules may be seen to alter their position in relation to each other. If the'mar..i„ of he body IS carefully observed, slow changes can be seen, whicirgracfually bring about alteratioi.s in shape. These movements, which appear to be amoeboid in character, can often be traced with great ease. They are well represented in Fig. 1, and, better still, in Fig. 2. Changes in position of the body of the corpuscle result from them. They are r'ff1;ir; i r ■ 1 \ if ■ h^ 1 : f 1 ' j ■■'f'i '' i 48 decidedly slower than the uinocboid movement of the colorless corpuscle. I have not seen any evidence of migration from the corpuscle. In dry Fia. 2. ■ Case Vr. Pigmcntod liuily in rod blooil-cui'imacle ; outlined with camera (1-12 Zeiss, C eye-piece), by Dr. J. P. C. Grillitli ; illustrating some if tlio cliangoa during aii liour and a Imlf's observation, a, at 11.45, slow aiterations in outiiue, and tlio piguijnt-grauules are in active dancing motion, in, 12.1.5. an, 12 25, body has rotated as well us altered its sluipo. oiii, 12.30. o[v, 12.40. av, 1 o'clocli. OVI, 1.02. preparations the.se bodies stain deeply with gentian violet or fuchsin and present a granular stroma, in which the pigment grains are imbedded (Fig. 3.) Fia. 3. Cover-glass preparation of blnod stain-l with fuchsin. Tlio amneboid bodies stain deeply in tlio corpuscles. Soino of thom are not pigmented. (b) In seven cases peculiar hyiUine structures existed in the interior of the red corpuscles, which differ from the bulics just described, in the absence of pigment and in the much greater activity of the changes. Fig. 4 illustrates the appearance and the alterations in outline. These bodies are devoid of structure, and the corpuscles in which they are present are not so pale as those with the pigmented forms. Marchiaiiiva and Celli, who have given an excellent plate of these bodies,' regard > Fortechrltte dor Mcdiciu, No. 24, 1885, 49 them as the initial forms of the pl.^meuted bodio, n , Fio. 4. »cre, at 3.10 p.m tL lvalin„ , ','' '" " ''"^ "'Puocle, tiiere changing rapid,, i , oliSe'T'?- -'"'"'' ''°"'"' "'''"" -- fnlly »atcl,i„g these form, the Z^«!l ^ ,^ "'"■■ '" ' »"" ««■ exit to two distinct .nasse, e,r S w ^ f'^' '.""'"'■«'- -^ Save spherical bodies. No elmn^e tool I u "^ '"'° "'" "'■ «"«1™ except that theybecaJe , ,1 and i sTi„: "^ '?' '"'='" '«-- pascle beeame quite colorless On twnl °"'°'"" "f "« c™" c„„n ™ witnessed, b„t r„„e^:, „ frAT'"''' » ^^^ l"--™- '-""erial. This is cvidcntlv a p "si ,„ ' '"' r?",'" "'° """'"^ pale hyaline bodies m„st be caie llldl " ', !, ' "''"'< ""^o ™ry fonns, though possibly Joeir , ,,' ^ ^^t^l ''■°;" "'= "«-'««^ (c) In seven eases there were vae ,oUi^H-V "'"'""""■ -li.Mookiug bodies of variols ir, r^cT:"""'? r"'""""''' taves rescnbled u.i=r„eoeci very closelv F 5) ?, "' T *"'=• J v-i io- '-»;, and stained deeply in t'XG. 5. Covor.e,a,s preparation, showing co,,„.c,e with soli,,, deeply st,.i„eH h r ■ .,. , , ' ' -^ "'"'""^ l""''™ m small vacuoles ,,„;i;„„ 1 , ^-" "•""^ m small vacuoles. "^^:^:^Ji:^; Zz t:r '""-*■ »■- ■•-•■ -^ ones were usually l,i,.|,ly "f ° t if "''f ""°« ' "'»• «'• Tlw sumller ' W^ rV' I' I '■ ■ I , I t^^ i ***! ii-i P ^1 -i ■! ! } !| J 50 had a deep brown tint, as if composed of pigment. The larger bodies were bomogeneoiis, very variable in size and shape. No movement was noticed in them, but the outlines of the ^rdccs in which they lay some- times changed actively. In Case XXIX. these bodies were very abundant, and for days formed the only noticeable alteration in the corpuscles. Flo. 0. 1, li, 3, hirgor solid bodies in the interior of vncnoles (?) wliicli nltor in outline. 4, a red corpuscle, with a small vacuole containing small pigment-granules of a deep hrown-red color. 2. The free forms. — ((t) Pigmented crescents. These bodies, which were found in eighteen cases, present remarkable features in appearance and structure. The form was usually that of a beautiful crescent (Fig. 7)> with rounded or gently ta{)ering ends; but the degree of curvature was variable, and many forms were almost straight. The length is about double that of the width of a red corpuscle, sometimes more. They are not attached, and they never show any motion. Joining the ends of the crescents — or, more correctly, at a little distance from the points— a narrow line can often be seen on the concave margin (Fig. 7, e). The body of the crescent appears made up of a structureless, homogeneous material, in the centre of which is a prominent collection of pigment granules. This, with the peculiar form, makes these bodies very easily Fio. 7. I I I c:::^:::^. yC^^ CrcsceutH, a, (>, <■, show the slow ullerationH in the form of the pigment, as sketeliod at 9.20, 10.40, ar.d 10.55 a.m. *, shows the narrow nuMubrane sometimes present in the concave side. reccgnizable in the blood, even when closely surrounded by the corpuscles. The pigment is very dark in color, distinctly granular, and varies some- what in its arrangemt-nt. As a rule, it is central and aggrcgared, either in a hea[), or assumes the form of a band placed transversely to the axis of the crescent. In some instances it is more scattered, but I have 61 never seen it at either end of the horlv a ui i , »•»(!, A 3). A c,-«co„t became witliin ■„, l,„„r, „„ „;„a -Pia. 8. ni -ill Se of tie? Zi^t r '-V " ^';^'' ""^ ^ ■^'' ''■'' ^••- The and rounded bruff iLJr'', ."" "' ''"""'• ^^'"^^' ^^-^'^ted, crescent, prodon inJt T^ f "'" "" ^'^'^ '"^^ ^^''^h' ^"' the Blide, to sil or "h in tt "n .■ ^f "V"'''*'' ^'"'" '''' ^ *-^ '» ^ ' ui cign^ in the field of the 1-1'^th im Tl. ^,. i i always fl-eo, they „ce„r sometime, in the nter or Tf' . ° , "'"" "«io 1.^:::;:: :r;i':: :t:%T' --^ ™-^'" ""'"-^ » i" the eentre a ,«ette ofX"™ Fi,! '^ "''>,-™"" ^ I"-'""!''"'"', ""d ^^ ^■■*"'' '---^.Xa'JJrotLtrief ^\:'r'it Fig. 9. Rosette form: 1 freo- 2 u-ithi,, f i ., „ "eo, J ,Mth,„ t^o Bhell of a rcl corpuscle. «::*:;: r" r™ : , : "■«%r»' »' "- --- -f «gme„ta. 'l.e finely mn„l,„ ^Z^^ t » ''o' "1'°": "'' -S'"™""-" i» •' 1 ■ ■ ', a' . ' ' i ■ i i's 1 '< Ih at or about the centre. At 10.40 they had not undergone any material change. In Case LX., one of quartan ague, this phenomenon was re- peatedly observed. The devehipment of the rose ..e form can, I think, be traced from the intracelhihir pigmented bodies, wliicli increase in Fio. 10. Sognientation of a rosette form ; a at 6 p.m. ; h at 6.10, sogmontaUon proceeding ; c 6.30, segmeutation complete ; the pi,n.nted six weeks, antemic -md hnd -, ).,,. , ^^^^VII.: quotidian for off, for si. „.ed<,, t„e„ .o,.,«, ; „,;,:•.„ •,;,^, /'^ X^'cl: ; T "K-leirhehitorvlo riT' "^ P-^'"'^^ — - exannnations were The results ^^^^ ^^^^1'^ ^"'- ^^'^^'^ ^'' ^'^^ ^""■-^^-'• recent, in which the a!nl^ i^^ta.- I .rdl^H T' ^"^""'^''^^ '' and larger before and dn.-in. .,.r!™„. !'!/^''':^''^'l'>'/""»-« "'""^'•""s were others in which tl small, that sxampl es w uung the paroxysms than in the inf.erval«- thcro lie number during the chill and hot sta ere very hard to find i?e was so taken before the attack and durincr each in others again, slides stage were negative, and yet ) i I .'Sk 1 .m r » I'' i f' 1 I' D ,1 J \H Hi Y:irt '\ii li i m 56 m i K :» wn subsequent paroxysms the bodies were present in tlie blood. I think, on the whole, that pigmented bodies in the red corpuscles 'ire more numer- oiiM bet'ore and duriiiu: an attack, but the ditt'erence is liy no means strik- ing, and I have repeatedly li;i'i to search long in slides j)n pared during a paroxysm for a single example. In acute cases which have lasted some weeks, and have had no medicine, the amcvboid bodies have seemed to be quite as abundant at one nine a?i another. Nor ha\e I been able to see any special diderenee in the ibrm of the bodies just before or during the chill, though in the early days of the attack they may be snnill and less distinctly pigmented, or, indeed, may present, as in Case XXIX.. already referred to, the appearance of vacuoles containing small .solid bodies. The renuirkable segmentation of the rosette form was in each instance met wilh during the ])aroxysms, and Golgi claims to have traced in five cases a series of changes corresponding to the stages of the attacks. In the intervals, the pigmented bodies gradually increase in size until they fill the affected red corpuscles, and, finally, the pigment collects in the centre, as shown at Fig. 9. The process of fission coincides with the onset and course of the paroxysm, and by the time of its ce ores Xwere'l i r-'''.V"/'"'^ '^'' '^'^^ of the first observation " ^'""' ""^ ''''^^ ^■-'" ^'^ ^''^te Genuine paroxsynis may occnr in tl„..« i repeatedly made in Case YYV ^'"-^'^'"8. I his observation was Jiiflnence of medicines on the ornnnisim ~C\u\..\,.r. • tho pigmented bodies to disanpea7 L Hen J k-?""^'^ ^'""^^^ stu>CiT2:t;, r^: ^::::-^:— - 7^^^^ first chill „„ October 1st, and a dailv ::c:n:: ^l.^ hf lOU ' T ' came under observation. The pigmented 1.! i t .' \h ' ." ! continued so on the 11th -md I'/th , » /■ abunaant, and paroxysm to lO-,- n • ' ''" ^^'^ temperature rose in the f"i ij 5 It I !• « ! r>H ■ ' • i' vm ' ' i i I The bodies were proHont on the l.'Uh, ami ii ftnv on thu 14tli. Tl»cy were nut (nimd on siil)S((|ii(>nt (lavH. In less acute ca«'H the iiction of the (jiiinine did not, .seem to be so prnnipt, and the creweents did not 9 cxaMiinatiuas. without rosu ^. ""^ K'^en. Ihrco 8n)«<.,,„cnt Cahh XXVIII.-.Aran, tvt. iX. ,.„.nitto,l ..,, J4tl,. Woll-marl-,.,] •■I'.llH for c.,,l,t weeks ; l.u.l on. ,,1,,.. ho c-anu. in, and four at, 1 examine,! on 28th two sII.L.m r( i i i '"•'"' ^'^"'^ ""i'''- -"'"od «inee adn.is.ion. " '""' ''"'' ''^'"""'^ *?'•• "^^ --'' ^-Y Cask LI [.-Man, jot. 25. Chilis .nd fever for six day.s Hlood ox a-n-ned .n eh.ll, and on the ioilowin, day. Had had ,uinh,e CO Intel out. In ( ase X., the ch.ld was i„.o,.^d.t from tl.e countrv "and only one exam.natio,. wa,s ,nade. Case XI. Jas u,.doub e Za case of t''^ '"!' and s.xth paroxysn, was „,.,,uive. I did not see the , tlent am 'n,..her exan.inations were not ,na,le. In , -„se XXXVI tt' l'o.lie. we,-e not found on two oeeasions Thi. ,. ^^^^-^\i/^- the followed and f ,ln ., M , '",'-"•■"""■• ^'"^ '"an also could not be loumNc,!, and J. do not know Im suhse.iuent hist.u'v. wiA ','Z;! ""■ "'■'?.';"'""-'-I' '" «■'■.>■ "-iilcnt that we are ,leali„. here iind with bodies wiiich 1 lav niii cocci, and bacteria of certain acute d e no relation whatever to tl tion to the remarkabL by Luveran, Kichaid, iMarehiaf ise e iinan '.e spiriil.'i uses. I would call atten- iniity in the description of these i)a,-asites ■ iva and Celli, Councilnum, Gol«i, and 1 I. i m 1 1 ':• ' •J ■;.9 '• ;■ i 60 ,1 ; » ;i ■- f myself. Lavcran's oriifinal (lcscriptii)n is well-nigh coinjilote, and sub- seiiiient workers have done little else than conlirni his results, though to Marehiaf'ava and Celli is due the credit of insisting upon the aniceboid character of the intracellular form. Before discussing the relation of the forms to each other, it will be necessary to take a brief review of cognate organisms occurring in the blood, upon which recent investiga- tions throw an im])ortant light. It has been known for some years that hrematozoa exist in the frog; one form, a flagellate organism, the Trypanosoma sanguinis, described by Gruby in 1841), is a well-recognized monad ; a second, the Drepaiii- dium ranarum, of Lankester, is evidently a gregarine, possibly a larval form, as he suggests.' Having been long familiar with these bodies,'^ which were very abundant during several winters in the frogs in luy laboratory at Montreal, I was at once struck with an apparent similarity to them of the forms found in malarial blood. The crescent-shaped body in particular resembles strongly certain of the gregarines, and I thought it possible that we had here an instance of a sporozoon becoming flagellate at one stage of its development as Rivolta affirms may be the case. I soon discovered, however, that there were other observations on hiematoza which bore more directly on the subject, and rendered possible a more likely explanation. Mitrophanow,' in 18815, announced the discovery, in the blood of the carp and of the mud-fish, of parasites belonging to the flagellate infusoria. A description of these forms need not detain us, further than to note that they were polymorphic, and one stage was represented by an amoeboid body without Hagella. In a report published by the Punjab Government, December 3, 1880, and in the VetcriiKir;/ Journal, London, 1881-82, my friend, Dr. Griffilh Evans, described a )iew and very fatal disease known as t^urm, which prevailed among horses, mules, and camels in India, and in which he discovered a /arasite in the blood during life. At first Evans believed it to be a spirillum, but subseciuently came to theconclusiim that itwasa much Ligher organism. His observations have an important bearing on the question of the parasites in malaria. In 1885, Veterinary-Surgeon Steel published "An Investigation into an Obscure and Fatal Disease among Transport Mules in British Burimi," which also proved to be surra. A careful clinical investigation of the disease led to the conchi- eion that it wa^ a true relapsing fever, very similar to recurrent lever of man. Steel found the parasite described by Evans in all cases, and ile- ' yimrtcrly .Journiil of INIicroscopicnl Scionco, vol. xxii. '•i CiuuKlian Niit\iialist, tS8:). » Hiolog: has Centnilbliitt, lid, iii. p. 115 61 the rosnlf« of 1 • • "^ ''"''""^' '" ^'^^ P'>Per just mentioned, mves In the Ji^oloffisches Centmlbhdt, LS.So, Proiessor Danielowskv of Charkof.n,akes an important contribution to the subject He L^^^^ h t 1 ypanoson,a the welM noun flagellate organisnAf fro't^ b o d to ..-,t,..th greater confidence, that we are here dealing nith the f I it ■■ Journal of (lu- Uoyal >I oyii yiiiuterly Juurijul of M H'I'lW.lllicill ,S,)cicl}-, ISSli. ' Centiiilbliitt r. il ll'IO.-iL'0|liCill Sci L'lico, is7a. iu lIlLMlicillHilK'll W 33fiiscliartt.li, Nos. 4! and X:, ]S8P. ?: % r s I l D 'i I ;! 62 varieties of a lne new light which Evans and C^^. L^kn ^ *" '^ '""'^^ ^^'^ conditions under which the disease 2 . ' "'""" "I''^" ^^- The ^.aracter, are so similar ^t^ J::^ •rt:^^^ '^ 'n'""^ lis patliogfiiy woiilil have a vcji-v ,!;,.„„, I • oxplanation of "™™'"".' "'.-'■- - gicai as j: r , ' ; :, r'"'rv't"' ^«- tive anatomical chan.r,.y u-hich p..,, 1 ,.'"'" /"'^''""•- i^ irst, the posi- changes ^.^n .,i^. ^ :!'tZ ^:^^::fy^^ to their acLn. 'I'sease de{)ends. T refer to the ,]o-u., V \ '^ «ym|,toms of the ^vHich can be fbllowcd'.ti tt^^ "V '" ■"' •'''-'^-'^--Ics, ''"" "^' tissue brought al o t T' ""^ '^ "^ "•^^" ''''""-' -' altera: ^-''e second fact is ti.e ^t::; ^^i, r:!;;:^ "^ "^" .^^•^'•^^' - ^-- '"- "pon the parasites. The simul- ' 1 ( r i :^m i-' I I ri I 1 .1 64 • aneoiis disappearance of the symptoms of the disease and the hrema- tozoa suggests that the specilic influence of the medicine is ujion the parasites, though it may l)e urged tliut tlie quinine, wliile curing the disease, simply removes the conditions which ])ermit of the! • growth in the blood. Practical considcraiiom^. — An interesting practical point is the diag- nostic value of the presence of these bodies. There were six or eight cases in which the examination of the blood proved of great service in determining the existence of malaria. Some of these are worth men- tioning. One of the first was a man ret. 37, who had been under obser- vation on three or four occasions with antemia and an enlarged spleen. He had had three attacks of huematemesis. There was no history of malaria, and, from the gravity of the case, I was led to regard it as one of severe splenic anaemia. On his fourth visit, however, a careful ex- amination of the blood revealed the presence of the parasites, and I gave, in consequence, a more fiivorable prognosis in the case, which has since been justified. In an instance of pernicics malaria admitted to the Philadelphia Hospital, under the care of m volleague, Dr. J. H. Musser, the diagnosis rested on the discovery in .-iie blood of the char- acteristic changes in the corpuscles. To a third case, XL., I have already referred, and there were four or five other instances of chronic malaria in which the nature of the disease was deternuned by an ex- amination of the blood. On the other hand, in many cases of suspected malaria, the absence of these bodies led to a more careful examination, and to the discovery of the cause of tlie chills and fever. Four of tluse were cases of phthisis with ill-defined physical signs; in a fifth, after several negative blood-examinations, the ague-like paroxysms Avcrc found to be due to a septic pneumonia; in a sixth and seventh, renal disease was discovered. I feel confident tinit, in malarial regions, the examination of the blood will j)rove, in skilled hands, a most valuable aid in the diagnosis of many obscure cases. Melanamla.- — These researches on nialai'ia throv ji i ^n the forma tion of pigment in the blood and various organs iii i' o ..aronie cases. Evidently the primary change is in the red blooci corpuscle, which is gradually destroyed by the amoeboid form of the parasite. ICvery stage of this ])rocess can ha readily trjiccd, and these observations bear out the more recent views on the origin of the jiigment in the blood itself. The pigmentary degeneration of the red cor[)uscles noticed long ago by Frerichs and Kelsch,' was no doubt the same as here described. The A colorless c ' ArcUiv (1. riijsiologie, 187S. 65 of the spleen „„d bone-m-.,Tf,„. „ ■ "'"■''' """ ''^ ">" »"» ...vo ,h'o offe,e ^"0,^ ,1 •:'',:::,■ ^-'li'' - :■■ "=»'■'■.- com,,,,,,, on„„gh when S,e,v„,,W,„, . ""h teluT"""'" •'","'"'"'■ now become very rare i„ Pl.il, 1 . , . °"',"'', "c'Winoivn arliclc, has n.,.! Cell! h,.ve «.„,,, e! , '^f /" """ «"*'' '^I"-'-'"'™ mat,.ix. 0„„„ei„„„T, l,?,. Abb! ^ , ttZi' u" "'' '',' " ''™"™ accompan,.i„,.she.eh >vas t„k !„,''%;""■"""' '""" " '''* "- u i„. io). It represents a small brain- Fio. 15. ".itMiu, a„a m (,ve (hurt, aro pigmentea bodies. capillary filled with corpuscles, in manv of w],; i ^vhich stain deeply and so f.r ■' 7 ''""' '"^"'^"ted bodies ..'n,.me,...-„,r.i::r-^=:trt;i::!;i^ ' American Journal of tl.o Modical Scioncos, 1851. 5 " Ibid., 1885. 1 ;i ;• '1 Mrl' i i ■ -.'■J'J I m III 1 ! . t! ' * ii ' ■ i:; 66 Only one instance of futal malaria came under observation, a man set. 70, iulmittod to Dr. Mu.v^cr's wards on October 2"itli. He bad been on tbe Istbnuis of Panama aii^. Tbere was jjroat stiipoi, and be wu.h ruujed v.ith difbcullv ; tbe tniigue was dry. Tiie tcmijeratun, ')ecam\' ^.tibnormal on Ocla^jcv 27tb ami 28tb. lv\;!.minati(m of tbe blood showed many pig- mented iKHJii.- in tbo reel corpuscles, numerous free circular forms, a few crescents, and rs tbere were bodies identical with tbe small pigmented forms so abrsidant in tbe blood during life. Tbe marrow presented similar cbang( ?. Tbe number of red corpuscles containing the pigmented bodies was not great, nor were tbe capillaries of the liver or tbe brain stuffed with them, as in tbe in- stances of pernicious malaria just referred to. Pr(>bably this was an instance of severe malarial cachexia of many months' duration, and scarcely should be grouped with the pernicious comatose form. To my colleagues, Drs. Curtin, Neff", and ]\Iusser, I am indebted for tbe privilege of examining the malarial cases in their wards; and to my resident ])]iysicians, Drs. Donobue, Albertson, and Westcott, for assist- ance wbicb materially lightened my work. Ocioher 28, 1886. Timid c<'lii)i<)roccnf<. This rare i)arasite was reared experimentally by feeding a dog with hydatids from the liver of a pig. The animal wii I'illed about seven weeks after the feeding nvben tbe intestine was fo' < 'o contain many hundreds of tl"> mature ta])ewornis. Tiie porti • ot bowel exiiibited bad many adi':'.. 'it to tbe mucous mcmbraii ; • nn tbe small si/e of the worms, only n few lines in length, the <-\. apt to bo overlooked. Cobboid states that the only specimens procuc'> i 'a England have been experimentally reared. Dr. Leidy has never iiitr ihc adult worm in tliis eountrv. That it may occur here in the dog is ^ r^- .^vich^it i'rom tiie frequency with wbicb echinococcus cysts (tbe lar ; -o met with in the hog and other animals. ^September 24, 1885. ^, ! 07 Ci,Meercus cclluloscB of hndn, heart, and voluntary muscles. The "measlo-' or cysticercus of the T.ouia solium is found very fre tra the extraonl.na.-y nu.nbe,. which n.av exist in a well .^.-i 1 d ioity il encysted, and very readily seen as o,.a.j,.e white bodies th« s...eof hn-ge peas. It is rcnarkable that the a,, .nal dies no cv n In the heart the cysts are also ve.y nu.nc.-ous and at least a dozen may be counted beneath the endocardiu.n of the left venS "l^ were_ very generally distributed throughout the vol ^t ^ , ^tles a^d "Jtl..scase the "'. ' ■J..:;.M 1 1 1 1. ■;; '• ■ 1 1 • r 1 > * ;■;■•■ 'III tk ( ^i I ' ^ ^H I'D- , ; 1 ■ ^ ? *■ , ' ' jf t It.: ,..• 1' ! p ■ P''' !' 1 M ' I'l ' 1 1 4 .1 h 68 through the kindness of Dr. ITcrtwig I was enabled to secure a hirgo nuinluT of interesting specimens. Tlie liver liere shown represents a condition which may be seen almost any day. Tiic organ was not nuicii enlarged and externally did not look much altered, though here and there a gray-white spot could be seen. I have dissected the bile-ducts of the rigiit lobe from the under surface, leaving intact the upper portion of the liver substance. The ai)pearanec is not a little remarkable. The ducts arc uniformly enlarged and converted into rigid, calcified tubes. The primary branches arc as thick as the thumb and the teruiinal ones toward the edge of the liver the size of pipe-stems. AV^hen broken the wall is from one to two lints in thickness, cal(;ified, quite brittle, and without a trace of any tissue. Here and there are saccular dilatations. The inner surface is roughened and irregular, stained of a black or yellow-brown color, and in the larger tub^s there were a few tlukes. In other specimens I have found them in numbers, dead, broken up, and calcified. A bile-stained glairy mucus filled the tubes. The condition is one of chronic cholangitis due to the irritation of the fiukes. It is interesting to note that the liver sub- stance is not much changed, and is not to any extent cirrhotic. The aninnil from which this specimen came was fairly well nourished, sutH- ciently so to escape the vigilant inspectors. In shec[) . • .• , Palmer Ifow.)rrl ,.fAr , , ^. **" ^-^'""mation by Dr. aimci llo\ aid, of Montreal, consisted of ten or a dozen I.v<]..f,V1 / ranging n s ze from n no., t,. „ . li}(latid cvsts, '■^^^'^- n./z::j-:XtZ;:;:^::::^t;:;: ""■»■;'■? was in communication ^yUh flf • '= ^^^ ^^ ^^'^ "* ^^ J'»y^'»- oue which '• ». .^ ic:.":r\t: 3^^^^ otr .<";.'■« ^'^ di'op of; the uruie in whioT, tl.o, ' -*■ examination of a :K-.'*tL hook,:: ::;;';': :„:• ™"- - "°"» '"■""'■* ■■"-> "- c,,... >* eicn (spleen), i/ecjjcai? iV^ms, 1884. «7^«^e 25, 1885. I ^1 I' > 1 i' '' i [a 1: * i I f 'j^^^ 1 i 1 '■■.. I 1 i T.fflJl ij! 'lir ). i: ;, f: ■•♦ .1 fl^. i It ! d •1 '• C 1 !f^t- I i i til s « mJi CLINK Ai/nio ciiito certj tlio Ibll solution of Samuel '. Ho.spitiil 01 <',,„ki,,.„,. .....vcmnic, ,.„v.„r,A TiIKr.|..H..„KU.a0H,.,TA.., ,.HM.A..KL,.„M. ANM) WlLMAM (>sij;u, .M.D., "I l'ull,„l„xi.-l» ,ig,c« will, ll„. ,i„to«„„t „!■ W..|,., i ' !„?''° 7 r i,v:;r :;■ "'■",""•' '"'"' '■'■ ^^•"-^■^^^:^^^ •'""'■laia "f wJik ,i. l„i ,,1^ , '., "''^' '-lore tl,i, dal« l,„ llegHuto oon,..]Iod to -si ^w.^ T cTs ";':' '^^^r-ff with vertiVo, ana be par. of the hodv. Tlere\ s am Hm'" /' '"^"""•'•••age from any treatiii^r hi,„„.|f with om lU . r ^''""'" "'t<^™ittent. After -;.. to ha. . .■- . i i' 1 ""'^ ''^' ^ eruviau bark h- tio «uppm-a.i„r I . : " , t *;f,S/;;,f"^' '^ ^--f '-'^' «ore. followed He was' in the Jolico S-oc fro ^ 87 fr"^'"'' symptoms. - tJl'^ ill'' I i, .1 - '■;' fe^.:^ • I' 1 ■■ 1 r U p ! '^1 : J I -I ' i I I f 1 iWfllf 2 HENRY, OSLER, ATROPHY OF STOMACH. an ice wagon, and was af'torward a ('al)-(l river. Eight years ago he had an attaek of gonorriiira. In 187() he weigluMr.")!*.')" pounds, and was a pro?»iinent ligure at a "fat-men's hail." His lieiglit is six feet two inelies. Jn LS77 lie hegan Ut grow thin, and eontinued to lose flesh at the rate of one, two, and three pounds daily. lie was in the habit of weighing himself on the same scales in a shdp in his district. He oiicc during this ])eriiul of rapid dimiuutioii of weight, Inst seven pounds in twenty-iour hours. This loss of Hesli continued with intermission.? for eight or nine months, until his weight was reduced to 147 jtouiids, when he began to regain, and in a year thereafter weighed IMO pounds. The jiatient's memory of the exact dates of tiiese lluctuations in his bodily weight is not alwdutely accurate, though sutiieiently .so for the purpose of this clinical history. lie attributed his lo.ss of "flesh to indigestion. At the period referred to, he was in the habit of vomiting almost in- variably after taking food, and was fre(|uently obliged to leave the table liastily on this account. His weight at time of adnM.ssion was l.'JO pounds. His skin possesses the peculiar yellowish pallor that is almost pathog- nomonic of pernicious anuMuia, and the ocular conjunctiva is of tlie characteristic yellow hue, w Inch diilers, however, from the tint of icterus. The palj)ebral conjunctiva is milky-white, apparently bloodless. The skin of the abdomen is flaccid, and easily gatht-red in folds by a grasp of the hand, which fact is corrobonitive of the ])atient"s statement regard- ing his former obesity. This statement, however, is proved bv the best ])ossible evidence, that of ])hotogra])hs in his po,sse.«sion. His girth was once iifty-two inches, and is now thirty-two. The patient dates his ill- ness from a ])eriod about eight wee'us prior to his admi.ssion to hospital. It began with dizziness, nausea, jjulpitation of th-' heart, and a sense of great weakness. These symptoms have continued up to date of admi.«sion. The results of physical examination are, for the most part, negative. The heart sounds are very feeble and distant, and unaccompanied hy murnnir or hruh. The lungs are free from any sign of disease. There is neither tenderness nor increased area of dulness on percussion (jvcr liver or spleen. There is decided tendei'iiess over midiUe of sternum, and a tender spot was al.so found on one of the lower ribs when making jht- cussion in the splenic region. There is no enlargement of the Ivmpiialic glands. The tongue is exceedingly pale in the centre, with piuk edgf.'r and tip, but without fur. The urine contains a minute trace of albumin; its reaction is acid ; its specilic gravity 1.020 ; it is free from sugar and bile pigment. On June 10, 17, and 18, the temperature rose above normal: on the first of these dates to 101", and on the two latter ti) 102°, in tlie evening. After the 18th the temperature was normal, while in hospital. June 17. First examination of blood. Nund)er of red globules ])or cubic millimetre, 7!)0,000. Troportioii of white to red, 1 to l."),S. The percetitage of red globules, as compared with 'he normal nunibtr (5,000,000), that is to say, the " hsetnie unit," is 15.8. The majority of the globules are larger than normal and thein are j)ear-shaj)ed qmxntity. Hchultze's tested Ijy (jlowcrs's hi amount of hannoglobin and oval 111 ^. jfii ^»- 1 II Microcvte ifiji 1 nil Ml sent 111 iUlll in con :iKtii sider \ HI ihk! gram le masses S( antih • present. The coloi , as eniog] ohiiK )meter, is 1(! l)er cent ; there fore. the 1 is re lativ ely normal. This is a cardina I feature ars ago lie loiiiids, and six foot two (ISO tlosh at the habit of :. He onco 1 pounds in iiissions for iiiiids, wluii uiid.-j. The 1 his Ixxlily till' [Jiirpose int iii- I leave iho ion wa.s l;)0 lost pathoLT- a is of tlio t of ic'torns. dless. The v a irrasp of lent regard- by the best is " was verv (initoccar. The oonditim. i< H,.,f ,. '"- '"'''^- -^'o modui were 10(1 globules varv greatlv in i I and ii-iTKiiliir. '"'ii, .4. („l,„,iH. Ololniles al.uomallv 1,,,'ge I"' had a deeided chill P,, 11 > I ' i P'^'^'F ^''^^ "'•'-^''t. about 1..S0, l-'^pin-g slightly; ninperalu^^.?^^^ 'S2^;C:>}''^ ^'^-.'"'^ --i evory throe hours, and suppository of lu If a r i 'Vh ^ ■''''' '"^^^' lI"-eo hours until diarrh.oa is oiiockod ^ "^'" '''l" ''"'"^^ ^in™ ». when la^;'™pV«iS;Z';:;;|''" ^«"-'> ^ "■■-' « - M. .None ;|.-a. i« nnnarkublo.-- N;,;;,l',';J'',,'i" '"tr.',".?.'!'! '«■'■■" ""»'* "'_■«»' slia inber of rod globuio.s ]wv ol>i'lcs, for the most part, nnioh larger ih 'pes. IS o M-liite in specimen. II -W(. Num 0. ni., l.ti.So.ooo, im normal, and of irroLnilar verv hi )er of rod globules [)e ■ge, some of thorn throe times the normal ^omic u.iit, ;}2.r). Color, 40 I- f.m., 1,()()5,0()0. (ilobul 111 shape ; a few mierocytes. H icmic unit, 32. Color, 80. Th les mostly size, and very irregular c count is llii 1 3 ■: 1 ;-.'i ■iM HENRY, OSLER, ATROPHY OF STOMACH. almost tlio same as tlie last, although tlio i)atient feels decidedly better, and walks eonsiderahle (iirilaiiees without i'ati still decidedly above nornuil. Very few microcytes. No granule masses. Shape of globules less irregular. No whito cells seen. lOfli. About the same. Jilood not examined. Hydroleine prescribed. i-7//i. Feels iiuich better. Weighs 140 pounds. Talks of getting to work — cab-driving. Has walked a distance of two miles without latigue during the jjast week. Appetite good and bowels regular. Did not take hydroleine, but, by advice of an officious friend, took elix. ferri, (luinia", et strychniie i)hosphat.. instead. Numl)er of red globules ])er c. in., l,80r),000. Hiemic unit, of). Color, o'i. No white seen. Patient lo"). Oct. ^1. No. of red globules per c. ni., 1,2.")."»,000. Ha-mic unit, 2"). Color, 20. White corpuscles to red as 1 to 500. Globules large and irregular. Patient complains of great weakness in legs on walking slmrt distances. Has bee:) continuously at work as car conductor, though nut on full time. Nor. /!>. Sent for, and found him lying down thougii (lre,[aury. J'a.s^ed a No. 1 ">( French) cat heti r and drew otf a little limpid urine. No bhdd followed passage of ii:stiu- nient. (About ten days later No. 21 was passed without difhculty. ) His quarters are very contined and (hirk, and exceedingly noisy from ceii- timnd pas.-^plrc)i is sj HEXHY,OSLER, ATROPHY OF STO.r.Cir g "'l""'".t(T ars..„i,.. The diMrrl , '. u I "''""'•'^' '•'■^"It .,f' attempts to watery .tool., was c-lu-eke , Jft, ,'': 'r"'''!!'!"' /'' «<^ven or'ei.I "*'t, 'vfn-n. ' • ^ ^- ^ '" '" '^'^', to hegni to-inorrou', if .liarrluea do^l! ~'W/. E>.('oc(lin,2:ly nale and feeliln V i^'J^'^i/t.!:^- ,;■;„;; :;r;:;x':/:.;:;;!;;r- ^•"- -•'-'' 1- eo„,., ,« ^■^^ty, very snmi], soft, and c-on, .re^i l ^ f ,""^' I'^i'^''^ The pulse •^'^^'"",ir. prcssiDii , and the respirations deei' and Nninl)er of red ololMiles per e ni 1)-^)^ /. • '"'"' ^'"i "^ "';■ '>1"-1. the color ;.■;;]', ''r.t h ""7 " 1'"^ "^■^'•^""*')^' )VM.s nia.le at throe o'clock. At i nlf V A ''"'I'loyed. The count '"^!''^' '<■« iMt.rnal saphen, I -e l^ , r;\ '" ^ ■".)-f«"« '":' ";v'''- tl'inls of the le- fifti fl ;- ^'"V"»''t>"" of the n>i.|nu<.d with 7"''l ","t reply to .,uestions. P ^1,? "\";''' A''*^'"*'"' '"'■^ ''Xcs, hut ;;l:;.ni:;'.l m ft-e,,uency (80), but „„' h.^ f I /' V 'T'^'''''"' »»- ':■'< V^'- !'=''"'"t i" condition of le/vv 1^' '''"•'"' "I"''''"'""- ''"^•'"V '''''^^' ^'.vt-vn.elv weak, hut st lY 8( ' = '•"'"'■' '".'.leratelv ''•'■";'7' "'"I fi.u■lii...^ hut not .t(.; us Di,,f .';'■, ?'':"f ^ : respirati,,;. ,-'"''^/-7/. i'lcvvn hours after de' P; "^ '-•'*'*' f""'' '"""••^ I'Uer. ;'l' ^'"".eiation. (;i<.atrie..s on d^ ^ .Jl f'" T''^'^ '-"-"t- < oMsider- ''•'If '", inch in thickness; fiit of V^^^^^ Pannu.ulus not n.ore than ^'^'" "•"' all organs. JM f !^ t 1^7 T^T ^^'-^"''^ P'^'lor of ;;r';'""-l"' -'-ooth ; sn.all an.o nt'o '; . r • li ■ "^^^"r'"^' ^"'"'''/' '''■^ten< led with j-as. fn nV/A/ Jr^-a —A^^^l"^ ''r^'''' ' the intestineJ "^■'■'•ef ^'^'"/ ''^'. "'"x'^"'".-. Pencnlium ''"'"""•.^' "'<'''^'<'<'s show in Wo-.t':, ,i. "V^ *" '- ""^'"--^ «accid; pre- ■T"'?^- ••'"t; in rio-ht ventrd a .]!'"' '^^rr'-*''"^ » lar^c ••I'-ly adherent ^.' trahec.d^ a „i\. ^ "V"'''^' ""'"'•"^"I ^^'th s<.rum. "'■'•" •■""''•■t'''l fron. these S tL 1 l^^*'''^ 'I^ " ^^'^f^'O' ''l<.od ™'"f^- " " "■• ■ ■• '"'"""• '■^- llu' left (■hMnd)ers Avere nearly '■"", "f the heiu-t. walls\.f "'"•nial thiel, .'"itral orifice. On further,] isse -..lH.tly tatty : ,.i.ht .handie .; 1,!;;;:;^ ''""-'^ very anuMuic, an,| iltl croniiit.iiic. . '^' ""''led ; valves iim-ni.il i . .i iitlicroiiiaton out; the tlic adhcsi till ; "^'oronary arteries healthv. /. valves normal. Aorta ivcr lohes y «»ns which exist 'het ciy o'dcmatoiis. and tl' "".7'^' pale, crepitant throunl not "■■^ anu trachea. iSjili ^■wii the lobes; f'rotl nfilt ration extends t( ''" '« .'-liglitly enlarge.1, nunleratelv fi nil : '.V iiuicus in hronchial piiip of a deep puri)le- ( i i 1 I.' p 1, 1 •\i \\\ i> rill 6 HENRY, OSLER, ATROPHY OF STOMACH. w IJ B !;i red color ; the jMalpi^^liiaii eorpiiscles not evident. Kithici/n of normal size; eapsnies detaeli readily, surfaces a little roii^di ; on section, cut with increased resistance; cortical Mortions pak'; small arti'i'ies at hases of pyramids very prominent. The ■•St()iii(ich looks natural, contains y'as and ahout an ounce of dark fluid; pyloric orifice firmly contracted, and the ring' seems tiuckened ; cardiac orifice normal; lentith of orj^aii eleven inciies; breadtii, when opened, eight inclies. Walls not increased in thickness; at fundus two to threi! ndllinietres, at middle of anterior wall two and a half to threi iiiilli- nietres, and at ])yloric zone, ten centimetres from thi' ring, eigiit to nine millimetres. General surftu't; of mucosa jmle ; mucus covers the ])yloric region ; there are a few dilated venules in several places. At the fundus the nnicous nuMuhrane is very thin, smooth, grayish-white in color, tough, and teai's with ditliculty. No trace of superficial softening. Jn tlir middle zone it ''as the same pale gray as])ect, is smooth, and there is an entire ahseiu'c of the velvetdike appearance of the healthy mucosa. About the middle of the lesser curvature there is an old cicatrix, phunlv shown by four or fivc> radiating lines, In the pyloric zone, the nnuMi.-a is more vascular and decide readily movable on the muscularis; the sid)MUicosa does not appear thickened ; and, with the exce])tion of the j)yloric region, then is no thickeiung of the nui.scular coat. The (esophageal mucous glands are unusually di.stinct. /)u(Kl ••^' "'^^ ^ta.ne, preparation the mucK n I ' '^ ,^' , j!* jf--'; "-^''i^^- In the im; feebly marked. The muscnlaris ..n? '''«t'>i<'t. but the outlines ti«>"- There are two
  • kne.ss in .liff^ e t ,h ^ ^^^-fd, which varic-s son.o- Fifl. I. H tHjiil .(... n.M.ihii- iin.,«t;>,i,s, f,, (,; c, rcnumnt-. „f fnl„,i , ' "' '""'""» mcinhvano '" ^'"'" '■'""• ^ ■""-- ouna,.A. o,j.r;r:i^/ivt;~'''' '"""•*•-'"'«>- ;:St 'i;.;;"';;/ 1;;;;;^,,:;^;;,,;|-'; -^---V ami in places there are <■ i>-i 'n- ^,y I pi events coarse fibre j i 1 ill I."* . ,, hi liltri-s cij t lony;itiniit)iiiI.v ; c lumiUoB ; df Iicgimii] 1. ............ /. ...l.._ 4 < .. ! SllhUUU I yisth \J\. 111(11 ^^ ibtifi.tif't li iiicli. Kin ti -V |N t' -ft' ni(| Xu. s. -I, tH of the pi'plic "EXRY, OSLER, ATROriiy OF STOMACH. <'ell.s and is Iim.-oIv ('(minw.f,.,! f *i 'I'^^HocollH d„ not look- ;:i ;.;?-J;,.^,;';;' f' ^'I'Ih...' nonual. Tlu, ^fe^"-l ns thos. i„ tl„. nn,s,.ulari; ;,";;;,;;^' ""• "' '''^^ ^^"""■'' "- "dl \^) 1 ortloii oftlic inl.1,11,, ., f.i. ■ ■ , . tl.o lon!.it,Hli„allv rut l.am friCf .k''"^' <'*'"? "'"' "''"^'^ ''i'-'-f'v soction ]. ' '"""' '"'^ *'"■ !>l)IH"iraiKv (IcsrrilM'd Ill 'Ctl in I I •"" I'" I'll i'OM(U'ra '"I'y lit'iv and there notic."d(l.. 'I'l„. n l- . i-m-" '^"■' "'<■ <->'tn,l portion of ti e 'iev f ' ' "^ ^''*' '"''"'"'' '""'< ""•■"'"I i- under (,!,. ""^^^ ''"*" '" llie ^eetions desorilu'd F'.ir. 4. '^ "Diiitunal j.r.difemtion, as rei)rt«i.nti'd in J5it8 of tl.o fresh MHioosafn "" various parts wore teased earofullv in salt •1 ti 10 IIEXKY, OSLER, ATUOPHY OF STOMACH'. solution. Except in the ])ylorit' zone, no tubnlcs or cvlindriciil cpitlu'liiini were i'oiind. In sonic of the nodnhir projections renmiints of uland tissue and ii few colunniiir cells witc seen, (ientlc .scrapinus of tiie surface and the teased bits show a hirgo luiniber of ttuttened cells, unlike anvthin^ "" '"'■'' '" breadth. Some of these arc rcmarkahlv lonjr; mcasurenients of four o-ave ij^iy, ^pV^ 1 and jijv of an inci and from ^^^ to yo^oJT ''^ "" '"^'1' "' l)readth. Many t)f the ceils, par- ticularly in the pyloric rciiion, look like swollen ulandidar epitluliinii of the peptic follicles. Flat ribbon-like muscle cells are numerous in till the portions examined, and there is a distinct fibrous stroma thickly beset with cells. Throughout this there arc in places jjroiips of rounded, translucent bodies, resembling the amyloid corpuscles met witli in dc- generatiiig tissues. Sections of the (liuidciiHin show many normal-looking tubules, but here, too, the amount of iutertubular ti.'is swollen, and in pla •e very nimicr ■intiiolnini of the' L •oll.- ees verv '"til in the The />o :>ps of llcnl,., and 111 IS very little fat ; the mar I'iift, lint the ord •o\v ee i; ;;::'":;;:{ ":i'r'T^';''? "•■". "-i-.;. ::;::i I";.; v..n. ,,,^. o,,,.,ri„„.,,,, ■ xu*,;;;;,;:; (•wistitnents of this tissue. There various sizt-s make up the ehi,.f nianv )ers. Tl .f tl and til) lere is no essential diff contained flit ii, exeept that in the I fence iietween (I corpuscles occnr in nti ist-named hone tl H' uiarrowof rih, sternu leni m- in. "•ections o and an f th It; eaneelhe at the end at' mi I mint v\('i'fi& of connective ti 1/(1 IH/f. lu sh( T Sl-mm.\I{v — CI in lad. II 'sue, >\v deeply iiigmented nerve cells cu years a;i'o severe (rast '•■^tory of diii,], Kiuir hahits for iiKU'e than nine niontl iiianv vearr fii'ual diarrlKea, and irrer(>,s in the ics. Atrophy ,,f„|iicoiis le secretory iiscularis JvK.MA HKS. -Th e patient with the {\ )ro;,M-essive jiernici a vivid jiicture of | pivsent in hold relief: the exces.si fi'ver, th(! retinal 1 tlie iiumher of tl ''•<',u'"iu,t;- clinical hist K'lis aiuemia. Everv ve pallor and prostration, tl ory presented iui)tt)m was sv u-morrlia,!.es, and, above all tl 10 aiiiemic w. re( 1 -dol porfm, of hiemo^lobin, the al globules (poikilocvt "lailt's, with, at tl , tlie extreme reductioi 1 in le same time, a i teratioiis in the s ()SIS > '"""""t- The most promin and the j)resenee of ize and Sli iormal pro- ape of the Uiicrocytes in abnormal disturbance, due to the in-oloni:eil al uution of weij.dit. In less tl ^■"t symptoms were those of profbun.l "ise of alcohol. a?!/' liunilred and tift lian one the nieious aiuemia to wliiel ar cases have been y pounds. This is 1 .var the patient lost more tl irastric rapid (limi- Siuii iiaji:ei .f th li ^rastric disorder stand >.v no means the fii^t case of um ono j)er- o reported by 1 ■ouseu re disease, and it is for tli nineke,' and Xoth- ipon the patholoo-v IS reason that e xec to eases of 'serimnmte application of the term "idiopatl ption I It progressive ])eriiicions jm »e regarded from aiiotl :eni.a. he rapid loss of fl luc is a well-atteste.l fact that fe iiinre serious import in fjeshv icr point of view ^ii.m that of .^crs, inflaniniatorv and those of so-called jile sparer habit, and, in explanat plethoric individuals, tl ioi:, von Reckliiml Atitiphy of tl csh may symptomatology, essential, are of lan in luiLsen* susr- ' Deutschos Arch licStuiimcli, 18-1. ivfiirkliii. Mod , lid. ' Viilkiimiin'e Sii * Deutsche Chir iiniili iiiR Klin. Vortrago. igie, 1«SJ, ltd. i. p. 18U. ri i f i I 12 HKNRY, OSLER, ATUOPIIY OF STOMACU'. ; ■; f I frosts that the nipid ahsorptiuii of fat and tlic |)r()(lu.ts of fatty niota- iiiorpliiisis may jiivc rise to a iiiialitative cliaii'rc in tlio coiniuKsition of tlic hlood. 'fill' ('(inscrvatioii of tlu' muscular str('ii;rtli is also wortliy of notice in this and otiicr cases. On Ani,nist 15 tlic patient walked two miles with- out latitrue, when there were less than "i.OOO.OOO red e of tlic other tissues. All attempts at treatment in this ease were rendered iHi<(atory liy the irritahle state of the intestinal tract and hy the patient's wilfulness and ])('rvei>it;. i'l re cooperation in any diajrnostic or therapeutic ))rocedure. Alth; H',.li ;• 'pcatedly reipiested to .save the urine secreted durinu- the whole l\\eii(y-four hours, in (U-der that its percentaire of urea mii:ht \w estimated, he only managed to do so once. On this occasion (,Iune '_'<•) the amount was 4.5 oz. ; sp. gr., 1 .01 •_' ; i)ercentage of urea, 2.05 ( normal . There was no alhtimen. The only special lesion in the ca.se was the atropjiy of the nnicnus membrane of the stomach. This was evident to the naked eye in tlie thin, cnticular apjjearance, and was abundantly contirmed hy the micro- scopical examination, which .showed that the jiejitic glands had heeu destroyed over the greater portion of the organ. The iiunn'rous small elevations which existed in the middle zone, represented areas of the mucosa less advanced in degeneration, and are comparable to the nodules of relatively normal tissue which beset t'.ie surface of u cirrhotic liver. Toward the pylorus, where the atrophy was le.ss advanced, the various stages of the process could be traced, consisting essentially in a small- celled infiltration between tin; tubules, such as occurs in all forms of slow inter.stitial inflammation ; and we may reasonal)ly conclude that thi:- process, extending over many years, ultimately led to the condition here described. The only other alternative is the supposition that ii cree])iiig ulceration had at one time involved the greater part of the mucosa, with the exception of the little islets of ti.«sue already mentioned, and in healing had left the membrane in this state. Tlu; radiating cicatrix at the lesser curvnture no doubt indicates that the patient had had, at one time, probably in 1877, when the gastric symptoms were so marked, an ' Die Anamio, S. Loailic, Cliristiania, 1883, p. 147. HKNRY, OSLKR, ATROPHY OF STOMACH. 13 iMUn,.su., an. not , .ist •, H i '"""'''""' "^^''" ""-nluri.s •■''-•"tiv. .1... n r 1 "''"^^''"'^'"'■^' '■"•• '-•" ^'^^tcnsivo wns in tins ciiho froelv niuvMl.l.. \ ' ' """'""'"^ "lombrano i" tl.e unsf i,K.,l n :, . "T '" ^''" '•'""^^'^'"" ^'''' '"'•'•-'^^e =:;M!;::rt:!:;;;:r^ ii>i:en,iu. In son.c. of tlu'si- c-a«os tl„. 1.; .f, I poniicuus .i<'f-tiv...ana tl. ...a. ..on^;:;;' J ^ jr™ r^;;'--';;- vc-y f'l'uh.^ atropine hn t 1 fc;'-^'"^^ i.KToas.,|. an.l the .lan.l Klanduha. la ■^. I^V T^, ''': ^'^*--- ''"^t'-tion .J the i.>.ioai a..onnt i^ x';,: i; v:;: '' ;^''^-;' ■- -- ^i. 1,1.0. tl'--- wa. con.plet,. atn.pl.; of it tn n,l " "•'"''"' " '^^'""' ^''"* exemption of the nyloric n „ ''".' '^ "' ^''^' ^""■•*' '"-^an, with the n...seulari« inucoi^ ' ' ^'"'" "^'^ »^^^'^ ^'''^1<--'^ «!-> of the abL:fi:;;oi'::xt:;;a;::r':'" '"' '- ^''^ -^^ ^- '-- ^^--i^-i. the tion of the : .h sz;;"T''VT'v*'^ suHe,-e.liVon,a.. de.dl^ , r '" ^■'"'""'•" '^'^''^i'^'^'' ""'' ''-^ a.ay lead to n.o^ e w' U;. " t^ ^^"^ ''"" ""^ ""^""'"- -""''tio-- do«tn,etion of tuhnt T X'l^^ ';;r;;"^ '"^'"""■-^- --'^ -tensive there was no hi.torv of • -n 1 I r ' '"''' '''''''"'''''^ ''>' ^'^'"^^iek ^uhn.te..iti. of thriri:^ sn; ji: -t:.^;^: ^'--^^ve * Loc. cit, 2 T * Brit. Mod. Journal, ISTS^Ii " ' I eei,trall,I«tt f. d. ined. Wissonsrhnftei,, Bd xx s Archives Geuerales, January, 188fi. 1 I I i . ;' ' ii f ^ ^y^ ^. IMAGE EVALUATION TEST TARGET (MT-S) 4 // 4* #3 ^ M fe /. fA 1.0 I.I ia||24 ■ 5 '""== ^ 1^ IL25 ill 1.4 IM IM 1.6 V] <^ /}. / ^^ Photo^aphic Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 1. ,\ r\^ \\ >v<> '^■b'^" i^^'*" #e 14 HENRY, OSLER, ATROPHY OF STOMACH, certain forms of gastritis with tills disease cannot lie regarded as in any way successful. It is quite possible, however, that the stute of the small arteries may have had something to do with the production of the atrophy. We have learned of late years to connect indurative p' icesscs in other organs with arterio -.clcrosis and the endarteritis of the nutritive vessels of the mucosa may really have played an important part in inducing the wasting. In a recent review of this subject, Martin' sug- gests that certain lesions of the mucosa may be due to these end-arterial changes, but acknowledges that, with regard to the stomach, the facts are as yet too few to warrant any conclusions. To the other anatomical features of the case we do not propose to refer. The reader will doubtless have noted the identity of the condi- tions with those in ])ernici()us anseiiiia, even to the hyperplasia of the bone marrow and the pigmentation of the cells in the organs. One point, however, is worthy of note, viz., the large size and healthy ap- pearance of the pancreas. This organ varies greatly in size, but we re- gard it as certainly hypertrophied in this case, and we may see here pos- sibly a compensatory effo.t to supply the defects in gastric digestion. A careful study of this case justifies, we believe, the conclusion that a primary atrophy of the mucous membrane of the stomach does occur; and it further bears out the original suggestion of Flint, confirmed by Fenwick, Nothnagel, and others, that certain of the cases of progressive pernicious ana;mia depend upon profound alterations in the gastric tubules. For the sections and drawings we are indebted to the skill of Dr. J. P. Crozier Griffith. 1 Kcvue de M^decine, January, 1886. ' (1 aa in any i)f the small tlon of the ve \v 1C0SSCS he nutritive ant part in tiartin' sug- ond-artcrial •h, the facts ; propose to f the condi- )lasia of the rgans. One healthy aj)- ?, but we re- see here pos- igcstion. usion that a docs occur; onfirnied hy f progressive the gastric ill of Dr. J. li.: "I S'H li m \ ! 1 i 1 1 1 : i 1 1 j ; rt t' ; i ^' •i . 1: ^X X CI f^' TiVRjGjjT I. liCTVKES. n- \ ON CERTAIN PKOBL HMS IN THK PHYSIOLOGY OF THI: m.OOl) COKPUSCLIiS. ''delivered In-foic the geous, r » >'% . ir^! i ul RY \V1IJJAM OSLER, MD ""■'"" ■""■""•«-'Valco,.lh.;e OP PHvsKiAN. . ' '' ■■.NNbYL\ANIA, PHILADKLI'HIA. 'I I KEPRIXTK.r) I-KOM THE iMEDICAL NEWs April 3 > lo, 17. 1886. ! I !'. * nU 1 i WM. J. DORNAN, I'RINl'ER, 628-634 Filbert St, i V : I THE BLOOD I'LAQUK tre so,„e<.f the mul ,- , "'' '^^nn.scles .till .en- ->^' P^'tholo,. i t lu h ''■;'''"''°"^ '" physiology nevertheless sS'ni'r; I'?" '"°"""^' ''->• -^ Wood haie een . d s in - '" '" ""'P"-'- "^ 'he of physiolo.vSr'^^e ,''■'; """"^ "''^ ^^'^'^^ ^^-^^^ts sands of alMe ob^e S h" i;!" '" ^'^l' ^'^ "^ ^■-- ently, with rude and nil ^"'' l""? and ard- endeavorin,. to so "e tl ^ id' l/ '"=tr,„„ents, vainlv bytheseco;;n.ono;-e; S:,r-;:;t'V^-P-'-ied pIiysiolo-vhassomi,HH-,K 1 • "" ''apartment of pan.ntre;A,lt. ^Z^S^^:^::;;^-^^^^- o the centre of certain biolo^L '; "^ "^'^ '"^"'^"-'*^d here seems painfLdlv slow xJxZv' '''^' P'"^^''-ess ton Jones, in ,846 oft em ^hscovery by Wluir- corpuscle;, .he 'ed :;.:";,"'' 'r'^^. '>'' "- -"orless gratory power, and he d "r ' ^"'!" ■^"" "^ their mi- '^.nction'of the nu'r!^ " r^,;;^^ h.ood-forn.in, P'^'tant additions to - A peculi ' peculiarity of these p erennial problems is tiiat cer- I (' If. . > f ■i •■ . i i ;■..-, , 1) i 1 1 ? .' I. 3 A 1- y ,■;_■»- 5 I- , il ; / -'! > 1: 'if ^ OSI.KK, tain phases for the time eni,Mge the attention of observ- ers, and the lal)orat()ry activity the woild oser seems centred \ipon them, with the result, in a few years, of an enormous increase in the Uterature. After the (iiiestion has been thorou>;hly fou^dit out and quiet is resumed, we are tlianliful if only an outpost has been gained in the struggle and we are a stej) nearer to the citadel of truth. As regards the blood corpuscles, the work of the past few years has been largely m two directions — toward the determination of the existence or non-existence of a third corpuscle in the blood, and in the study of the his- tological processes attending degeneration and regene- ration of the corpuscles in disease, and upon these subjects I shall hope to engage your attention during this course. I propose, therefore, in the first lecture to consider the much debated third corpuscle, or hicmatoblast of Hayem , which, so far as 1 know, has not yet received systematic consideration before any American or English audience. In the second I shall discuss certain histological prob- lems connected with the degeneration and regeneration of the blood cori)Uscles; and in the third 1 shall present a statement of recent views on the relation of the cor- puscles to coagulation. THE THIRD CORPUSCLE OK HLOOl) I'LAQUE. i J: i Definition.— ^^ colorless protoplasmic disk, constant in mammalian blood, measuring from 1.5 to 3.5 micro- millimetres. The number per cubic millimetre in the blood of a healthy adult is about 250,000, but their num- ber varies greatly at different periods of life and with varying conditions of health and disease. The ratio to the red is about i to 18 or 20. They are delicate elements, and, like the red corpuscles, tend on the withdrawal of the blood to adhere to one another, when they form the irregular granular clumps which have long been known as Schultze's granule masses. ,V,,,;;(.._It will be necessary, at the outset, to refer to the names which observers have given to this corpuscle. Unfortunately they are rather numerous, and no one of them entirely satisfactory. Donne,' whose description CAKTWKK;!,,. r.KCTlKKS. observers, Hatx^n /,„',■ ^'"""^^ '^'' '"'"■<-' ^^"^•^■"' writers refer to this p1..,,, . , "'"'^''•p'^f'-. \ annus in the rese^JcS k:^ ""^^ '"^ ^f ^^^ ^'":^-'^'. while Laboratory of lohns V , f' ^'•'"" 'he Hioloyical Pl'r>/ue is Ise 1 an h. "' "'' ,'''"i^--''-^ity, the tern, Manin. To the' erms M w""f "^' ^■'^"^^'"" "^ '''"f- [Here is the ti^ ,S:n tu^^"" ''^•''"'^'^'^"' been appHed to other bocC"l, ,'.'■"' ""-'"'' '"'' With the elements i„ que S„ H . ' "°"'"'*^^ '" ''" called invisible corpuscle f M ^"'•'"'^■■' '" ^be so- the nucleated red cor ,I r ^"'■'"' ''"'^ "^'^ '^tt^'r to name h.L„nob ""'"-'" "^ "'" '^""^ '"^^"ow. The theoreti on e; i ;J"°'^^ --"i- with it certain bodies whici: ::rrm.;f n'lT '" '""^^'""^ "^ "-- to favor the name ^hich Hi 'l"'- ^ ■'^'" '"^"""1 because we Se In leh f'T'" ''"' '"^^'"P'^''- P''>'-"y l^rofessor fo. a se, e of .b. "^^^^^^^^ Turi,I awakened the liveTies in ■'T''''''^' ^^''^''^h ha. P--'lv because s el ttel '" T ^"^P"-'-' ='"'^ Jilood-plate. the En dish t ''^^^""'^'•'"^^l the name. //<^M/..;/.isl no.Sn "''7"'^"' "f the word bint- ^^"'' >"iKht be emn o^.J'^',' ' f ^'''' '""''^ convenient English writer^.! " "' '^^ ^^'"•-^^''^'^" ^"^ barelyvisible corpuLl of ' l' '" '' ""'^.."" ^"'" "^ "- f'e boau.if,,! photographs i„ s hnnf m^?' ''"' ^' «'"''y "^ "- with . p..,i,,t knl V «::!;;"; !■';"'■ "r""'^'^ ^^^y- "'^" "x^yare separate elomcms T '''°°^ P'^"« °f Hizzo.ero, '%.45) as resulting tZZ\n^Z ^''^""'''■^ ^^'"'^'^ '>'•■ figures fugitive corpuscles are i^re- li.v , 7- "" "' """ >'''""■"" ^^ Moreover, tL corpuscl. w hS "': '^'^'""-'S'a'ed I.looan the blood-plates '' '^^"'"'-"^ '''''' "'"^"'••"'y 'arger '--e ;;::iJS:;:::?s^o;';:'"-^' ''''^" - -^y -^'■^"•« ^or already long lis, „,„ eover a ^ ''"°""^' '° ""'^ ^•"""''''- '" ""-' connection with ho!r.o,e;Tfeh 7", T' ''''= ^""" "^-' '" rini ,I,„i,.. „.. .,._: : . ° ""^^' ^ f*" absolv-> r. . ., 5 rial duties on their behalf. led n om further sponso- ^'il . I ! . j., I ' 1 1 ' i* , ' 'i ) i '1 : ■t /jl ril rl Hi G OSl.ICK, Mi-tlioih of Study. — Let us first consider llie phuines in l)lo()il ex;iiniiic(l in the >imi:i1 manner, willuiul the ad(lilit)n of any reaj^a-nt ; and let us suppose the blood to be taken from a case of consumption or cancer, or from a newborn animal, .is in these states these corpus- cles are abundant. We then find, in addition to the red and colorless corpuscles, many ^jrayish-white j;r''i">'l;i'' masses of various sizes and shapes. ICxamined at once, and if too much pressure is not exercised by the top- cover, the edf,'es of tiiese masses are clearly defined and they form compact aggregations. With a power of 500 diameters, the composite structure is well seen and the granular character is ])lainly discernible to be due to I'l'i. I. ^ k:^ ct .''.^ a. Aggregations ot pi.uiurs 111 human blood, forming tlie so- called .^/-.f^/Zc «Mi.>v?J of M. in Scliiiltzc. i. DisinlogiMlion of tlie pla(nies, with fibrin filaments and inucin-like spheres adhering to the mass. c. Isolated plaques. the agglutination of numerous small bodies of uniform size. At the edges, isolated or partially free corpuscles can usually be noticed. The fibrin filaments, as coagu- lation proceeds, seem to radiate from the masses as centres. This remarkable conglutination of the plaques and a tendency to undergo rapid change liave retarded greatly the recognition of the corpuscles as veritable elements of the blood. Observers have, as a rule, seen in them nothing more than a granular debris of no special significance. Nor is this to be wondered at, as they so cjuickly undergo change that the clusters, in the course of a short time, really present the appearance > ll ' Ali„pl„„, ||.-i„. ,. /,,. The ,i,, .,„H aTaf: n'iif ';;;r ;" "■"•: '»'^»'* ^ "- ''"-''■" o.i»lhc at„reKal„.„s; ,!,„ »,„.,||„ „„^. „„„„„"'=' blood of the adult the placuies are nnt v.. Tnri ^1 ^ r h-xjiiucb are not verv numerous and bO do not form vcrv larrp r„ii..,..;„ '. "'^'^""^' rii,,;^, 1 1 ' ''"^e collfctions. In some in "'^' \' 'J,- I, t }. I'OSSIJ V this mnv 1i,. .,., -1 tion th^ r„ I "^ peculiar mode of aerrreea- non.tne red in se: ■ ; in- -^-' e |'"Uon and a clearer substance. Usually this ,],rl:,- l'";t.on ,s peripheral, hut it „,ay he cen 1 , t^' not unhke nucleus. It is as if a material h ul e^^^^^^^^^^^^ -", the stron,a or bases of the plaque, us 'as the .nu.^ob,,w., the reel co,-p.,scle 'm '"lluence o( rea,,^ents. The plaques undergo the mos^ cunous chan,a>s in shape, to'the study of t^^^i h de voted much tune in ,873. Wuhin the vessels tiev re' c.rcu ar, but when at res: they not unfrec,uen, Iv been; e p-.ul or prolonged, or slightly angular ,n ren t , •iKI M\e a stellate appearance to the plaque The ; -.'RCs HHor.n are very fully described Tn irurec[n c ced by chan.es >n the external con.litions and a e not . n -^1-jd or vital in character. The addition o se' n ' '^1 ' "od drop, and the exan.ination in a warm staJ l^ven u thin the vessels they n.av show these chancres -^^1 -" the course of a few hours alter in a re,, tk tbTe "'anner so as ,0 he sca.cely reco.mi.able '""'"'^'^'^'^'^ Averyconunon chan.L;e ,s the separation from the pHue . fa, nucn,.like(?) material inthe form ofapS rate f.on, „. U ,H.„ a:,,.eKateesh blood, th,s process can be readily seen at th. "lai-m, and the held in the vicinity n J , , -th these pale ,loln,l..r iKHhel T • " lit dc:;;btr ^n,thesepa,at,o.,ofso.nematerialf..;m;h;:SS o.ien seen attach-'d tn spermatozoa in urine. i t4 OSI.K.R, i .-> I IlL'ii \m In marked contrast to tlie stability of the plai|iies within the vessels is their rapid disintei^-ation when withdrawn. At a low temperature this does not occur so quickly, and of this Ilayem took advantage in his researches ; but at the ordinary temperature, and in the examination of the blood without any rea),fent, the platpies unite with each other and underL,fo rapid change — a viscous metamorphosis, as Kberth" terms it. As I shall have occasion to point out, this is associated with the separation of tibrin which seems to arise lirst about the groups of placpies, as Ranvier noted in 1873, and he spoke of these little granidations — arraius sarcoditjuc of Vulpian — as c-;ntres of coagulation. Action of Rrai!;tiits.—'^\\\'i has already been referred to in the consideration of the best modes of examining and preserving the plaques. Water reacts upon them as upon the colorless elements, causing a swelling of the protoplasm and a rapid |)roduction of the jiale spheres already described 1 )ilute acid and saline solutions act in the same way. In three-fourths per cent, salt solution, or in the sodium sulphate solution for lilood counting, they retain their outlines and do not so ra])idly coalesce and disintegrate. Dilute potash solution causes speedy dissolution. The aniline dyes stain the plaques as other prcUoplas- mic bodies, and Hiz/.ozero's lluid has the advantage of tinting them and making them more distinct. In prepa- rations by I'.hrlich's method, the tint of the central por- tion of the plaques may be deeper than the periphery. Carmine appears to have no effect. For i)ermanent preparations the dry method is the best, and they may be stained with hiematoxylon, fuchsin, Bismarck-brown, or methyl-violet. The blood in osmic acid may be kept for some days if the cover-glass is carefully sur- rounded with paraftine. A solution of corrosive subli- mate I : 1000 is also suit.ible for their preservation. The precise chemical composition of the plaques has not been determined, but from the similarity in most points of their reacticm and behavior with dyes to the nuclei of cells, we may supi)ose their composition to be of a similar nature. Tlu- Nunihcr. — The numeration of the plaipies presents serious difficulties, on account of their extraordinary ad- hesiveness and the nundjers now given may be sub- M' I'AKIUKKiii r l,i:( TI'KKS. '5 ject to revision when better nietiiods are devised In n the u b.c milhnietre, li,^r,i,.es wliich c-orrespond to hose of Hayetn. Full-blooded, plethoric i Sa ^ 1-e rarely ntore than 350.000 per cubic millinie e Ihe varuxfons .n the san.e ind.vidual n,ay be co d^ : n 1 me, 1. A^e has an important influence-in the in- k' '''"."• ,'' "'^ newborn of all the mammals I have exatnmed they were specially abundant. In d vanced a,.e they seem more nunirous, parti ulhf the md.v.dual is weak and debilitated "'^"'•'■'>'f Lnt.l more extensive an.l nu.re reliable counts are announced, we may say that the placpies in J- h number between 300,000 and 300,000, the ratio to cies 35 01 40 to I. I he nunierati(.n of the i.huiues is 1 much more tedious n>atter and requires ti morJ a -ence than countin, the red ancl white omsxles e. ^ appa.atus. as the mixtme can be n,ore thorou- •'" "^' necessarily exci 1 e a tem.on 01 the student, but every constant obser er of the blood m states of disease must have marvelled a' tin and agam at the extraordinary number and ! e of^l e granule .nasses met with m certain cases. L d " nv \ by the.r constancy and pecuhar character, writers hive regarded then, as specific and dlstincvc el nents In certain aflecfons (leukaemia, phthisis). K.on T ab * . I %\ 1 t i 1 I I:;, I' '"■*■' ■ ■ r , 1 1 » ;, ii, i6 OSl.HR, and comprehensive paper of Riess to the more recent one of Afanassiew, tliore have been very many observa- tions on the freciuencx' and sii^niticance of tiiese bodies in disease, Ijut we still lack careful and i)ainstaking enumerations in the various acute and chronic tliseases. A rouLjh estimate of their increase or diminution may be made by any one well accustomed to their observation, l)ut for scientific accuracy the hicmatocytometer must be used, and means must be devised to overcome the present serious source of error. ^ly own observations have been very numerous, and I have for years been in the habit of noting' the paucity or abundance of these elements. In the absence, how- ever, of systematic and reliable counts the notes are not worth much. The ^'eneral results I may state as follows : 1. The plaques are increased in all chronic wasting maladies — cachexia- — with or without fever. This is very evident by examinini,^ in rotation the various patients in a hospital ward. The debilitated individuals, the subjects of phthisis, cancer, or other chronic wasting diseases, present a marked increase. In phthisis the number per cubic millimetre may reach 500,000 or more, and the ratio of the plac|ues to the red may rise as high as i to 5. 2. In acute sthenic fevers the plaipies are not in- creased in the early stages, but as the disease advances, and the patient l)econies weaker and more debilitated, the increase is usually marked. This is well seen in typhoid fever, in which the number of placpies during the first week may not rise above normal, while in the third and fourth week there is usually a notable in- crease. 3. In the so-called blood diseases the number of the platpies is variable. Many observers have remarked the great numbers in certain cases of leukicmia, but in others the increase is not apparent. So, also, in lymph- atic aniemia. fn some cases of Hodgkin's disease I have seen the placpies in extraordinary numbers. In profound an;emia the plac[ues may be very scanty. 1 have long noted, in cases of pernicious antcmia, that the clusters of placpies may be almost absent, or much more scanty than in health. Distribution of the Plaqiii's in Animals. — So far as our present knowledge goes, the plaques are constant con- !■ -ivr \- Hi ' AKIUHIGIIT I.KCTrKHS. ,7 slituents of the blood in mammals and with fh. cept.on of .li,.ht variations in si.e tie ene <^^? '" ..rtheir'p.-::;;;:.:";;^;;::!'--:;!;:;;,--;^-^ ^-.nea-p,,, .-abbit, .hcep. ox. honse ,^1 '' "'' '"°'"^' nul^ld .-"""■ '" ^''^ "-I--''. -^'1 here they are logically an^ii •:rS1;;;z;:^^:'';;;^ '^p^fo- ;;;™als, and .h,ch behaves Le',t.i;:„Xt:,;^ accS;b7ii"':;';i:^!f;;;r'";" '"-^ '^^" ^'-" '° "derates no loss 1 ," '''''"''' ''^"'' '^'^'"P enu- the most pr V le t de?"" ,"";""/ ^''"^^- ''-^'''1- physicians' Lt-Utl '7",'"'""'^ •'^"'""^^ '^'i"'^'^' -Hi ciegenera.o; o LT;'"' '"'" '^^^^ ''-"te.ration the leucoc^,es Tl"i J ?"' ""P^-^'e^. especiallv in-e,tdar clumps l?;,",^';'rV'"-^^'"-'. for the ordinarvway look ven lit '/ -^''''"'"^'^ '" '^'' Plasmic'deb, s iLZl ^ ' '"''""''■ '"^-P'oto- ciisinte,.^ati^■in 1 e ' lo I " "° '"^'^ ^'"'^^^'^^ "^ '^P'^'^ "uarkablv strblTelomet , "''■'"'''''' "'^''^'^ ''^'■^ ■'^- ciecompo^itionet ":;;;::, '""" '" :'"'^ "^'■'^'^ -^1 structures sin,i!ar to the rn '"7 7"'^" °"'' P''«^"<^e that the form on °f the T ''^ "^ /''^^^'es. The fact of placues l:^"!^"^^""'''-''^^''^'-^ ^he groups the blood direc.h int o. ; " ^'%P''''''''<^ '^v drawing ""-". i" whi 1 he n ts' " r^'r-'^"^' '"•• '"-'"• ^ be sufficient to con -in e '"'' '"''""">'' ^'^""'^ does not, the stud c th. ? '""*' .'^^P''^^'" = "^"t i^ it -ill satiJf^, I U ink l' 'Jfr"'r^ "^ ^'" "^^^■'^"■•" ^^^ ^ anceandiarge l^f iJ ' "'"'-"■'^^"- '^''^^ '-^bund- d.ope.ami,Sn:;u:;ts::af'^;;n:^'r ti-ewithZ^^ X'v;rv^'"''"'^ --• -ith those in . le o^'.i; 'n V^"' "' "'^ ^'™"P^' elusion irresistible Int'r , r'''' '''''^'' '^'^ ^""- .'^teindepende.!:.;?^;;;,:!::^^::;^--^-. -.en.at.onort^-:i'r;;:s;'^.^^---! ■ r .-i r i t I I' I -I 1 i- f 1 1 !! I» OSLEK, sider the views thai the i)la(Hies lepiesfiit fibrin par- ticles, or are tlejiositions of i,'liil)iiUn. A majority of observers rej^ard the plaques as inde- pendent elements in the blood, others a^ree with Hayeni that they are yoiin^ red corpuscles — haematoblasts — and a further discussion of this point will be best con- sidered in the next lecture, when 1 ^peak of the regener- ation of the corpuscles. Historical. — I do not propose to enter into the literature of the blood placpie. This has already been done very fully by several (lernian ohser\ ers, and (piite recently by Kemp, whose pajicr in the " Studies from the Biolo- gical Laboratory of Johns (ioiikins University," will be readily accessible o all American and iji};lish students. In my original paper 1 have also <,riven |)retty fully the older references. We may conveniently divide the work which has been done in this department into three periods The first embraces the time prior to the ])ubli- cation of Hayem's researches in 1877. The masses had been observed frecpiently, and the corpuscles had been studied, notably by Donne, Zimmerman, and Max Schultze. In 1S74 1 demonstrated the corpuscular nature of the granule masses, and showed that the bodies of which they were composed "were present as separate elements in the vessels, and showed no ten- dency to adhere toj,rethcr." In 1873 Ranvier'-' called attention to their possible association with tibrin fcnana- tion. Riess and others had called attention to their in- crease in disease. The second period dates from the publication by Hayem, in 1877-78, of his researches, and to him really beloin,'s the credit of establishing the histological jjosition of these corpuscles as con- stant blood elements. It is curious that his careful ob- servations met with very slight recognition among physiologists. The interest in the (piestion had almost died out when, in 1882, Hiz/ozero, ot Tiirin, published an exhaustive article in X'irchow's A>ihii< upon the Blutplattcltc}i, and their relation to fibrin formation. From this we date the third period, during which there have been already published eighteen or twenty essays, chiefly in Germany, and the most intense interest seems to have been aroused in the subject. The weight of histological evidence is strongly in favor of the views which I have here laid before you, but there still re- ' AKlWKU.ilT 1-KCTUKKS. ti-'of t4r*, ;'7r''', 1 ">r"" •- "■ •'- f"."-- I!lli[,|()(;|< U'II\, ,8;3.'^"""'" Co,„p,. ,.enc,. .,e I'Acad. des Sciences. J. ^immern.an: \'irclunv's Archiv, Bd xviii 3- Sclniltzc: Anhiv f nnl-,. a . ' +• |a)cm. Arrhiv del-hysiol., ,878-70 5- Hi/«,zer(,; W. Low's Archiv. IJd. xc! j.'?n'H:;!;:,,::'S:,Sr!-.r-'"--'^-'o™ «• O.ler: IVoceedin.us of the Roval Societv ,^^, 9^R:.nv,e,-:(;a..Med.deI>a,is;,873 ■ ''^• »' I ^11 i t i 1 ■ j I ! .: 1 ■;? '; ■. fj 1 !i) I ' ?•!] If LECTURE II. DKCKNERATION AND RKGHNKRATION OF THP: CORl'USCLES. . 'I'lKie is evidcmc that tlic iciloriii;^ mattcis u( tiie hiic and of urine are (lfri\i'(l t'lum tlu- li.i in')L;lol)in, anil to siippb their daily aniount many CDrpurii Ifs must hf di'stroyfd, and to replace wliii h new ones ninst be foimeil. 'I'lie variations in number at dilTereni times and uniler dif- ferent conditions, indicate that waste and repair arc ceaseless processes. Moreover, there is the direct evi- dence in the present e of dei;eneratin^ ''ed corpuscles in certain or^jans, spleen and bone marrow. Our very imperfect kno\vledj,'e of the details of de}.jeneration and re;,'encration of the corpuscles in health has been sup- plemented to some t.'xteiit by exjierimcnt and Dy the study of th" blood in disease, and I jjropose in this lec- ture to touch upon the salient features of these proces- ses so far as we at present untlerstanil them, As it is difficult to separate the two conditions, whi( h in many instances coexist, 1 shall lirst take up the consideration of the state of the ( nrpus( les in an.emia, as induced either by increased destiuctiou or loss of the corpuscles, or as it results from ncanty production. The loss may be sudden, as from hcm()rrha;;e or acute poiMins, or be a slow gradual process, as in fever and chronic poison- ing. Aniumia from imperfect production of cells may result from primary clianj^es in the cyto^^enic tissues, or be a secondary effect of imi)erfi'ct luiirilion, but in either case the reduction in the number of .he red cor- puscles is !i\- far the most impor'aiit < '' t " anil upo . this the symptoms mainly ilei)e"i'. In health the red corpuscles present a remarkable uniformity in size, or perhaps it is more correct to say that tue variations which occur are within very narrow limits. The large ])roportion of the corpuscles have a diameter of 7.5 //, but there are a few to be found which measure a micromillimctre less or more, 6.5 or 8.5//. These slightly smaller and slightly larger forms are not r -.mierous in normal blood, not so numerous, 1 think, ;-.s Hayem's ' researches would indicate, for he places the medium-sized at 75 per cent., the sntaller forms at 12 per cent., and the larger at 12 per cent. Gram,'' who ' I.econs sur les mollifications du Sang. 1882. ^ Foilscliriue dor Mcdecin, 1334. •■AKIUKIi.llr I.Ki ||Il<|.;s. ,, 1.- ....Hi. , ,nnnbcrof,..rcful ob.erva.ion. on ,|.,. 7.5 /(7.« //) ln,t the ,,cr,cnta;;c of ror,,us's 'ells may be ?or ;r ■ " "■■ '■■'^■" '-^"- '^'^ ">"-■ '-^hnotmal J/Zfrnj/... occur n.an.ally ,n the blood of the embrvo f- K. to, /M an.l newborn, but are rareiv to be seen n a healthy adult. I.whsease they are \„ostabu,ulant I 1 ■i ■■ ■ > r: Ou.lm.s of r..,l co,va,cl..s „, ,> case of profound an:.n,i , , i Very irregular forms -poikilocytes a V t,. *= , -V"- 3.3- i.J an.cmia, whether from hen.orrlu.^e or as a result f chanj^estn the cy...^enu- „r,ans, or secnulan di^ease of important . „cera. When the attention o observers was lust dnccted to these bodils t V" S^!^l^:^^-"^"^^-"^^'-^"--m;;rMn »in forrns of aiii.L-mia, but we ki ow now that they i f 1. ;': -■'f i " ■ R) . 24 OSI.ER, i !:! I I. occur— in variable numbers, it is true — in all forms, in chlorosis, splenic auicmia, jjernicious an;i;mia, leu- kannia, Hodgkiii's disease, and in the aniemia of cancer, phthisis, and otlier chronic affections. I must say, however, that so far as my ])ersonal experience jjoes I have not met with ihcm so uniformly or so abundantly in any condition as in those cases which we designate by Hiermer's name of progressive pernicious aniemia. In what may be called the ])rimar\ an;emias they are almost invariably to be found, while in the secondary form they are variable and may be absent. There is unfortunately a difference of opinion as to the nature and origin of the microcytes, some regarding them as disintegrated remnants of corpuscles, others as young forms in process of development. Possibly both views may be correct. The small, spherical bodies of a deep red color, 1.5-2.5 /; in diameter, should, perhaps, be distinguished from the forms slightly larger, more dis- tinctly discoid, and less deeply tinted. That they may result from changes in the ordinary red corpuscles is, I think, certain. I have fre(|uently noticed that they ap- peared to increase in a slitle kept for observation. They resemble, too, ])articularly the small deep red ones, the fragments into which the red cells disintegrate under the influence of the imluction stream and of various solutions. In a freshly prcparetl slide of an;umic . • V\r.. 2. :^j ^y^ Ol\^ tkiMii I Extreme poikilocylosis in blood iVom aiKcinic patient, ex- amined in Pacini's tliiid. It illustrates also a possible mode of origin ol tlie iiiieiocyles- blood firm pressure on the top cover will sometimes be sufficient to produce a large number of microcytes which result from the destruction of the red corpus- cles by pressure. They may, indeed, be observed in process of formation as shown at Figs. 2 and 3. \m CAKT\VKI(;HT I.KCTl'KKS. n Normal blood ,n Pacini's fluid does not often show special chan,^res ,n the form of the corpuscles, l,ut the con.uscies,n. cases of profound amumi;, ma; bi;': m t ve >• M-reguiar ,n outline and deeply fissured as .n the field as microcytes. In the bone marrow, tio I have often noted a somewhat similar process (Ki>r. 3), Tit;. ^. M' ■ * ■i 1 1. &>^ Origin of microcytes from red cor .'uid fission iipuscles l)y process of Ijudding .Specimen from red marrow. ^^'Zir-n! '"""'"^' •^'"' '^--^ --^>' -"all forms 3 . ?° niicrocytes are not always to be re- S In'brr"' °' P"^^-"-'-^-" c'^-^^e, tiLy n. • be seen m blood exammed with the irreatest possible ap.d.ty after removal. Whether the s li,l ly' K^^' form of ,n,crocytes from 3.5 to 5 ,, and .hid. a re X les deeply tmted, arise in the same wav is still an un sm!Zr7'^''^'T' '"'''"" ^"'■''^'^^'^^' '^^« '-^"ention than the They L.y reach a; t;:o,^,^.;.;^^r;^ 'r;::i even ,5 ,. They are very constant elem n'ts in -es c.f pe..,c,ous an.mia, and also occ.!;-" Jhl" "osisand leuk;emia. (}ram' has made the interestin^r conservation, which I have been able to confirm t"xf these forms occur in numbers in cases of icter He |iUo states that ordinary red corpuscles placed in .aenc serum (of ascites in cirrhosis) seem to hatie neS^;he'\.f^- '^ '"^^' '''' '" '--' ■-■-"- nection the peculiar lemon or subicteroid tint of the sloTMTMnany cases of pernicious an..mia, and possibly ' '''o'tschritte der Medicin, Rd. ii. I ' ■i, » I 1 ■jLt I I i i m m Ji, , ■ 1^1 i I [ \4 i). } it P OSI.KK, there ,'xist in the l)ln(>cl-sernin smne clement — the product of destruction in the h.tiiu .'hich niav ict upon the red cells and cause them to assume a more ilattened form. These mei^^alocytes often show the most eccentric chan,i,'es in outline, to which I shall shortly refer. When I speak of the development of the corpuscles, 1 shall return a;.,Mni to tiicse forms. In the normal red corpuscles re.Ljularity in outline is not less constant than unitormity in si/.e, Init in the blood of the various an.cniias we now recognize the loss of this character as a very distinctive feature. Here, also, many of us cncd in sujjposing this condi- tion to lie ijcculiar to jjcrnicious amemia, the disease in which these irrej^ular forms were first accurately de- scribed. (Hiincke called them /ni/Vc/Ahj/tS, a term which has been very gener.dly adopted. At Fijjs. i and 2 this condition is rejjresented. The corpuscles may present the most remarkable shapes, ovoid, elon- gated, pryramidal, balloon-shapes, with indented edges, or rods, either straight or bent at right angles. Many of these bizarre forms are scaicely recognizable at hrst as red corpuscles. 1 still hold that we meet with these forms in a more extreme degree in cases of pernicious anae- mia than in any other disease, but they occur also in the aniumia of phthisis, cancer, and inanition. This is a physical change depending jjrobably upon alterations in the blood serum. It is not induced in the healthy corpuscles by dilution of the scrum or slight grades of concentration or by any of the reagents which tend to produce crenation. In Pacini's lluid the corpuscles of anitmic blood may sometimes he observed to become much more irregular in form (Fig. 2}. Peni-n/i>i^f of l[a'mo;j;lobin. — We know as yet little or nothing of the processes associated with the produc- tion of the coloring matter of the corpuscles. In a state of health the percentage of hiumoglobin in each cell is tolerably definite, v.irying within very slight limits. In diseased conditions we have learned to recog- nize two remarkable changes in the relation of the coloring matter of the corpuscles. t3ne is the observa- tion made some years ago by Duncan (1867) that the htemoglobin in chlorosis was reduced out of proportion to the reduction of the corpuscles, so that the individual worth of each red corpuscle in coloring matter might i A; «' ! ( AKT\VI K'>;e;Uer than the lu.ml.er of red corpuscles per cul.ic nnlhmctre mi^ht indicate. Subsequent researches lave fully borne out this fact, for which, however we Have as yet no suitable explanation. The pallor of the .:orpuscles may even be reco-ni/ed with the microscope. In ordinary anamiia from hemorrha^re or or-anic dis- ease, the avera-e worth in ha'm(.,;lobin of each corpus- cle usually remains unaltered and the percenta-e of coloring matter .-orresponds closely with the pcrcenta-e of the corpuscles, but in certain cases of pernicious anannui the mlerestmg fact has been ascertained thnt the percentage of h;emo,^riobin in each corpuscle is in- creased, and the ana-mia in realitv may not be so yreat as the reduction n, the number of red corpuscles would appear to indicate. The individual worth of each cor- puscle m lKi-m<,Kloi)in may be actuallv doubled and -he hei-htened color be evident on microscopic examina- tion. Ihese two facts, intensely interesting and sug- gestive, may be said to comprise our knowled.re of the changes m h;v..mo,>,^lobin percenta^^e in the corpuscles in disease and they serve as a back.,Mound aj^^ainst which to display our i-norance of this most essential feature in niematogenesis. NucL-atci R,d Corf„nclc,.-\n anaemic states there may be present in blood, nucleated red corpuscles such as normally oc( ur in the blood of the embryo, and such as are present ii. the red marrow of the bones, I have not met With these elements so frecpicntly as the state- ments of certain observers (Khrlich) would lead us to ; ? NucU-atcl n-.I l.loomia. 1 have met with them in leukaemia in larger numbers than in any other state. (Fi- ,) rhey present characters identical with the nucleated J 1 V ! .1 ■ !!:.}' vm / / if 'in ■ ill U i) ' 1 Ji 28 osm:k, red cells, which I shall speak of shortly in connection with the rcj^'eneration of the corpuscles. They are usu- ally a little lar<;er than the ordinary red corpuscles, and the tint may be slii^htly paler. The nucleus may be seen in process c^f division, and I have seen corpuscles in process of tission, identical in ap|3earance with those long ago described and figured by Kolliker, as occur- ring in the blood of the embryo. They may be not in- frecjuently found in groups of three or four, close together, or even in contact, as if the group had resulted froni the division of a single corpuscle. I was parti< ularly struck with this feature in one case of leukiemia in which they were very abundant, and I regard the explanation just given as a very likely one in the light of the recent ob- servations of liizzozero, upon the rapidity of the pro- cess of division in these forms. That they originate in the bone marrow there can be no doubt, and in my e.xperience it is just in those conditions in which this tissue is hyperplastic, that they occur in the blood. A rare and odd element in the blood is the corpuscle containing, red blood corpuscles. Several observers have noticed the presence of red cells inside colorless cor- puscles in the circulating blood. It is very uncommon, and the sketches at I'ig. 5 represent the only examples Vic.. 5. 1 Corpuscles containing red l)lo ul-corpusclfs. t. From blood of child .It term. 2, From Ijlood of a leukiumic patient. which 1 ha\e met with. Considering the aljundance of these cells in the marrow, spleen, and lymph glands n certain states, it is surprising that we do not find them more often in the blood. It is quite possiljle, how- ever, that the colorless corpuscle circiiating in the blood may itself take up a red cell into its interior just as it may an oil drop or a particle of pigment. I have a sketch of a colorless corpuscle of the blood of the frog, with three or four human red corpuscles in its in- terior, which it had eaien. I have sought in vain in I. lAKTWKKillT I.KCTl'KI'.S. 29 chronic malaria, for evi.ience that the leucocytes in the blood take the corpuscles entire into their interior in the formation of the black pigment. Thev would appear to take in the disintegrated particles, possiblv in the spleen and liver, but not the entire cells. It is interesting to compare with the sketch I have thus given of the state of the corpuscles in ana.>mia with the condition of the blood in the acute anicmia follow- mg a profuse hemorrhage, either accidental or experi- mentally induced. With our present knowledge there IS a really serious difficulty in deciding just what feat- ures of the blood indicate degeneration and what a process of regeneration. Thus, the microcytes as I have stated, are regarded b\- some as evidence of a ret- rograde process, by others as indicating repair of the waste. In an animal deprived of one-third of the amount of blood, or in an individual after a severe prostrating hemorrhage, the changes noted are almost identical with those already described, isi. The red cor- puscles display irregularity in size and shape. The microcytes are numerous and resemble in all respects those of chronic amvmia. The larger forms of red cor- puscles are not so constant. Poikilocytes also occur As the percentage of red cells approaches the normal these irregularities diminish in a marked manner. 2d' The colorless corpuscles are relativelv, and mav be even absolutely increased in number. ' This doubtless IS the result, in part, of a relatively smaller loss in white corpuscles in consequence of their adhesive, wall-loving property, and in part, to the Hooding of the blood cur- rent with leucocytes poured in with the copious flow of lymph which takes place to make up the volume of blood. 3d. The nucleated red corpuscles may appear In the experimentally induced amemia in animals (dogs) they are more abundant than after profuse hemorrhage in man (cirrhosis. h;cmoptvsis). 4th. Th?re is a marked increase in the number of the blood plac[ues. h\X';u-nUi(m of tlw Coypuscles.— Yhtr^ is probaMv no subject in physiology upon which opinions differ more widely than in the mode of formation of the cor puscles-particularly the red— after birth. The possi- bility of a solution of the question seems to have been offered in the discovery of the blood-forming function i r ) { \i c 1 I I' •I s \\\ -:li k t ; k... Pi' --.-■ii' II ijl ■■ wHS' I AK 1 WKK.II :■ URh.S of the red in urow l)y Neumann and I!i/./.o/ero, and the positive assenions of llayeni ie,i,',ndin,n the blood i)laqiie and its connection witii re-:cnciati()n, have served to arouse a>,Min the interest in diis impoitant c|iiestion. I profjose to hiy before yon briefly a statement of the rurrent views, as interpreted in the li^du of more recent investiKalions, and I shall tir,t direct your attention to the stuily of the formation of red corpuscles in the bone nianoui. I bc'^in with this, as I iiere fcol more at iiome, having for some years i)een an observer of this tissue in variout states, and havin.LC arrived at certain conclusions which appear to me justifiable. The red marrow which in the newborn and youn<,r child occupies the bone cavities of the entire body, is confined in the adult to the cancelhe of the short and flat bones, but even with this limita- tion tiie entire bulk is very t,'ivat, and if massed as one organ would exceed considerably tlie volume of the^ spleen. Without entering into |)'reliminarv histo- logical details on the structure of the marrow, which are now incorporated in the text-books, [ shall proceed at once to the consideration of the cell elements of this tissue. With a fine capillary pipette a small quantity of the soft red marrow is placed upon a slide without any reagent and a thin cover applied with gentle pres- sure so as to procure a layer of uniform thinness. The plasma of the marrov is usually (piite sufficient, and there is serious objection to tlie addition of any reagent, as the delicate colored stroma of many of the cells may be at once altered, I feel sure that neglect of this pre- caution, so strongly emphasized by Xeumann, has time and again prevented observers from seeing the very objects they were in search of, and thev have ended with a denial of their existence (Rutherford, J/isMoj^ry)_ Examined in this manner we can usuallv see the Vol- lowing elements: r. Ordinary marrow cells, [a) with coarsely granular protoplasm (F^ig. 7. '«). coarser-look- ing than that of a colorless blood-corpuscle. The nuclei may not be apparent at first, but they gradually become distinct, two or three in number, oval, round, or reni- form in shape and vesicular in character. On the warm stage these elements display feeble aiiKeboid move- ments. b. Smaller cells about tli e si/,e of colorless corpuscles ;■■ i I-- ' ■ 1 I' p i 1 I I' s n ^ i l| m y , ■ M 1' ; I fm L fc^i if , » !l I ' ; ! 33 (ISI.l'.K, with more solid nuclei and less granular body [iroto- plasm; they art- not so nuiiuroiis as the larj^ei' cells and some of them may he colorless blood-corpuscles. Ki,;. 7. # # # ^' (?^ n (S) id) (^^ (^^ Cell elements of red marrow, a. Large granular marrow eells. i. Smaller, more vesicular cells, c. F'ree nuclei, or small lym- phoid cells, some of which may he evenly s\u-rouniled with a deli- cate rim of protoplasm, d. Corpuscles wiili clear, translucent protoplasm. 2. Marrow cells (9 to 12 /; in diameter) with smooth homogeneous protoplasm (Fig. 7, - are carried about among the other corpuscles they show a peculiar flexibility. 3. .Small lymphoid elements, resembling free nuclei ; solid-looking, homogeneous, 2.5-5 ;/ '^ diameter. Fig. 7, c. They resemble the smallest lymph corpuscles, but about many of tl.em no distinct rim of protoplasm can be seen. In others there is a faint border of protoplasm. These bodies are variable in number but they may be regarded as constant elements of the red marrow. Identical structures may be found in the spleen, Fig. i:if C.AKTWKKillT M-CTIKKS. ■-' ',-,• o> ' ^■^•-^•"'"ed the ptotoplastn is homo- gcntou. clear, and the nucleus indistinct. The color '^ of all grades up to the intensity of an ordinary red rmf T ■■ '": "''""•>• '^^ ^'^^ "'■'•'"-•>' ^°l">-ed "tqucntly seen ,n all .staj,'es of division. It is not ntc'te tl ;; u'"'" ?''' '^^■•■^ "'^ appearances ^hfch •ndtcate that the nucletis undergoes changes pnor to Fit;. 9. (^ Xiicleated red corpuscles, i nucleus from the cell, a process '11 irrow. '"^'ratiuif the mi-ration of the 'lot infrequently seen in the red ini},n-ation from it thee.^eofthecellasifi;-pr;;esj:f l^'S- 9). 'ind bodies of seen in the i snnil; mmediate vicinity of »r appearance may be the red cells 'If il s » ''"'h I i 1I I I / 11 ii'ii'l f ■i 1 ) . i i M 34 OSII'K, 5. Red corpuscles of ordinary form and appear.incc. Upon their alMindance or paucity depend the color of the marrow. In addition to the usual biconcave disks there are commonly me<;alocytes, especi.lly if the marrow is hyper|)!astic, and a variable mur'.ber of mi- crocytes. Tlie larj;er corpuscles are, I thin!:, more fre- cjuent than the smaller ones. 6. Myelopiacpies or j^dant cells, the description of which need not detain us, and 7. Corpuscles containing; red blood cells (Ki^^ 6, d, i). Some of these are evidently collections of red corpuscles imder^oin^ disintegration to tbrm the cells containin}^ granular pii^ment ( Kli;. f>, b, i), while others, resembling rather the giant ceils (Fig. '•, 'k 3), may possibly bear a different interpretation. The chi(;f interest cenlres in the nucleated red cor- , puscle of the marrow and of liie spleen. From what does it originate ? What is the process of its conversion into the ordinary red disk ? All arc agreed as to its im- portance in blood-making. It is the earliest red cor- puscle in the embryo; it is constant in the cytogenic tissues of all animals, .mil it would l)c unreasonable in the highest degree to suppose that in the red marrow of the adult it was |)reseiit for any other purpose. More- over, in states of aniemi.i and after bleeiling, the nu- cleated red corpuscles increase in the bone marrow and even appear (overtlow) in the blood; and lastly, Bizzozero has watched the (iroces, of division, which may occur with remarkable rapidity, within fifteen minutes. My observations lead ine to regard the nucleated red corpuscle as the product of transformation of the clear- bordered homogeneous marrow cell, as all grades of tint can be seen, between cells with scarcely a trace and strongly colored forms. There is no essential difference apparent in the body protoid.ism, in both it is smooth, flexible, and translucent. It is not difficult to outline corpuscles in series from those without a trace of color to forms well and clearly tinted. The colorless marrow cells with clear-bordered pr jtoplasm appear to be the descendants of the solid lymphoid cells — the primary lymph cor|JUscles — the |)roioleucocyte— which grad- ually becomes surrounded h\ a zone of homogeneous protoplasm, (lertaiidy intermediate gradations can be seen between the forms figured at Fig. 7, c, and the smaller coiniisi les at Fi,r , / •,., formation of the nti,!,.,. i ','■ ' '"■"'■'^'' "<" "■•ns- "I'cleus. as .ho„„ at p,,:";' ;'' /''-I'Pearanre of the impossible to drau' un mh-M- . ' ""'' •^" '' -'^'•''"^ "f ^"'.■1> cells, an t'snl ;""''"'"" ^-m a study tl'ey contain may be thT fl ■'.'-'"'"ants which f'em front ordina y r c'n ush"" ';' ^"^''"^'-'"n^' servers have record -dn '7''"^^>'^- ^ ery „,any ob- •n.cleus fro,, tl e eel . d i "' ^ '"'''"""" "^ "^'^ of the process a! ep;e „, , '"r,,-"'^ ^^?" '" ^'" ^^^'^-« '^een able to convince ;, 1 1 , 1 '•■ '"" ' 'V"" ""' a post-mortem chan>re S , i . ;">'"^'"S but there are not ne riv . ^'"•""'>' '" ''^^ fresh marrow P^'-tially ex r de i ■ i ' "•' .'^"nn.scles with nuclei modeof transfornriiir.n .'^'""^ 'his as the normal ^^.1 observation ;;:ir ;;:' z r' ^'f !!"'-■ --e. the nucleus unden^oeJ li L ^■'""'■"^ "^^ ^■'^'"- "''-^t similar process 'inv L ^T'-''"" " "^'-" '"^"'^ "'^^t ^ blood ceils o dt "m, .„'"^'" '" "^ "-'-'ted red as the cells are idem ' "'n V '""" '' ^'^" '°' "' ■'"'' "cntical ,n appearance and probably CIV I'K;. io. p. tt- SI. nioorl of ...nhryc,. four ,„o„,l,s. ,,13,, ^ , 'Corpuscles. In a th*.^,,,,,. „ 1 , ' ^' 3' 4- Auclcaled red ">e nucleus as ir;" :'::^'J^'T[ f ^""^^' "^P^— "^ 3, onluwry re^-Proce. of develop. The nucleated red corpuscles are slightly larger than 11 I I i I ' i i ; .1 36 OSI.KK, ortliiKiiv l)l()iiil-i:<)r|Mis( Ics, and in si/t- ifst'ml)le the megalocytes whiili art.' usually aliimilani in the bone- marrow. Siicli a cfU as is rc|)rest;nti'(l at V\'^. 8, fi, 4, dift'ers in a|)|)iMraiitor.s of the red corrni.cles. A fe, all, the most .s„hd acquisition to our knowledge of the process of regeneration of the corpuscles if he pan,npatK,n in the adult of the bone n.urow an t le c^u; rs;L H ' '■"' '^"■•'"^^'^^ '^•""-^---'-'^ •-oloiiebs cells. Here we seem to tread on a firm nun .-nt of caref^dly observed and well work::/;; act" xst^ ::;;:'" ^'^^.^^'f- '^-"^^-ul uncertain.vstiH P ore's ' r' ■■ '" "^'i' "'""' ^'''-' ■^"'«-'" ^''-••- i" "-■ drvTi;;d,r;r '"°^' "''^"■^■^-^ (Ne,nnann,would cle in i?' ,'■ " f T"''^'^^' •"'"••"'"i'^n of red corpus- tl , h ■ """^ ^'"^ "^■'■^'^"^'-' '-^ ^-fi-'-i'-nt to show de pen tl af';; ■ " ""' ''^/"'•'■'-^-'■' - ''- subject lowstlu'l '---^yenerat.on of the corpuscles fol- Seneial. In the adult body there are permanent and t> ans.tory tissue elements, and to the latter the bloo corpuscles undoubtedly belon,. The uutritio he fo.mer .s entu-e y uUerstitial, and does not involve anv change ,n the element, when once fullv developed Of ..n.Ujry elements the epidermic tis.,es are \S^ examples Ihe epithelium is in constant process of .egeneration. and the sheddin, of the superficial eel s is analogous to the destruction of the older red co n,s le The new growth takes place by the constant fissu.n an d '""Itiplication of the cells of the deeper part of ^. '"ua>su.. and if the entire thickness of a portion ftht epidennis ,s reuK.ved by accident, the remnan o 1 c' in 7T '" '■'" '^'^'■'"'" '-^l^^'''- 'l'-^ 1««^- Just so •n he life history of the blood corpuscles, wh .h a.x' fleetmy structures, l.ke the epithelial ;:ells, the h.em o' genous fssues-spleen, bone n.arr.nv, Ivmph ' hnds- contam as permanent elements cells which by fission nuit.ply and pass into the blood current, more t^^s niociiied, as the red and white corpuscles _ The recent increase in our knowled-e of the chan-es -n the corpuscles in disease, and of^he proce e" of reproducttun, is an earnest of fuller info'rmatbn in .1 ■1 /i' i , 1 'i i t k 1 M Tl ^^^^hiI i< iH! 1 4° OSI.KK, (AKTWKKJHT I.KfTrUIS. li ih ; |j ■ ill •5 tlie near futiiie. A key lo the solution of many prob- lems in patlioloi^y, will, I doubt not, here be found, but in seeking it let us not for^^et that the corpuscles float in the blood plasma, the patholoj^'ical relations of which v'hich ^•ledtje await investigation, and offer a field for researc should be ecpially fruitful in adv inciniT our knowie ol the ultimate :csses of nutrition and of those devia- tions from it which lie at the very root of so manj chronic diseases. "■fl^t.- ^FCTURI^ III. THE kl.:i,ATi()N OF THK CORPirsciFS TO COAGULATION AND THKOMHOSlf ^ the a.i ,,,,,,,,,-- --^^ ecij,e nt the ((iiiiU'ctKjn hctuc.-n thnc^ „i co..«.,i u,„„ .u;., r,,„„ ,i,, :,i;:s;;,;:; ,fi™™;;,-;<' i .■.-*: T„"' ::,':;.':,":■ ■";':■■' -' - ■■'"«! »"■;,„" .cvuda., ;■;;,, ;',V"'' '■" l"'l>''». •<• wl«»e re- -^ *"«« i""'»;r ,!:;;,;;™™r;:;:;^,S!--'" °^ remains, consistin,,' of plasmi with f > ■ ^''' colorless cun.us.Jos \ t ''*''' ''"'' '"'^"y 'Ml J|: i r,'' )■ f 'f i^ {il n If 42 OSLER, li I I ,r<\ colorless corpuscles which have undergone destruction in the process of the formation of fibrin, and Schmidt and his pupils estimate that at least seventy per cent, of the colorless corpuscles undergo destruction in this way. They found that, instead of 15,000 colorless corpuscles in a cubic millimetre of the plasma before it is whipped —z. c, befoic *he fibrin is (.-xtracted— there were subse- quently not more than 4000 pcrculMC millimetre remain- ing in the serum. Kxamining the clot so obtained, it is stated that the colorless corpuscles have laigely, if not entirely, undergone destruction in the formation of fibrinoplastin and the liljrin ferment. This is, perhaps, the most convincing experiment which any one of Schmidt's pui)iL, has brought forward to sustain the view, that colorless corpuscles undergo destruction in the process of coagulation. There are many other points urged by Schmidt to which 1 need not refer, as they are readily accessible in the works on physiology. The researches of Wooldridge' have also shown that the colorless corpuscles play an important part in the formation of fibiin. He has been able to procure leu- cocytes from lymph glands in a tolerably pure condi- tion, by means wliich he has described at length in his paper. These leucocytes when added to an equal volume of a ten per cent, solution of common salt seem to be converted into a material resembling very closely ordinary fibrin. By ex])erimonting with what is known as peptone plasma he has obtained very striking re- sults which would appear to indicate still more clearly that leucocytes play an important part in this process. Peptone plasma is obtained by injecting peptone into the bloodvessels and then bleeding the animal. Co- agulation is prevented entirely by the inthience of peptone, and the red blood corpuscles may be en- tirely removed from the serum by the centrifugal ma- chine. This plasma shows no special inclination to coagulate, and is, of course, particularly suitable for experimental purposes. If t'^e leucocytes prepared from the lymph glands be added to thi~- plasma, coagu- lation at once occurs. If a small quantity of leu- cocytes is added, the amount of fibrin produced is small ; if a larger quantity is added, more iibrin is pro- 1 Proceedings of tlie Royal Society of London, 18S1. > CARTWRIGHT LECTURES. duced. In f^ct, Wooldridge has shown that the amount of fibnn produced in the peptone plasma is ^ec h proportionate to the leucocytes added The leucocvte seem themselves to form the tibrin-perhaps e em re as tlie ueyht of the leucocytes added. Moreover the album.ns ,n the peptone plasma, after coagula.l can be shown not to have undergone any change bJt re mam the same, quantitatively and qualitatively -and a rssrti^:;^;:'^^'^"--'-------^^ vens the" T- ' '-.°"'>' "^^ ^^^^ P'---^ -'ich con! nTn M , ^' '.' T ^''""' ""' '^'^ '"j'-^^tion of leucocytes mto the blood of the living dog produces no efiect ' buch tacts appear to show very conclusively that the corpusc es do undergo disintegration, and 4t if the blood p asn.a of the horse is examined after i has been wlnpped leucocytes may be found in the serum and also m the clot which has been produced, so tha all the leucocytes have not undergone destruction. The el st' ha Vc urre??'" ""'"'--^ ^'^ '— ytes after clot ing has occu.red has caused one of Schmidt's pupils HeyP to duMde the leucocytes into two sets : the alpha-^uco ot a leucocytes, wh.ch remain. From observation I do no beheve that the number of the leucocytes wLich un- nvth'in'rhr'"" " '" '^'""'"^^ °f ^'- ho-«'^ Wood A?;, ? '''f'' '° extensive as Heyl states. oftl "cotlef T'"'"" '" '''''' °f ^'^^ ^1-^-^tion o the colorless elements seems conclusive, yet if the hbrm formation is studied under the microscope it appears to take place without any disintegration' o colorless corpuscles, and it is extremely difficul °o demonstrate their participation in the process As 1° e known. ,t can be studied in a blood-drop e.xamined The dm' '"T' r'; °''' '^"^^ ^^'"' ■" ^'^^ --' ' chamber rhe .me winch elapses before coagulation begins is conditions. Usually, however, from fifteen seconds to twoor^ejmm^ elap^ the first appearance ' Dorpat Dissertation, Foitschritte der Medicin. 1883." ': ( 1 'S( a, 3 ( « f 3 i 5 Ff % i. f ^1 4 m ^ I. T ?! ) " I i :■;■ ! ! I s * 44 OSI.ICK, i I of the fibrin filaments is noticed. A slide can be pre- pared in a very few seconds, and there is sufficient time before clottini,' bej,nns to examine the colorless corpus- cles, the red corpuscles, and the blood platpies. I must say that, in a very careful examination of the process of the formation of fibrin in this way, I have never seen any appearance in the leucocytes which would indicate that, as the fibrin was formed, they underwent disinte- gration or dissolution. On the contrary, they seem most stable elements, and the ama;boid movements persist long after the fibrin network is thick and dense in the field. Certainly in the microscopical examination of the ordinary slide, or in the examination of the blood- drop in a moist chamber, I do not think anyone has seen the direct tlisintc.t; ration of leucocytes in.the produc- tion of fibrin. An iiUercstini,' and instructive experi- ment is to draw the blood of a fro^c, or of the horse (in which Schmidt and hi- pupils hold that the colorless corpuscles so '-apidly u .ergo disintegration), into a fine capillary tube in which the process of clotting can be watched under the microscope. At first, the entire tube is filled with corpuscles ; but, before long, it is seen that theclot contracts, and there is a peripheral layer of serum squeezed out. In a short time, leucocytes can be seen emerging from the clot in numbers, either squeezed out or migrating from it. This experiment, which can be readily demonstrated, forms an admirable mode, as Schiifer showed some years ago, of studying the process of coagulation. A study of die histogenesis of fibrin as seen in the moist chamber, in the capillary tube, and on the ordinary slide, affords, 1 think, no evidence in favor of the de- struction of the colorless corpuscles, but, on the contrary, is directly oi)posed to this view. In a certain number of instances the aggregations of blood plaques, to the connection of which with the process of coagulation I shall shortly refer, have possibly been mistaken for colorless corpuscles. The relation of the n'(f corpiisih's to coagulation is not regarded as very important ; they play a more passive part. But Landois and others have described a process which can be readily seen in the blood of the fro" and in mammalian blood, examined in serum. If we take the blood of the frog and examine it in the cAK-MVKif.irr i,i:( TIKIS. 45 serum of the blood „f the rahhit, it will be seen that the red corpuscles of the tVo.Lr crowd into colinnns and in a short time the luemo-l<,bin leaves the corpus- cles which become ^Manular, ami librin filaments form in then- vicinity, and, according' to I.andois, the red corpuscles break d<,un into a material which resembles granular fibrin very < losely, indeed. These observa- tions were made ten or eleven sears ago bv Landois and they have been confirmed by others; Init whether the corpuscles undergo transfnrmation into the fibrin hlaments, or whether tlbrin only clots about these groups of corjjuscles under the inlliicnce, perhaps of a ferment which they extrude, it is impossible to say' The relation of the blood pi.u/ucs to coa,t;ulation is particularly interesting, and is, at present, attractin' own o!;servations are in harmony with these, and we may say tiiat the platpies are the elements which fust settle on the edges of a wounded vessel and whii h form the basis of the thrombus. Fij^. 3 represents the entl of a [xirtion of the adven- titia indicated by a -loss (>: ) in Fig. 2. The sketch FKi. 3- :lll ICiul of small portion of advcntisia iiidicati'd at >' in Fij^, 2. TliL' fibres arr cvcrywhi'i-t' sunonmk'il witli ynmulur disintegiating pkuiues. shows the blood plac|ues in a condition of granular dis- integration, but under a high power the outlines can be distinctly defined, and any one with a knowledge of these elements and of the changes they undergo has no difticulty in recognizing them. If the cut ends of the vessel are examined when fresh, in osniic ai id or Pacini's fluid, the elements are still more clearly seen and are readUy determined to be identical with those iii the cir- Lulating l)lood and in th'- gr.uuile masses. The elabo rate investigati(;ns of Eberih, published in the January 1 Lubnitzky, .Archiv (. lixp. I'alli. u. I'liann., 1883. I' •AKTWRIfjHT t.K(TIM "ilcrcslins. Znhn' *> (y ,^ y>^ ( .J Plaqufs fron, ,h,n do. on w:,rtv endocarditis ncross a v.b»1 In ,l,c o„,.„ „„, or „ ,1 c .^J ,'"""' ; -'tihre^attci masses — w iitp thromhi ti ^i^::';-;:' --'-'■' wastheHr,st spcd.nen n/u , ' "'V,''''''"'; '^''"-^ strate that the white il,mn,i ' ''''''-' '" 'Ifmon- --i- „,y observation f .,.:^;r;r'" ''^"' '"''^" ve;;ctations on the v a v ' f ' '"mertHMi with '''-e specially i.te^"' 2' ""• '"■'""<'-•< ob.serve the white thr, n i 1 '"'"'";" ''•"■^■'"^'"> '" ficial parts of ti,e n '' ''•""'"'^">.v die super- C""'P<.sed not oC c , " "'^^'P'^'-'n they are '"-tecl hbrin netv, k 1 " ""''U-s, les, nor of a reticn- Plaques which ithe ' -^' luMVely of these .ranularclisinuJ,': J ;^';;;\r''^-'-ve undergone and, in the ^ame veTi- l.v u ' '^> Bi/xo/tio, •-ennotedhy;.-S.:;>^JX;r^'"'^'''^'-'''- aorllf ■wL;h'::::^l,r,;'r" ---- -' "- thoracic soft grayish-whii;^ :;::':;;-;;-;;-- a number ^ '''servers have noted On ' ''"-.'•'"""-. -uch as nil '""ndtobeniadeuoofH '^•^a'"'"^""" ^Lese will be compose the li e thn n b;'":"'' T'"''.'" '" '''"'' -'^-h "i^k-'^ke blood ,^ r • r ,^'' '"'"^">' ^''•^"'-■ bodies under,.o are 'erv pec , " a"^^' "'^"^'^ ^'^^^« ■">■ first lecture, they Vonel i ^' ' ""'"ioned in are withdrawn, and tl e^ ' '"'''^" ^^'^ ^'"^ ^^^ ^hey mation. whereby le l,se r'^" ^-{-rkable transfer- converted into \ j;;;^^;; S:..°r '?^..?-! -on,e ^.viduaipia,ue;b^r;;:rr:;:;::,:r^!-''r'"- =^.i:^nti^:;::;r^----vt;.n/;h;i:':E -edini.;tth:'^bL;;;rp;;;.;;2fi,rr'"^'^^^-- and become irranul ir -.„ i '^ ''"-' ''''f' fl'-^'inteorated recogni.able;^;^ ,;';,"?*-: "" '""«-" distinctly tinct, their outlitt' J "e ^ .n'; l'h^' ""'^' ""^^^ ^i^ 2i;v::-r--"--"^^ I r ) i I I* t p I' 3 .5 it ,\ i i- h ii ) I f-'f r. t MBM ■ i s ' BH < -S 1 if 52 OSI.ER, dence of this important jioint on a firm basis, and explain the production of white thrombi. In the Fig. 7. .Small aneurism of thoracic aorta, showing the internal wall of the sac covered with numerous curvilinear eU-vations, grayish- white in color, ant is seen that, in addition to the leucocytes which collect in the still layer, tC Llood P aques appear; but in the rapidly circulatm. b ood as '^een m the mesentery or the omentum of the JLl- P.g or the rabbit, the still layer, the peripheral no tion contains no blood plaques, and only occa's.onally eu Fbe n 1 '^'"'^^7^^^' '^y ^ distinct tube of plasma, -be.tl bnngs forward these flxcts in explanation of the development of white thrombi. So lon'r as the cir- n"e uTto "'■" T "^^'^"^^ '"'-""^^■" central.-and adh re o ' n c i;;' "h "" '".^'^^ '-''''^ ^^^" = ^-' -hen. ion f the corpuscles ,s disturbed, and the plaques end to collect at the periphery, and aggregate in grupsal any point which has been injured, or which h.as b L' deprived of the endothelium. Slowing of the b oo stream ,s then on this view, one of the essentials i the formation of white thrombi, and this is entirely in Vcco d his i:ot \ir T' °'^'^ P^^'hology of these'structiS It is not alone the presence of intact endothelium which prevents the formation of tarombi in the vessel tb we frequently hnd in aneurisms, on the hear va ve Vr^d z^^-Tn:!:'r''' r\ ^°"^'^ ^^^■"- "p- '^'-h o 1 d on nH ■ ^"'^'''^ ^'^'■°'"'^' "'^ "°t Often found on atheromatous ;ilcers. which would offer the avorable localities for their formation if it is the ei it e hum alone which prevents it. The other condition wouia appear to be slowing of the blood stream, wh and 7^'^^^".'^"^;-" '« P'ay such an important part Sht of'tle" ^1^^""^-"-- °f -hich is wel'seen in tl e light of these observations of Eberth What I contend is. that the white 'thrombi are com- posed chiefly of plaques, and that the colodess cor- pusclcs play an altogether insignificant part n the r S'-olfcled" T ^^P^"'"-''^' -'dence which h! morbid an:fomy.'""^ "" ^°-"P'^'^'>' '^>' ^ ^'"'^X ^^ The further development of the thrombus results from the disintegration of the plaques, and the LrTna! I • i n i ^4'/ r ) ) 1 i' (•'■ I :■ 'Im 1 I ! Uta^li^H d .31*11,... 4; .; ,! .i'i ■ ' , li «■} u H ^m I^S ■ 1 H IB ■ 54 OSI.KR, tion of a finely j^^ranular material in which there may be no fibrin filaments. We must recognize a granular or stroma fibrin, as Landois call it, and a fibrillar or plasma fibrin. The former is a granular material which develops when cells undergo the peculiar metamorphosis described by Weigert as coagulation-necrosis, and it is this in reality which goes on in the white thrombi. There may be no trace of fibrin filaments, but the chief mass is made up of a granular matrix in which the out- lines of the plaques are no longer v-isible. The stages of this transformation I have traced in thrombi of the femoral vein, and it is well seen in passing from the superficial parts to the deeper parts. The plaques on the surface of a while thrombus, as at Fig. 5, may be intact, or they may show signs of disintegration and conversion into a granular debris. The central soften- ing of a while thrombus results from the liquefaction of the plaques, and is a result possibly of the presence of fluid in greater abundance than is necessary for the process of coagulation-necrosis. (2uite recently in a case of typhoid fever, I had an oi)porlunity of studying the histological characters in thrombi in the femoral veins. In both they were mural, and had originated behind the valves. The attached portion was a light brown-red color, but the upper half was of a dead-white color, and the extension into the iliac was of the same character. The line of demarcation between the two parts was pretty clearly defined. At the thickest portion the superficial while thrombus had softened to an opac[ue milky liquid, but at the prolongation it was firm and consistent. A few colored and colorless corpuscles were scattered through the white thrombus, but the great mass of it was 'omposed of blood plaques, and a study of the softened milky region showed clearly that the granular detritus was composed of the altered plaques. In the deeper parts the plaques became less and less distinct, until a point was reached ii which the individual cells were no longer visible, and tliere was nothing but an indift'erent inatrix. The contrast in color between the outer and inner portions indicated a difference in age, possibly in mode of formation, lliough in the outer por- tion of the brown and the inner i)art of the white, close to the line of demarcation, the structure seemed identical. In the light of these new observations on the connection 1 ■ if ; 1 -v^be'ttiSi'is;:;;!' 'r-'' "^^ ^"^'- ^i--- tio" of the e ■ n II ^''-■' ''''^''"^"'•'^•■'y the rela- statements here made rc/m , , , ^'^ "'^ t--^"!^ ^^ the plaques with thrombos'' S u::rr''°" ^'^ observation on the strucne of fh ? ?"' ''"■"'^"' j^a.h..mato„s.eers.^:;r:,;j:^j:^r';;;^n^ '■^lobular vSa un'^of "P'""'^."r>- "^ examining a venture to s a t e t " .h/v"" '"'"'' "■■ ^•'^""■'<^'<=- '-'^ I similar struares ' "' ""'"P"^^^ ""^''"-"r of ! 3 1 .*' i' • ■il;i I J ■ J ft ^^ :| >i ! nm '■ " ' ii i'l 1 b 1 ;/ ^ ,-h vir ? 'I Hi !■ BICl l^yxn 1 THE BICUSPID COiNDITION OF THE AORTIC VALVES. ■.- \: I f BY VVILLIAM OSLER, M.D., F.R.C.P. Lond 1 1 REPRINTED FROM THE TRANSACTIONS OF THE ASSOCIATION OF AMERICAN PHYSICIANS, JUNE 18, 1886. 11 > ■-! i PHILADELPHIA: WM. J. DORNAN, PRINTER. 1886. M II- I J # ■ 1 ■ ■ ! i ^ ' h If* i I THE BICUSPID CONDITION OF THE AORTIC VALVES. Ilv WILLIAM OSLEI!, M.D., F.llC.P. 1,„„. rwvan.,!^ ^^ ,. _ * I-ROFESSOB OF CLIMCAI, MKDIO INE IN IIIK I'MVElisriY ,„• rEXN.yi.vAxi Def,n.,t„«._A ,,„umi„„ of ,1,0 arlori,,! vaivo, in ,vl,iol, „v„ of 1^ ,,«,« a., „..„.c. or 10., porifcotl, f„sod, ,0 tl,a. .he orifico b JZ°i by only two segments. to^aiuLu common al,„„„„„li,y, „„,, i,ilg. 1,,,, „,„„,„„, e/casos , o ll » ■;oco,„ ly .00,, „„„,„ bj, Mar.i„o..i „,„, Spornio^ an,I , ! "w m tho aort^ ,„lvo ,n,j;l,t I,o gi-oally oxton,W. I„ „vo,- oi,.l,t l.un.lrcj ,™iops.o.,, I ,„vo „,ot with it io LS oaso.,, 17 i„ ,l,o ao.tic'val ^ „1 n 1 ca.0 m boH, aoH.o a„,l p„l,„o„„,y valves. A .letailed aceo, „ „ • "otod n, f„„,re observations. The undeti • Viivhow's Archiv, xci. s \Hi,l .11., r. » . ■ a ,;„,,etu ,!oll,, riin|,,,„._ ,S8G r,.„rint "'" "' '*''"''''''"" '" '^"^'"°' '^Sl, reprint. Tl.i. "hviatc. Iho o„Mf„«i„„ which at , r^on r™ tffr ," ' "^ " ""'"« '•""-' "■« ""-•coronary. P.-Hor an,, one anterior ..,, a.„. h^.tr .^r.:;:; ■ ^'I.ir^^C;: .Sr"'^ """°""^'^ "^ '-^' ^:'! Vi Ml;: 1 M"! i lii i III mt 1 III ii. " ■ II ff H ' iH Ki^ 3 1 H Sf' •' 1 11 r ' III i'- T "W • i ill ■ !'■ 2 O.SLKK, ciisjis may liiivc :i itorfectly iioniial appearance (Cases 7 and 10), but in tuliilts tlioy are almost invariably tliickened and tbe seat (if sclerotic or, in some cases, ulcerative cluuiges. In Case 7, a fa'tus of seven montlis, tbe tissue of tbe valves sbowed no trace of tbickeniiig or inflammatory processes. In Case 10 tbe united segments were practically bealtby ; in tbe otbers tbere were sclerotic cbanges more or less marked, and in several distinct losses of substance. Unless seriously stiffened, or tbe seat of erosion, tbe bicuspid segments seemed capable of closing tbe aortic orifice, and in several instances tbe valves held water wben poured into tbe aorta. In 13 cases tbe valves were carefully measured. For piir})oses of accurate comparison, G of tliesr may be excluded on account of incompleteivess or extensive disease of one cusp. Of tbe 7 cases, in 1 tbe two cusps wore of ecjual size, in 2 tbe single curtain was tbe larger, while in 4 tbe fused segments were larger than the single one. Tbe average measurement along tbe free margin in these 7 cases gave for tlie fused cusp 3.93 centimetres, and for the single cusp 3.4") centimetres, so that the former was, as a rule, larser than tbe latter. In tbe conjoint valve tbere are three points to be noted. Tbe free border was usually straight, oftentimes curled, and in no instance was there any nodular thickening indicative of the presence of a corpus Arantii. The attached boi ler i>resented, from the ventricular aspect, either the nonnal contour of a , cmilunar valve, or, more commonly, a shallow groove, indicative of tbe junction of two cusps. Tbe aortic side of the valve presentetl in all tbe cases a more or less distinct raphe, or fntnum, dividing, or indicating a division into, two sinuses. This raphe, tbe representative of tbe bands which in tbe nornial segments unite them to the aortic wall, was present either (a) as a narrow elevated ridge confined to tlie aortic Avail ; {b) as a sini^lc band passing for a variable distance on to the valve; or (c) wiis divided into two distinct portions, which passed out the inner aspect of tbe valve and were ultimately lost. The sinuses of Valsalva, thus incompletely marked, were usually of eipud size, and in sixteen of tbe cases they gave origin to the coronary arteries. Of associated lesions in this condition of tbe valves, hypertrophy of tlie left ventricle is llie most important. This existed in a majority of the cases. In Xos. 10 and 14 it was scarcely noticeable. The stale of the other organs, when of interest, is mentioned in the tables. 7 and 10), the scat of r, a fo'tus of F thickfiiim^ ;nients were langes more iCC. Unless lents soeiiieil cs the valves ' valves woi'c 1, G of tlie.se ve disease of |ual size, in gnients were long the free :imetvcs, and IS, as a rule, I. The free instance was of a eor[ius cular aspect, e commonly, Tlic aortic less distinct two sinuses. the normal her [a) as a as a sinii'Io ; or (c) was inner aspect alsalva, thus n sixteen of pcrtrophy of a majority of :. The stale 3 tables. BICUSPID CO.VI.TTIOX OF T.rr . 01. Tin, AORTIC VALVES "aining 7"t there was ulcerative ;:;::,^'':-;^ '-';; '''--. I^ a verv severe typo. Cases 1 ' - ^"T, !' "' ^'^' '^"J 18 "* .^-lual heart failure with t h'o '„ ' '"'•'" ""'^ --"'l'>- compensation. Thus ir, fiHeon' /f ^^^'"P^oms of disturbed eould be attributed direetlv or inihr .VTt^ '•'"" '' ^^"^^'' anomaly. Whether the rjs.dfc of , , ' existence of this ^.ii- in development. the'::;nt^, r;:;';^^ ^ '^ P'-^n^^^ ''« '"Story of aortic valve disease The ^ ^ ■ ""''^^''^'"^^ P'^''^ in tonned structures to disease is well J-., ''T''', I^''""*'"^'« of maU ;'- --ely, in the adult, f^^J f^f ^W "T '" ^"''"'"^ ^^^'''^^^ '^'fofmycases there wis atoZnt^'^j'Tf' 1"^ '" '^^^^^^ tJ'c fused curtains is more severe ^^'^-'^tloss, the strain upon '» the f. no,t t .^ t f'^''^^^ ^f ^^^^ ^'"^-^ investigations in experimenfd em r. , ' ^''^"-'''''- '^^'^ '^'^^^ «™od by the beauLl"^^, :: r^ l^^ are con- woid.lin.licatethatthemicrocTc ' 7r''''" '"' '^"' '"^^ting) ^'•^theslightestabrasi "^C::Z ? f-"' '" -™=^^ val^ i^ibbertM.as been able to n , ■< en r '"" '"''■'"^^'^- ^^^^'^«»gh the n.icroo,^anisn,s w t o t" T T '•' '^^^^'"^ -'^"^^f '-^-^y i^ the material 1:1 Zo^ZtZ f ''' "'''''' ^-'- '•ecent experiments support th. 1 ='"' P'-^^'ti^'cs, these tl'at a damaged valve if^ n s Trf f '" ^"^■"^^^•^^ -- ative changel '^ '''"''^^ ^'^ ^''''^'^ the seat of ulcer- ■■isonably be iussnciatea with iiiiglit 1 = British Meili'cal J.ni'rnai.' ' Tagolihut tier 58 V ^ valve loHion. Culstoiiiaii Lectures, 188"., vol. i. previuiia eiiihuljc proc, 's--*, which -.Co .^.^v::;— - -r-- f-.-.-er ..-strath ft, 1885, No. 42. Ijurg, 1885. i >l ^i ' ■ OSIiER, f ; * t I ! Of tho cif^litoen casos lioro roporttMl, all snvo one were in iidultn. In Diljf's tablt" of twcuty-tlirco ciiscs tlic iigo!- of nineteen are ;.;iven, and uf these only nine -wore adults. Seven wer" under five years of age. My experience has licrn in a general hospital in wliieh the great majority of the patients were adults, Dilg's paper is on various cardiac anomalies, so that his search in the lilcraturc has tended in the direction of paediatrics, which may account for the large number of children in his list. OiutiiN. — Whether the condition is the result of a foetal endocar- ditis or is an anomaly of development cannot be finally settled until we have fidler knowledge of the details of formation of the svuiihniar valves. The advocates of the inllammatory view urge that indications of the original separation invariably exist and that the valves as con- stantly present evidences of endocarditis. 'I'o this view A'irchow has given the weight of his authority and has recently' stated that an examination of the (piestion has convinced him that a majority of the cases show signs of a " secondary fusi(m of two cusps." This cer- tainly may be so in some cases, but the following considerations lead, I think, to the conclusion that in many there is a faulty arrange- ment at the time of the development of the segnrents. First. The greater frequency of the anomaly !it the pulmonary orifice and its association with other cardiac defects. In the sixty-four cases collected by Uilg- there Avere fifty with imperforate ventricular septum. Errors of development occur more frecpiently in the right heart and involve the pulmonary artery more often than the aorta. Foetal endocarditis, however, shows the same preference, and un- doubtedly plays a part in the pi'oduction of stenosis of the pulmonary orifice and nari'owing of the conus. So far as we know, the develop- ment of the segments occurs at a very early period, eighth to tenth week, and it is really difficult to conceive of an inflammatory process so extrenaely limited, in an embryo not more than a few millimetres in length. Second. A careful study of the united valves throws light on the question. (a) In Case 7, a foetus at the eighth month, the curtains at both arteries were involved, but the conjoint cusps were natural in appuur- 1 Virchow'fl Archiv, Bd. 103. ' Loc. cit. I BlOUsni, c.,X,„TIO.V OP THE AORTIC VAI.VKa. 6 »n™ a„,l wi,l„„„ . „,.co „(■ i„ll.,„„„„„, ,,„„ (,„ »,.™,l „,.o.. .,„ ,„ ,, „,„„,„„ _„, ,^,, _,;.^ __^^ J^ZZ lo, .. ,s .,„■„.! V c,,uoo,v„l,lc., if ,l„. |-„.i„„ „,„ i„||,,,„,„„„„.,, „„."„,„ V. «. In d; i^- i . • i"'i^^ J" me ,t tl.o .,H, 111 ""/^"*^P-^- -I'lo slight indentation usually present a tl.e attaclH-d honlcr has been, in most of my cases, without a trice ". tUj btlow .t. If we consuler the extent of the space existing oU-; two segments and the nature of the endocardia 1^ ef 1 .cl. cause curling shortening, or other deforiuity of the se.„ c^t t .almost unpos.ble to suppose that a fusion, caused in thfs Z C....1.. leave the ventricular fi.e of tho valve smooth and tt:i T/iM A staily of other an..malies of the valves has an im„„,.(,„, l;.-..>g on tho suhjeet. VVithont any fusion of the c„s Z ""'u:::;;:™''"'" "; "-'r' -* -^ -tachmenti'.;,::.^ an IdistinT Int , 7" "" ""™' "' ™'='' ""^ ■'■=""''- ^OP-"' anil aistina, hnt the tivo may join at a lower level and at an anterior n most of hese cases that the anomaly is the result of a innetion .^f t>.ofrc= herders of the cusp, from four to tive centimetres of tlXa;; (i ■ i I'-i > ' i <;;! • ■■ ^• 6 OSLER, furthest from the corpua Arnntii. The condition is not very unconinidii. In a recent sjiceinicn two of tlie aortic valves hml pfii'tiiilly united and were a gootl (U'ai tiiickened. They wore united to the aorta hy a median raphe, siniihir to that no often seen in the conjoint valves, but in adilition there were three strong ehonhvj tendineic, seven millimetres in length, which united the ed;i:;e of the valve to the aorta, to which they were attached at the noruial level. TImSO cords were thin and free from any trace of intlamniatory thickening. The condition was un- questiunaldy a defect in development and was of a similar character, though not so e.vtensive, as that under consideration. Fourth. W it turns out to be correct, as my cases indicate, that the affected valves are usually those Iiehind which the coronary arteries are given off, this would point to some error associated especially with the developnu'iit of these cusps. It would appear from the ohsiTva- tions of Tonge,' that two of the segments arc formed before the divisiuii of the primitive trunaus arterioaus is complete, while the third arises latci- after the pulmonary artery and the aorta have divided. It is •not at all improbable that we may have here a clew to an explanation of this anomaly, but this is conjectural until we have I'ldler details of the process of the development of the sigmoid valves in mammals. J ProcoeJ^" jf Royal Socii'ty, 1808, xvi. 1 miconinioii. united and iuntii by II valves, Ijiil luilliniL'tros wliitdi tlioy n and free m was uii- • clmractt.'r, ilicato, tliat iry arterii's !cially ■with 10 obscrva- tlie divi.sidii liii'd arises Jed. It is '.\]ilunati()u r details of iiuiulij. 1 -- - Cause of Ueatli. ^ a r> — -.^-_ '_ ^ 1 n ru J ' i . ' ri: . . ; 1 ! 1 k V'H-' 1 , ',': I u. 1 : .:! _ ■ 1, H A'/ ■ ';1' ^^^MUttb.!^ll'.?H! %- BICUSPIP CONDITION OF THE AORTIC VALVES. S .a O -3 * ?9 £ oT i £ <« a 2 4) ? 3 ™, t' ■- p3 M — ■2 .*■ £■3 a a: n i5 o. a "- o I'- "rt "* "" Son S :; fl a •S c IMS'- Is « > g =•■5 S o > t, (»- w « - - a s ^ r; ^- to rt ;- o ^ :; ^• - — oj 3 S 0) — . C - 'C 5 2 ^ - *o 3 - fe - =5 c = „ &=§■ CO ^ *" I 5 2 = ^ C 1> *■ t/s? s s. - 4Jr3 — tc 5 to o a ; 5 "ST? 3^ it u ■ E s o p~ — •^ s •h'c: ^ ■= C i -' « ^ c ills ^ s o C N ^ _CJ ™ — i ». 3 c - S "^ "5 ^ S S| 7= E tc £ = '« ft^ ■g is J^ - r/J ^ 5) "3 2 . ? -J .2-3 ?f^ ^ o r ^ - f^ rt — o U 3£| •a tt r is ^ -f ^ = - 3 W ? tfi'-S ■« ■ t (I-Td t4 •^ .2 >-. = s? ~,'c 2 s . 'E.'i ^ r»i ? S "*- £ >. ::• £iS U w o ■5IS ^1 tl M K§-" • ^. mZ a ■*-* — "3 ^ 'tr o -0 ■-> a __'3lC 3 « o - 2 u -■ *-■ 3'<;"3 £ ^ s- 3 rt trJ fc - * " "C .— t-'^ ^2 x: ^ c ^ © .2 ci3 ^i 1- -J.E ci II 11 a 3 2S .2 f^ Si 51 11 5s |S &^ 1 o »- - - l-J o h:^ feS as I LVES. •=£ i is. I-. ! ,' 1 ;^2 •^ a ; o'-' 3 s X -n 1 ■s ^ c tc ^ ;: 3 H 3 "■? V '' S C. ^-r- ►J p >^ a i e' r ) J I I' D ; 7 ■| •t !; H lijij JLxXUt ON THE USE OF ARSENIC IN CERTAIN FORMS OF ANEMIA. N an address last year, Dr. Wilks remarked 1 that in therapeutics we do not so much need new remedies as a fuller knowledge of when and how to use the old ones. I do not .sTo^n' ''''''"^ "'"^^^^^'°" °f ^h'« than IS afforded by arsenic, a good old remedy, for cases oT '"""'• "'" "^ ""^^ -^"-^ - -«ain cases of pernicious anaemia. The attention of the profession was directed to the subject reCr '" ''^^' "^'^ '-''^'^""^h ^-"-« reports bearing witness to the value of this c'rug have appeared from time to time, the knowledge of its efTicacy does not appear to be very wide-spread, and there are still points in connection with its employment upon which we need information. These. I trust, disc s- s.on may bring out, and render clear the di- rection which future observation should take. I' ..-; 1 :■ ' 1 t'-'- ■ ■ : > ' 1 s 1 '< ■ \l \ i .^ '' 1 <'j ! i i i , ,: I , I ^H i'^M ■ , ' 1 .^:flBl ' ' \ ^^^H ^^^1 •i 1 ■ ^•• :.i *tlr 1 ,; ||9|; ||l,#i i r i ■ J In treating a case of anaemia, it is of the first importance to ascertain, if possible, the cause. For convenience, and until the pres- ent complex pathology is simplified, we may classify the ancemias into secot.dary and pri- mary ; the former induced by causes acting upon the blood itself, the latter the result of disturbance in the blood-making organs. This distinction, not always clear, serves to sepa- rate two clinical and pathological groups of cases. The secondary anaemias are the most com- mon, and arise from a variety of causes, as hemorrhage, prolonged drain of albuminous material in chronic disease, and the action of toxic agents on the b'ood. In very many of these conditions a return to the normal state follows naturally upon removal of the cause, and the regeneratio; .jf the corpuscles may take place with exi '.ordinary rapidity, as after a copious ble^ uing or a sharp fever ; but, as a rule, iron in some form will be found useful or indispensable. In three of these secondary anaemias I have found arse- nic very beneficial. I. The Ancemia of Heart- Disease. — In chronic valvular trouble we not infrequently meet with an impoverished condition of the blood, which materially aggravates the car- diac distress. The comfort of such patients is in direct proportion to their corpuscular richness, and without any apparent increase in the valve mischief, ' duction in the ratio of the corpuscle.' • lowed by short- ness of breath, palpuati'— ., and signs of heart-failure. The vai>. of iron in this con- dition is well known, and its combination with digitalis a universal practice. Arsenic » criudren, or if, as sometimes happens iron does not agree. ,„ m„e of this ^ aw va e;d ,ea« for r'"' '''"' '"" "'"' "^^'-^ aisease for four vears. He had h^^„ wmtenn, in the South," and went a terwa d him he ""' ""^ ■''"'"^■^- ^^'hen Tsaw n'm the an.tmia was very marked pn.i t .u«.red fro. „reat,„ess„eL ^te si^^ exertion. 1 here was no cardiac distress an-' aZT:T-'' T not seriously dist:,;bed. felr f t^T^' ^^ ^"^ ■'^^^'^'■^1 chills, with fever, for wh.ch he had taken quinine He was ordered Fowler's solution o/ arsenic ^e g>nnmgwithn,iii,threetimesadayand?n creasmg to n, yi, if ^ell borne. He had bee: akjng an iron and strychnine pi,, for ,:,- era! weeks, and had with him a boxful which he was advised ^o finish. dS' wasprescnbed.butw...ottobetake'n'^^^^ iess there were signs of heart-faiJure The d.et was carefully regulated. The lad im proved rapidly, and within six week had a' Tweig^ rh'd'^ ^^'"^^ -erlfpo'ut: n weight. He,iad not needed the digitalis ment "hid" ""•"'" '^°"'^- ^'^ ™Pro e' ment had continued on the 3d of thi. t:r.\u;"'"^ here there was'l mLa " tamt but, in any case, if medicinal agents had anything to do wuh the rapid impSy s^oSon'.'^ "^"^ '^ ^"^ - ^'^ F-ierl arsenf -ft"'"^ ^^'^ma.-The yalue of arsenic m chronic ague-poisoning is so wel recog„,,ed that I need scarcely 'deLn ;" with the narration of cases in support. There ^l I y i 1 I c 1 \' \ ' '*■■ ' ^ \ 3 , > . 'i ^ ■ } ■ I ' ■/" w V. ■ I have been several at my clinic during the pa.'." year in which the Irnproveuient in the blood condition, •> tested by the hacmacytometer, has been v.' y remaricable. One case in par- ticular, from Cape May, T may refer to, as the p?,<:!ent, with onla< ged .-^pleon, had on two oc- casions hemorrha>',e frcim the stonu-ch. I'he arsenic in this case v.as pu^h(;d for several months in increasiiig doses. At one time he took TTijxxxvi of the Fowler's solution daily. When last heard from, in July, he was at work, and had gainc: in flesh and strength. On May 12, the date if the last blood count, the percentage was over eighty (it had been scarcely fifty), and the. -pleen had diminished materially in volume. Jn certain of these cases the ratio of the corpuscles may increase rapidly without any essential change in the volume of the spleen. In the case of M. D., a girl of 15, \vho has been in the University Hospital on several occasions for the past two years, the arsenic, which was very persistently employed, does not appear to have reduced the spleen in the slightest degree, and yet under its use the corpuscles rose to eighty-five per cent. In this instance, with a history of malaria, there is evidence also of congenital syphilis, to which m.ay possibly be due the splenic enlargement. Injections of arsenic into the substance of the organ were tried without benefit. 3. Certain Ancemias of Gastric Origin. — As a tonic in debilitated states of the stomach, arsenic has long been c fnvorite remedy with many practitioners. 1 .ometimes also of great service \v the . mia of chronic gas- tric catarrh, part •. .. , in alcoholic patients. V G ao-Pri „. / ""'^P'tal this spniisr. \v April 5 with an.^mia and aua 'ks of •' m' "ess. Ill for ten davs • v ^"^'''■ stomach, and fai in, ;;i,::;;:':;';^' '"" ''" stand. Hadbeenfaniri^s :?^^^^^^ time and p-ettino- ,.oi ''^^^ength for some palpitation' i",, ."[f ^"""^^^ fron, He was profound, a„L„ Z""' n °""- coated : g„a. irritaf,",; „"!"?,„ '■°"«- 'ng on the s!ip-liff.cf ,. S'tomacn ; vomit- bin. of :£■ ,i?rr":?; rr^r" rest, given a miik diet and P. , f ""''' ""^ in 3-drop doses. Th^ ",/.', '°'"''°" not more than twenty five 1 ''"'"'' ''''' coloring matter Tnt \lr:,r''Th' ■'' provement was ran.rl .n . f ?" ^^^ ""' corpuscles had%;r.'orer'?;nt\:"' "•= J;ad„ai„i^^.eTs:r.r;;:,f.''rTr^d"^ had been at w° k p"/',"? " /'•'P'" ■ ■ •"" •here was „,ce "*; of Xf' '" .l".''' '''''■ tion ,„ the chroni cata rl, Tf ^ '," '■""'''■ theco„di,i„„.i,„„j;„='Y: .,ieT;j''«"" seemed to be highly benefcill and a, h""" ceived no othpr m^,!- • ' ^^ he re- ably att*„eo"f ';:":"• ''' -^ --- It the stimulation of the > * - 1^ 1 1 ' fM f X-' 1 s } i-r ■« blood-making function. As we shall see, there are ancEmias of gastric origin in which this drug is powerless. These are some of the secondary anannias which have, in my experience, been apparently benefited by the use of arsenic. Turning now to the primary group, we have here again for convenience to make a division of the cases. There is, first, a large section of what may be called cytogenic an;tmias, in which the reduction and alteration in the corpuscles is associated with evident changes in the hasmatogenous tissues. — the spleen, lymph-glands, and bone marrow. Sometimes these changes are accompanied by an increase in the colorless corpuscles of the blood ; and, depending on the organ involved, we then speak of splenic, lymphatic, or medullary leu- kaemia. If there is no marked increase in the white corpuscles we call the cases splenic an?emia, lymphatic an;«mia (Hodgkin's dis- ease), and medullary anaemia. The pro- nounced leucocytosis in cenam of the cases, which gives a special character to the blood, is probably not such an important factor as we have hitherto supposed, and there are such insensible gradations between the cases that in a strict classification they may be appropri- ately grouped together. Secondly, there is the curious primary ana;mia known as chlo- rosis, characterized by '.veil-marked etiologi- cal and anatomical peculiarities ; and, thirdly, we have the much-discussed affection, perni- cious or essential anaemia. The anaemias of this primary group offer a remarkable therapeutic study, embracing cases of the most hopeful and the most hopeless "ons.a„,::Vra„7;TS:trnf^"'''' ana;mia prove obstinate to alUr ° ''""«'°°^ The relation of arsen c ','™""™'- this KrouD of nri„ """■' '"s a remedy, to ourcLests" dTI?/""""' '' ^'""'^^ "f years remarkabie' re^ L" 11""'^'^ " " ''^'= from its use fhi " '"^en reported eluded from ou"c„r? "'■''>' "■"= ""^ ex- ""'ybein^rtl^ttire^'T"' practitioner would re„,,i "'" 'h=> a The specific!" on STn '° T"^'"^' "-'"-■ defective haemoglobin i™?h' ""'"""« ""= d-btless, also, I st m„ L I'tZ";*" """ of new ones, is one of ,T1 f"™wtion 'herapentics 'in which detetl's '""7"' '" under the inflnence of ,1 ""''"'e-changes, wHhscie„tific"rc:ractrdrv':i""'"^ from week to week. ^ ''^^>' ^'^"^ In leukccmta and IIoJ?kh,\ .//<• has been extensively t Id n '' ''■''"'■^" temporary success 'wrt-sT""""^ "''^'^ "1 these affections th-it fh ""^ '" "^'"^^ -^s of i,np.o::^S Xra""""' '•^- medication. I have „,.,?, "^ '^I"''"'al mia. and i. must be ake. S " '" ""^- estimation of the effect „ "'""" '" °'"- ally, T have not seen k ''"""'>'• '"e'^on. ^f--nirinhrdSe"f'™ ''""»' --'ofthee,eve„=s:es;;i:er/r;n" if I'i in I III ^ ! ' ] ' 1 ! : ! i ' ■; j ;M.! ; i.5 i 'i 1 ) ■ l« ' ' 3 'i I .1 ,\ mm ■ r i .flj ^^^^B '*' ■': ,1 , ,t-i 8 u if Montreal, all of which were fatal. In Hody- kin's disease the report is more favorable. In 1883 I had two cast's, both in women, in which the large glands of the neck and armpits re- duced nialciially under the prolonged use of Fowler's solution, but I do not know the sub- sequent history of the cases. Several writers have reported most satisfactory results. Ka- rewski* had three recoveries, and of eleven cases treated at the Stockholm Hospital five were benefited. f The persisten'. use of it in full doses for many months is probably the most efificacious remedy we possess in this disease. In cases of splctiic anccmia of non-malarial orig'n, I cannot say that I have seen any spe- cial benefit from arsenic. \Ve come now to pernicious anccmia, in which so much has been gained by the judi- cious use of this drug. Pernicious an;emia includes cases of very diverse etiology. Any severe anemia t'liding to a fatal termma- tion may well be termed progressive and per- nicious. In a considerable proportion preg- nant y and parturition appear to have been detumining factors, while others can be di- rectly traced to defective food, as in many of the Zurich and Bern observations. E.xcluding these, 've have a jiioup of cases of which the etiolog)' is obscure, and to which, in our pres- ent knowledge, the terni.s idiopathic of Addi- sion hi. J essential of Lebert are applicable. ' 'ery year, however, we are reducing the lib of cases whic wc can strictly call * Beyliiicr- Klin. Wochensc- 'ft, 1884, 17 ,niul 18. f Abstiact in Year Book of Tre.itincnt for 1884. f^ J'opath.c. It is reasonable to suppose that he extensive ci,anges in the bonrmar >w onncl ,n certain instances are directlyTeTa d o the profound cIisturlKu,ce in bloorforma t'on, just as is the case in hynernl-isi-. of T spleen or of the lymph-lnd An medullaris ,s now very generally recognized I nen, there are the nsps ,^( ,. ■ '''"'^'^*^- mia in wh.Vh fL Pernicious anre- m.a in which the primary disturbance seems to be m the gastro-i .stinai canal, and the con i't.on of the blood the direct consequence "; he impaired nutrition. There remain cases >n which none of these conditions prevail and neither during life nor after deathVo w "fi, d such f"' 1 ''•' °''''^'" "^ '"^^ — a. To uch, or he time, the designation idiopathic 's apphcable. Clinically, it may be impo i? be to distinguish between these various form and the etiology is often very obscure and g.ves us no help. The cases w'hich come on dunng or after pregnancy, or whic^ esult o U,r, as a rule, a more hopeful prcgnosis • o Zi '"''"' '" ^^'^'^ 'here is atrophy of the mucous membrane of the stomach or ex ensive medullary changes, from those n which these conditions are absent. A m. carefnl study may m the future enable us to Terences in etiology and pathologv because n hem will possibly be found th'e ex^l ! t-on^of the success or failure of certain rem- .I'l""^ ?.'^^7 ^'^^"'^ ^^s not systematically employed m pernicious anemia, and to I ^am well IS undoubtedly due the credit of us inZ" f.j ■; ■ ! ft 10 duction. Neither Muller* nor Eichorst.f in their elaborate monographs pubMshed in 1877 and 1878, speai< of its use. i'adley.^ in an in- teresting review of the question, has carefully analyzed the cases in which arfienic was nut emplwyed, and finds that of forty-eight, forty- two were fatal, while of twenty-two cases treated with arsenic sixteen recovered, two improved, and four proved fatal ; and he re- marks, that " in the whole list there is not. with one exception, a single authentic case of recovery in which arsenic did not form the chief part of the treatment." Certainly the reports of this affection since iSSo have been much more encouraging, and it need not ne- cessarily be regarded as "almost invariably fatal," to u.se the words of a leading text- book. Of three cases of pernicious anaemia which I have seen this year two have already proved fatal, and one is in a fair way to re- covery. Case I.— A man, aged 42, I saw with Dr. Henry. We reported it in full in the April number of the American Journal of Medical Sciences, and it is remarkable as an instance of pernicious anaemia, with advanced atrophy of the mucous membrane of the stomach. Arsenic was given during the course of the disease, but not for any length of time, as it seemed to bring on diarrhcta. Case II.— A woman, aged about 45, I saw with Dr. Weir Mitchell on January 20. She had been the subject of dyspeptic attacks * De Progressive Perniciosc Annemie. Zurich, 1877. t De Progressive Peniiciose .\ncemie. Leipzig, 1878. X Lancet, 1S83, ii. 1 1 for some years, aiul had become very pale, and during last year the ana;mia reached an extreme degree. With rest, systematic feed- ing, iron, and arsenic she improved, and was able to go home and ittend to her household duties. I saw her in January on her way South. She returned in March very much worse; was again placed on the plan of treatment which had proved so successful in the first attack, but the stomach was so irrita- ble and the digestive power so enfeebled that, she sank, and died on the i8th of April. The ' improvement in her first attack was attrib- uted by Dr. Mitchell to the careful feeding and rest as much as to the medicine. ( ASE III -An active business man, aged 43 ; Wien M arch 4. H istory of dyspepsia, and for the past si.K months failure in strength. Shortness of breath on the slightest exertion," and at times attacks of agonizing pain at the heart resembling angina. He had not lost much tlesh ; indeed, as is usual in these cases, the subcutanef)us fat was well developed! When first seen, the anaemia was marked ; lips and tongue very pale, and sclerotics pearly. The general surface did not look so pale, on account of his dark color and a de- cided saffron-yellow, sub-icteroid tint of the skin. The temperature was a little elevated ; pulse 100, and of moderate volume. With the exception of heart- murmur, there were no symptoms elicited in the examination of thoracic and abdominal viscera. The blood showed in a n;arke the plan of treatment, in which it was a III les to the If percent- was put to et, ordered licines bis- th Fowler's to be in- I of a week, nee of his strychnine, :)nths there ;hough the creased to etre. The rops three syelids anfj itted for a Or. reach- red, and it ig at njjv On these more rap- :s or more, with diar- ;d for ten arsenious as allowed ; to move n has rap- :ount the the cubic iber 7 he good ap- very well. le success 3ut rather it was a 13 very important factor. It will be found, I think, that absolute rest in bed, with daily massage, and the strictest attention to feed- ing, are most important features in the suc- cessful management of these cases. Arsenic has been spoken of as :: specific in psrnicious annemia. This is a mistake. The disease, as I have indicated, is so varied, and results from the operation of such diverse causes, that we cannot expect any one remedy to be uniformly active. In a majority of the cases iron is useless, but it sometimes suc- ceeds after arsenic has failed absolutely. Such a case was reported by Finlay* last year, which was cured by iron after a thor- ough and but ineffectual use of arsenic. I do not think we understand fully the condi- tions in which it is most serviceable, and for the time we must be content to employ it em- pirically, on faith of the success which has at- tended its administration in so many cases. Ultimately, we may hope to be able to dis- criminate between the cases which call for iron and those in which arsenic is indicated, and with this object in view the cases which come under observation should bt carefullv studied. Mode of Admimstration. — I usually give the liquor arsenicalis (liquor potassii ansenitis), beginning, in an adult, with n^v three times a day. Occasionally this is found too much, and I reduce the amount to 2 or 3 minims. After ten days, if well borne, I order an in- crease of a minim each day, so that by the end of t he second week the patient is taking * Lancet, 1885, •• . C : • J I > " J r ) :!■■ ill! m\ 'aWMIi lo or 12 minims three times a day. This is kept up for a week, and then gradually in- creased until the physiological effects are ob- tained. The amount which will induce these varies with different individuals, and those who bear it best seem to improve the most rapidly. I have thought sometimes that the small doses are not so well borne as larger ones, and are more likely to cause gastric ir- ritation. Young people bear it remarkably well. Within the physiological effects there is no special limit to the quantity, and, as in chorea, I make them my guide in the admin- istration. A very important point is the con- tinuous use for many weeks or months, omit- ting for a few days if unpleasant effects arise. Even after apparent recovery I advise the continuance of the drug. When the liquor arsenicalis is not well borne, the arsenious acid in pills maybe tried, or the solution may be given hypodermically. In these cases of severe anaemia I never care to use hypo- dermic injections systematically, as I have seen ecchymosis of the tissues follow, and in several instances distressing small abscesses. By the rectum, it is usually well borne. . This is idually in- ;ts are ob- luce these and those the most 5 that the as larger jastric ir- ;markably ;cts there ind, as in ie admin- 3 the con- ths, omit- jcts arise, ivise the he liquor arsenious ition may : cases of se hypo- s I have IV, and in ibscesses. le. (' I. ,7 DUODENAL ULCER. The solitary ulcer occur? more frequently in ^h. a ^ than in any other portion of th. 7"^"*^^ '" ^^^ duodenum and -rbid'natomfi ,11 tLntl :'">;'",' '" ''' '^^'^'^=^ It is rarely met with bei:! ^ t 'n^ a '^n^^'^- "'"''• acid chyme is neutralized. Bloo* ^ f ) i ' M li , i V f> '!/* •'•iMa : »; 'ill ! Ill, i f Case I. — Phthisis ; small ulcers in ileum ; ulcers in ccecum and colon ; an ulcer in duodenum half an inch outside pyloric ring ; cyst of Brunner's gland. J. L, rniddle-aged man, died of phthisis in Montreal General Hospital. No special symptoms. The lungs showed cavities ; the heart valves were normal. There were a few small ulcers in the lower patches of Peyer, and a number of small ulcers in cajcum and colon. Just outside the pyloric ring there was a loss of substance in the posterior wall of the duodenum 1.5 cm. in diameter. The base was smooth, the edges overlapped so that the actual diameter of the ulcer was much greater than was apparent. Not far from this there was a small dark spot, with a little depression leading into a definite cyst-like cavity in the submucosa the size of a large pea, which contained a thick turbid fluid. Brunner's glands were very distinct, but not more so than is often seen when the mucosa is thin, and not deeply congested. The open ulcer with undermined edges had possibly resulted from the rupture of a cyst of a Brunner's gland similar to tlie one which existed in its vicinity. One can readily understand ' that under such circumstances the thin mucosa covering the cyst, undermined and separated from its blood supply, might be eroded^ or, after bursting, the acid gastric juice might dissolve the thin edges. In debilitated persons, or in conditions of portal con- gestion, such a small erosion might not readily heal, but rather increase, and be the starting point of an ulcer. Brunner's glands are not often found diseased, but they belong to the racemose variety in which cystic dilatation of acini is not uncommon. They exist most abundantly on the first portion of the duodenum, the region most prone to the disease. Duodenal ulcer is not so frequent as the ventricular. I am sure, from my own experience, that it would be oftener found if the stomach and duodenum were opened toge'ther, in situ, and the mucous membrane examined. If, as is so commoidy done, the stomach is cut away just beyond the pyloric ring, the chances are that, if an ulcer is present, the incision passes through it. I have found nine cases In about one thousand dissections. Males are more subject to ulcer of the duodenum than females. l-fl a.e^ 0„e of™, ease, „, in li^t^r ""' '" ™^^'» of the , as.™ „,ce. ha, ..'o spilrhle^f" ^^ P""-"™ -r=— -----;..W..3,a3 Case ll.—PhtJn^^^ . „ . J-nrnms, extensive ulceraimr, ^f •; E-G., a2ed23 diod in n at ^^^yM jaundice. '■-saa, »;™p.™/Xh:t^:,r' rr"" "°'^"" -■"• a"J abJ,„m„a| tcnilereess h,„ „ ■ }"'" "'""' '"'"■"•I'^a showed cavitie, i„ bo h „„' , Ex'" ■ '"'"f ""■ '^''^ ""'"P'* of ileun,, e^cum and colon" ti.lf f T "''"''"''•"" "'"""'io" »ion f,.„,„ the ba,es of . ^ ^ ," ,r"'°"'''"'"= ■" ^--'- Pa.-tofduoden„n, was a circl „ ,. e"r t ThH'V"" °""' ■immele,-, with dean out orl»es an,i ,,„ H T °" '""'' '» -™t origin. U did no. invtive ' t:"'^],, '' '°»^«^ »f ges .on of .he mueons „e„,b,.a„o of .he „ et„„ I "" '™- "leer the size of a. en-cent niece t!h ' "' """■" ™ an "»' .»o inches f,.o„ .heto'::: ''7z:t^ ^tr'- '»ere no signs of ,„,,erc|e in the base „f .1 , '='' """■" l.«en 01 this „..,are. In Kraus,' ,U ■ ' " "'"^ '""" =-oes of olee. ,„ connectrritrphrsL ''"' ""' '^™ - // r !^^* ■ 6 I have not met with a duodenal ulcer in death from extensive burns. In all of the cases the ulcer was solitary, and occupied the first or horizontal part of the gut. The form was round in all, and the diameter ranged from half an inch to an inch and a half The base was either the submucosa, the head of the pancreas, or thickened connective tissues. In Vases III and IV the ulcer had cicatrized. The edges were usually rounded and not under- mined. Perforation into the peritoneum, which occurs so fre- quently, was not met with. Perforation of a duodenal artej-y occurred twice with fatal hemorrhaf'e. Two of the cases illustrate healing of the ulcer, one with and the other without alteration in the lumen of the tube. CASElll.— Tt/phoid fever; illness of fourteen days ; per- foration; peritonitis; cicatrix of ulcer in duodenum. A. B., aged 40, night-porter at Montreal General Hospital, had been ill for two weeks with typhoid fever, when perforation' took place, and death followed in eighteen hours from acute peritonitis. The post-mortem showed extensive ty[»hoid lesions and a perforated ulcer one foot from the ileocecal valve. In the first portion of the duodenum, an inch from the pylorus, on the anterior wall, was a stellate cicatrix about three-quarters of an inch in diameter. There was slight puckering in the vicinity, but no narrowing of the gut. The heart and valves were nor- mal. A few patches of atheroma on the aorta. This illustrates the most favorable termination of an ulcer. Such cicatrices, according to some authors, are not uncommon. They have been so in my experience. CAi^^lY.—PhtJusis; healed ulcer of duodenum, with stc-nvm of first portion ; dilatation and hypertrophy of stomach. S. F., aged 35, had been in medical wards Philadelphia Hos- pital for six months with symptoms of advanced phthisis. He had on several occasions coraplaiuod of gastric pain, and at times vomiting was a troublesome symptom ; but attention was no specially directed to the abdomen. I// im extensive )ccupied the •ouiid in all, 1 and a half, le pancreas, Fthe ulcer 1 not under- curs so f're- enal aitoj-y le with and nys ; per- uodenum, 1 Hospital, perforation rora acute loid lesions valve. Ill )ylorus. on luiirters of le vicinity, wore iior- an ulcer, ncommon. f stomach. Iphia Hus- lisis. He id at times 1 was no Po8t.7nortem.— Extensive pulmonary tuberculosis. Stomach • moderately dilated ; mucous membrane thick ; muscular walls at least twice the normal diameter. Pyloric ring of normal size a httle firmer and thicker than usual. Duodenum, for three- fourths of an inch beyond the ring, normal and had a circum- ference of two and a half inches. Beyond this, at a distance of about one inch from the ring, there was a stricture admittin.r the top of the little finger. When slit open, it extended one and three-fourths inches, and measured one inch in circumfer- ence. The narrow portion reached nearly to the bile papilla. There was not much thickening of the coats at this part, indeed m places it was very thin, and the texture of the pancreas could be seen through the thin wall. Towards the stomach there was puckering and greyish-white cicatricial tissue. The ulcer ap- peared to have completely healed except at one small spot ihere was pigmentation of the tissues of this portion of the bowel ; not much thickening of the contiguous parts attached to the stenosed portion. There had evidently been an ex- tensive ulcer, which had healed and produced stenosis just as happens not infrequently in gastric ulcer when near the pylorus. Cases are reported in which the ulcer has perforated the liver or eroded the portal vein or the hepatic artery. The followin.r case, in which 1 performed the autopsy for Dr. Rodger, is re*^ raarkable, inasmuch as the ulcer perforated the gall-bladder, eroded the tissues in the hilus, and ultimately divided the right branch of the hepatic artery, from which the patient bled to death. There are four other instances in literature in which tins occurred, and in the first published case of duodenal ulcer by Broussais (quoted by Chvostek) the hepatic artery was eroded : — ^ j Case Y. —Jaundice for more than three months ; repeated hoimorrhagesfrom stomach and bowels ; large ulcer of duodenum; perforcHou of gall-bladder ; erosion of right branch of hepatic ariry. Mrs. R. S., aged 48 years, c. stout, well-nourished person. I ho following notes have been furnished by Dr. Rodger, under whose care the patient was : if I' s * !i «# '^ [\i\- 1 1 '.: u 8 " She had been married upwards of twenty-four years, but never had been pregnant ; menstruation had been regular,' but had ceased about three years ago. " The only ilhiess of consequence that she ever had was about fifteen years ago, when she was laid up in bed for about six weeks with what was called an attack of inflammation of the liver. No jaundice was perceptible at that time. Ever since, however, she has been troubled with dyspepsia, obstinate constipation, and more or leas pain n,- feeling of discomfort in the region of the stomach. Her condition to-day (March 18th, 1879) is that of a person suflfering from a well-marked attack of jaundice ; skin and conjunctivae deeply tinged ; urine dark, and stools pipe-clay m color ; tongue coated ; loss of appetite ; no increase of tem- perature. Slu- states that she has not felt well all winter, but was always able to attend to her household duties. " Patient came to my office for about four weeks, at the end of which time the symptoms had not improved. _ " On April 24th, visited the patient at her house. Examina- tion revealed no enlargement of the liver, and only slight tender- ness on firm pressure over the organ. Heart and lungs healthy, " Has noticed considerable blood at stool during the past few days, and fyeces still pipe-clay in color. No haemorrhoids. Dr. G. W. Campbell saw the case in consultation, and gave a very unfavorable prognosis, though the exact nature of the disease was doubtful. " All treatment adopted proved of no avail ; the patient rapidly became emaciated, and continued deeply jaundiced. Several severe attacks of epistaxis have occurred lately, and to-day (May 30th) has passed more blood than usual by stool. "At 3 p.m.. May Cist, commenced vomiting blood, and con- tinued to do so frequently all afternoon, in spite of treatment The hemorrhage from stomach and bowels became excessive, and death followed in a few minutes." Autopsy.— Hody that of a well-nourished, moderately stout woman. In abdomen, coils of intestines dark-colored from stain- ing of mucosa ; peritoneal layer smooth. Liver dark-colored ; the ascending colon, the stomach and duodenum are closely ad- /I 9 hercnt to the under surface of it« nnf • duodenum, pancreas S^LTZT'T '°"'^''"- ^^^'"^^h, dilated and contains ^1X1^^'^ >"""^- ^^^-^ mucosa dark and blood-stained oi remnants of food ; "ormal. Immediately outside it's wpIi "'"7 ''''^- ^^'"''"s and back part of the'duod L^ TT^f '"f '" ''' "P^^ length and 1- :, cm. in breadth T. • ^ ""^"'' ^"^ ^'»- '» clots, on the removal of .hid .n kI' ^'"""^ ^^''^''^ ^"'^ occupying the under surfac o th U ' ""f'^ '^ ^'««'°«^d, gall-bladder. The ed^os of the o fi ' '" '"'"'"" ^^ ^^^ and the two fingers ca^n it L H:;! ^"^""" ^"^ -""^^ second joint. A good deal of tit ''"'^ '' ^'^ "' ^^« denum, where it is^ttaeh:!!:; t^^^^^^^^^^^^^ ^^ ^he duo- brane is not, however, puckered ... , " '^^"^''"^ "^em- normal. The followi Ji .e ' r "' ''" ''"^ ^^' ''^ ^^^^^^ is hepatico-duodenal lig."met Porta ' '' "" ''""^^ '" *»'« f e. Common bile dul Lfol """e ""k"'"'' ""'•-^' '" the upper margin of the ulce vhere i" '""' '^"'^ ^« least the probe-pointed scissors cu down /T""' '° '^P^" ' ^^ orifice at this situation, and it cou , l" ^^ f^^ ^'^P^-' ^l- has probably been cut across by the ulc r VV n '"^^^- ^' B'anches in the liver norm.l ^"' ^^'"^"^ are thickened, s-all orifice, into whici l^e ,ro ''''' ^'^' >'"^ ^' ^y a ;^- -ts with an o^itrir : z ri^y^ ^"•' '"^ hepafc artery, when slit up, is n.turnll ' '"'- '^'''« the hranches,aprobeinserted into M '1'"°' '" ^""^^''^S branch, which passes back, ardl " """ ''"^"" '' ^'^ ^'ght -d of the g-all'bladclrra r ';:; :r;r''^^-f - the upp^r to be ulcerated through in a sp %'! T ''T" '« -- communicates freely with the L Th ^.'"u,' '^^ '"««'^' exposed, and is found in a c ndi'L r t ^^''-^'^dder was then the upper part is there any a "of l"'""^'^"' ^"'^ ^^-^ds rest of its extent the wall i 'n , '"^'"'^'''^"^ ' '" the Ploughing. There is a deen f ' "''^' '"^' >" P'^'^es, the liver' the tissue f whcTat';^:"''':"" ^""^'^ ''' ^^'- «^' -^'- It is here .hereto ujjr;^,^'"^' ^"' ^'^"^''^• place. The ««.endin.. colrn ! '' ^''^''^ ^'«« taken -endm^ colon, close to the flexure, is adherent to ii I' 1 k' > I' S A fl •^ '^^kiil IMAGE EVALUATION TEST TARGET (MT-3) 2^ /. / ^ «:/. "^z. 1.0 I.I 1.25 ■- lilM |50 "'"Si^ 1.4 M i.8 V # dW 0% 'ry v> .,^ _X_ Sciences Corporation «v « '^ \\ 23 WEST MAIN STREET WEBSTER, NY. 14580 (716) 872-4503 ''i'^^x «^% "^^ ? , . 1^« -nitral carina ali.t th „te J'd .^.'? ™ """-^ '"-i »»ft- 'b.ckened about the corporritam Th'''' ""''" °"'P» "''» ™noed alherooatou, !h,u,TtL- ?', '""' P™""'"' ^d' b™»chea. TbeabdomiM aoftewr "V" """■ ""'' "» "eg-lar projection,. The T„l™ 7"/''™''' ^^ "™«™» Tbe stomaoh .a,di,.ended .ir "^ "'"' "" 'P«^'" <">«"««s- •f "ark fluid. tZtTj'lT' °r'°'^ "•»'" « '■"' "•.ngea. Dnode„„„, half r ' ifV ™ i!""'''"''' ' ■"> °*er base formed partir bv hp»H !f '"'M""*'- P'ece (.3 cm.), the ; »-«»Ul tie J. l^^'^^l P-J' '"^ parti, h, thickened P«.ore.tico.d„odenalarter7wlT ° '° ""' "' "■« '"P"™' T^-^aa thicteni„;tr.t ~dtfte "~"'''^ •"bjacent tiaaaes were matted t^getheV '"°"'"' '""* "» sr^oH'tra:^ -4 "teXilTeCa: after taking fooa. la intj^VL " '"l'" ''^ ^°"" penoda of freedom from the attacks Th.^° °"'^. ** P™'''"^"' I'om gastric alcer is rarelv possible .,1 ^"^""^ °^ ''""'''^»»' features. The gastralgic aJtaT ^c'„ in ^inT "Vl"™"" jears appear to he more common in dTodena , "' "'"^ Ibe symptom, I believe, which led . ") ^ ''''°' ''"'' "« oboioian to make the diagnosis in ht iT^"."'' ^"■"■-" lanched ; much J7" f .Si i i' i i 1 ^^m .■ f ' ■ill i I 1 •■» .fl d LAVERAhf.. ^XJf^'/ ' m . I 'J^ ^e7iti''hotirs o/fter death. — -Skin hlanched : mucti y/C^ Lxtvi w. \ t lohert : mucti ss MALARIA.' ifesting the blood has low that certain of these y distributod and more the'spirozoa, and to tho nematode ann tro,«.*i '"''*''''* belonging to beenLpwn'to occur in ^hr^ood of vSfan'im'ir''^'%^°-"« vostigations prove that the llaffolkto nmf.-? aniraala. Recent m- blood.parasitL, .nd it is posX Ua'ttrmay be°th? "Zr^^'^ organisms of certain diseases. I propose in thi .!. pathogenio give an account of the htemato/oa whPr}, Ka^ k ''?""nunication to suffering with the various forms of malaria ' ^''" ^""'^'^ '" P"'"'"^ desf;irdi^°f-.^X'1^^^^^^^^^ i am about.to '^rialfevers, published in 1884^' He found. "^^^ '"?''. °? *h« »»»- ; , the blood oT persons attacked w,■^^,^n„V •' »? °baractenstic elements ^odies, (2) pig^erterboSln'tTntrioV^o ''tr r^^^ which underwent chances in form dn.irJKo i ,"?, corpuscles, pigmented flagellate organism Tlwse formic "i ""P^^id ; and (3) i jprpu.cf» to which th.7 Sv. S "me Pkl^r" °' "," ?'' red corpuscles in cases of "comatn»o T,nr„;l- r '^*«"or of the appear to be included L a hya h?e mlCaSfr'.'' >\^'^''='» and Celli, and Councilman rwhnV,?^ I' ^°<=°™>''g to Marchiafava *^ortjcAn(^jdcriV/edici», Nos. 14 and 24 Iflfi"! . i '* .hlM i f M- mm. ■di^^iM^ii^MSAJ^ ^ Autopsy, twenty -hours qfterjieath. — Skin blanched ; much 1 Lt%\/i AN ADDRESS THE II.EMATOZOA OF MALARIA.' huTiiatozoa, as thev aro calln.l Tm ^'''"'".V,'"'"' ''"*' certain of these important than wo^ had h Lir? Z^^T' v'''''':'''t ^'^ ^^- hesn,rozoa,anato the nen.atode anrtromatlrw "' ^'''^°"«'°? '" boon known to occur in tho blood rff vor? ■ '^?"'^' ^"V" 'ong vostigations prove that the ilaSfnLT"' '""","''^- R"™"* in- blood parasitU, and if, . nos Z t ° f^ H '°' "'" ^''° °'" "ncominon organisms of certain ai.eS I topo'i":hi '° '^' I'.''''"'««"'° givo an account of the hieniato/oa wh -h >, u ^ communication to sulForing with the various forms of ma aHa" ^'''' '^"""'^ ''» P'"'«°°« Historical.— Onr knowled™ of ti,o 1 1 i ^. doscribe. dates fronrthe resear ho^of fe'v'^ir^-^ {^"^ "'^""^ *" wore communicated to the Paris AcadomvnfM*r'" ^^^""^' ^^'''^ 1882 and which were finalirombodiod ?i^ °u^^"'^'"°? "' ^^^l and ariaf fevers, published in 188^ Ho found ,1 f T""-"? ^^^ '^^• m the blood of persons attacked with maS 7,f """^t^'ptic.olements bodies; (2) pigmented bodies in the iSoV^ nf .,'''" V' I''8'"''°t«'l which underwent changes in form drrr?h„ i *^^ /"'* corpuscles, pigmented flagellate or/anism/TTeseforms^^^^^^ ^T^""'^ ' "^^ (3) a m tho development of an infusoriaf n/J^n,- ^?-\^'^,"P°'^ »« Phases the germ of tEe disease S:?d3'^eonTmoTthesf^ "f-"^"*^ »^ more general interest in the niin-Hnn ^„ , ?^ observations. A of Mirchiafava and Sel V^ who VundT\tt l*'^''. publications patients at Rome the bod es descr b«H hi t ^^°°'L?^ malarial carefully the alterations of the oTan'sm fn fc"?- -^^7 «K«red corpuscfos to which they gave the nam « pi "*'?•'" °^ "'« '«<* Councilman, of Baltimore harmnrnL.^ Plasmodium malarife. vations.' The pigmo^rgmnulorso numoro^ ^ • °1™?'* *^««« "^ser- red corpuscles in cases of '"pnn,,f. °"^"* *^® '^t^rior of the appear ?o be incl^deT n a hya Ce iPrr'^'/^'^^-'^r'^ ^^''^ and Celli, and Jouncilman /wlfn^,?? ' *<'°0!'«J'Dg to Marchiafava J /ortscAriWBrfcr JlMictn, Nos. U and 24 Ififi? IN clumps or in rouleaux It^irwel Ito sn rn!^?,5 °°* nggregatod iii if the examination is Drolonir ^ ''^"°"i>d the cover with paraffin added. Cover ilLp?paratbi n^avT°'°*/^ ^^^ ^^"'^ ^^^^''^ be Description of thk Bodies scattered loosely, but are encCrHr, !^L , ''''*'°°, **"** ^^^^^ *^« not in the int.ij'^"^::^^i^i:^^;!y^^^i^^ no^ll^ryTat IXd ^"ett'tlt"' "^ r^,°^*- P^^" "-« number of corpu.cfe's sraffe ted vanSxtLri°"^'1-fr'^''"«- ^he In some instances they are readUv fom?,1 ft ^^^^ ''' difFerent cases. or two, but, in other cases rrroW.^ ^"'' •* ^^^''cl^ofa moment sary. Only one is usi-aCpVeLrt feh '^^'"'°?tion may be neces- or even four, may occup/the stroma ''°i'=°7"««l«. but two or three, smaller ones not occupling a £70? th« ^ ^^ry greatly in size, the ones may almost fill A! A delicate contnn, r^''"'^'' ''^"« ^^e larger separating the body from the stroma »lf ^'^l-'^^'^ »«"a"y be seen part cularly if the illumination tvery brifiliT'' T^ '' JV ^°'^'^""^'' hyaline, or very finely cranular nT^T+i!i ^- ^^e substance appears irregularly in il Th Jy^ay be Very nSZ^'"'* f "'-"^ are scarred to the body, or they may be scInTr Th„ "'^ ^""^ ^T' ^ "^^^^ aspect Brownian movements. Occasionallv a ... ^ /'■''l"'*'?^^^ P^^^^nt rlpid terior of the body. In severaHnSL«JtS''°^ J^^^ ^« «««° '" the in- closed ina cIearspace-vacuo]e-S tCtri^ *" ^e en- are more or less spherical, but as alreadvTf** , YJ'''' ^^^ ««e° ^^'Y -^stinct. The pignientVa^fr^jt^S^atS p^^^J;: the blood 'Irop ia examination is made rter the friction and apparently trivial, all particles of dirt, ntod bodies. The ' thin and uniform, not aggregated in ;over with paraffin ly kind should be I stained in methyl acid preparations ay bo seen with a 3 satisfactory study •mly worked with im. of Reiohert. orpusde.—{a) The il patients is pre- corpuscle. The attracted by the :arefal study of a that these are not ^r or hyaline body ed discs in which ihes were made «t often paler than Bss shells. The different cases. fch of a moment a may be neces- )ut two or three, satly in size, the while the larger usually be seen very indistinct, ibstance appears Qs are scattered ve a dark aspect ly present rapid 3 seen in the in- peared to be on- 1 first seen they outline may be • theij position in relation to each othnr if ♦! „ served, slow changes can be seen S" °^"'° ^ody is carefully ob- tjons in shape, fhese movements ?vh,Vlf''!?"*"^^•"?S ''^°"t "^'tera- charaotcr, can often bo traced wifl^ . ^''I'®'*'" ^° ^^ amceboid in sented at Fig. i. and, be 'stiH at'/L^'r^, '^^^^ "•'« ^'«» 4re" the body ,n the corpuscle rcsu t frm^' ^l '^^^"«<=« '^ Position of slower than the amoeboid movement of L .„7- , ^^'"^ ^^« ^'^^'^^^i not seen any evidence of migrarn* toX^:^^,^^^^^-,!^ 'p^ U- ^"-,iz?i:f. ;;.:, Js—'M >~iy TsiiiS!FSS'*^v\>;:i ?Ts:niSS£i Sli slow altoration.s in outline, .and ii." 'i'^T^^'^servation. daucinK nuitiun. «i, 12 ] Us shape, w", 12.30. a , 12.40. ' - 1 o'cfock; a^ 1.02.' '''" ^' "'tered parations these bodies stain deenlv wifi, „ .• and present a granular stroma, in^'^S\Cnr ^1°'^* °^ '""''hsin. bedded. (Fig. 3.) ' ^'"'^'^ ^^^^ P'gment grains are im! absenceofpigmentand n he ;u^,"^'''?^'*''J"^t described, in the Fig. . illuitr^atcs the ^V^s^c^^ ZSZ:Z^!^:j^t'^l^ %. .-.Ueteues - '^^---^-^ .™ oT ..1^ ,L ) I r r ) i 1 C ! I, at ilA bodies are devoid of structure, and the corpuscles in which they are Lvf °. Tru- '° f^\^^ ^^°.^° ""'^^ t*^" pigmented forms. Marchia- tltJ^f ^^'\^^? have given an excellent plate of these bodies/ regard them as the initial forms of the pigmented bodies. One does occasionally see appearances indicative of commencing pigmentation, fn fbr«L.'''' Tb "' " '•"1"',*^^^?,^''^ ""'i"""^ °f tl^« pigmented bodies In three cases I have seen the following remarkable changes. The hyahne body while actively changing shape, suddenly burst from the stroma, and disappeared, or formed only a few granules. Thus, in a red corpuscle, there were, at 3.40 p.m., two hyaline, irregular-shaped i^ 'w .1^ TT <=^J.^°?'"g '•'^PWiy in outline: Th^ altemtions ^^4o so marked that t^ie physicians present at the time had no dillicultv in seeing them. The stroma of the corpuscle was of full colour. ^ At d.50 r.M., as I was carefully watching these forms, the corpuscle suddenly ruptured, and gave exit to two distinct masses, whicrou S broke up into ten or twelve spherical bodies. No change took place in The'sfrn^'. r/r ^°'"''' T'l;' ^^'* ^^"^ ^'"''^' P^^^ ^^^ indistinct. Ihe stroma of the corpuscle became quite colourless. On two other occasions a similar phenomenon was witnessed, but in one no trace .ttl^' ''i°T ^l -^f !f '^^''^ '""^f^^^- This is evidently a physical change, and I think these very pale hyaline bodies must be carefully STeKrlX^'o;n^e^"' '-''''' ^'^-^'^Po-iblyaasociatel J^Llj'o ' m7 f'^' ^x^T ^T ^*'"°^^« '" 'he red corpuscles con- tainmg soxid-looking bodies of various sizes and shapes. Certain of these structures resembled micrococci very closely (Fig. C), and stained Fig. 5.-Cever.glas8 preparatioTi, showinp; cnrpusole with solid, deeply stained boilies 111 small vacuole.s. =«•■■«.« Uralj '"^ ^'''- '°^ *^r' ' ^'"* "^^''''' °^'<'n Jn tli« same corpuscle, wore larger, more irregular, and altogether different in appearance (Fig 6 5 ^'^"inmitlil'o^' Yf\ '■""'^ *"""?' '" t^' ">'<"■'"'• "f vacuoles (?) which alter ^.!l^^*"/^!' """^^ ""^'^ "'"""y ^^S^^y refractile, and, when two were hf L ."■'r^'^VP,^''^^'*"'^', «"gg««ted a diplococcu . In three insU l™ h*^]'' ^*^ \^''P ^'^'"' *^°'' "« '»• composed of pigment Tie larger bodies were homogeneous, very variable in si/e and shTne No ZIZ?' ^^^'^^''^^d in them, but the outlines of the lucSn whS vSy SnZt and forT*" T'^^'hu ^° ""^ ^'- '^^^^ Oodles -,; the^corpuscles """^ ^"^ ^^^^ formed the only noticeable alteration in we?; f^tdYn SlT^'*^ Pigmented crescents. These bodies, which rnceandstrm.h,r? TV, 'T'' P'-«'*«nt remarkable features in Appear- cent S 7? wi?i" ', ^?'"' wasu.sually that of a beautifu cres- cent (lug. 7), with rounded or gently tap ering ends ; but the degree 7 ForUchntte dtr Madicin. 18S5. No. 24. n which they are forms. Marchia- 3 of these bodies/ Dodies. One does ^^8 pigmentation, pigmented bodies, jle changes. The Illy burst from the ules. Thus, in a ), irregular-shaped le alterations were ad no dilHculty in f full colour. At as, the corpuscle ses, which quickly vnge took place in le and indistinct. On two other in oue no trace dently a physical must be carefully lossibly associated 1 corpuscles con- apes. Certain of ig. 6), and stained lid, deeply stained corpuscle, were loaranco (Fig. 6.) = ^\ les(?) which altor containing small , when two were three instance.s ■ pigment. The and shape. No B spAces in which lese bodies were ble alteration in se bodies, which tures in appear- ■ beautiful cres- but the degree more. Thoy ,„ „„i ,tt„i,„j .„3 ,K' °' ' ,'•'' '"PmsU, ,ometim,a a, ^ a ^ ,c^ ""'■'■as sfeed"I?'^'.'/o; l■a4^af,'d^^,J'i^ f^'^^'T^, "> *»"= form of the pigment sometimes present in the'concave side '^"""^ ^''^ """"^ meSbrane (F^gTr^hTbry irthr^rea^t ateT °^*^« « -^S- ess, homogeneous material, L the cen^r^ofwlT.,''- "^ "^^ ^*'"<=ture. ection pigment granules. This with tb^n ' v" P'jn'ii'ent col- these bodies very easily recognisable' in the blnn^""^'" ^1™' '""kes surrounded by the corDusele^ Thi i- ..^' ^"'^^ when closelv distinctly graLlar.l^d varies ieXTn t^^ ^"''^ '"^ ''"^l rule, It 18 central and aggregatX J/w" '^V^angement. As a form of a band placed trKrsefc ?o Z " * ^f P^ ""^^"'"e* the some instances it is more scatte'erbSt iLT^ °^ ^^^ <='««<«°t- In end of the body. Although the VosJ care?,7«r' ?''°. '* »* ^'t^^^ detect any movement in the hyalinTsubstan/^nf .if'"'°''"°° ^^'^^ to existence of such may be infe^rfiT fr„T A " "^^^^^ crescent, yet the which the pigment yanutunde? ^^^i^T P°«>«-« ^ov^emen? these alterations ; changes in form Ife'pri^;- ^' ,?' *' "' represents Fig 8.- . and 6 show (s^scents in the fntertor nf tca » , changes Tn a cresMnt ^ '=°'T««<=''"' J 1, 2, .nd 3, Sketch 1 was made at 9.40 2 af in m j „ outline of these bodies is very clear ^nd d«f I ''V*'-3° ^■^- The and rounded forms of identical stracture ar« ^l"^' ^1°'^' ^^^^E<^t,l crescents predominate. The numW ll«,^'n ^'^'^^t ^itli. but the ashde, to six or eight in the field of the rai"'- ^'°^2"« °^ t^" ^^ always free, they occur sometimes in tb"«-V"- though almost •'•?^?'**J°g'/'''jbtle8s. the mode oTdevlSen^^ « «on>uscle. (p)The Rosette Form In six \n^i^^nl^^^ ^^^^' ^> « a°d b). a little larger than red corpuscles wShn^-.™ ^''^ ™"°'^«d bodies, and in the centre a rosettr^f p'il^^ J^.^'^ g^^S"!" Protoplasm reared to be eaclosedjn . deliff rmSe? Vi^efe fr i Fig. 9.-.Ro«ette.rom = 1 free ; 2 within t^.e .heU oU red corpu^^ie. i-> ^ ' w ^i •I ; ' ^ ! vl? > ■ (^ ; I 'r li ! hi ,1 J -l^jly ; s t mm SmI II J ^' ^ 1 ' »• w. ' i: ^ P^^ ' segmentation. Ihua Fig. 10, a, represents one of these as seen at 1^0 g>t & '©& © a Fig. 10 — Segmentation of a rosette-form • n of « „ , . t.o„^procaeaing; c 6.30. ^'^J^^io^ ^Ji^il^ t^^^'^^^^ '4'^'en&t'Ltt4l'Z^^^^ '^-"-t -dications of resulted in the formation of A «wt P'^Sl^P'*^^^- ^t 6. 30 (c) this had about the centrlrpSent and ^^''' - ' °^ •°'"''- '^'''^''^^ '^''^^'«^ed (^) the shell had bSand^f^e^^^^^^^^^^ ^^ 7.40 presented a tiny speck'at or aC the centre At iT.^^^'l ''^'"^ undergone any material change n Case gO tne of ? n^7 ^'^ ''°* this phenomenon was repeatedly observed The d«v/i ^^'^^I" ^.8^' rosette form can I thinlr v,o ftn„„Tf ^;- -f^ie development of the bodies, whichTrIc eas tn si J mtflSe'^entlre?'"'''"^'*-^ ^'^'^''^'^^ some instances the body was rarroundP,rLfr'P''''^° '"^^^''^- 1° corpuscle, in others ther^e was no trace of l^ *^^\^«°»."^'>t «/ the red gradually collect in the centre of thf L^L • ^^^ P>gment granules rosette. I thought these cSn<.P. £?^ J?^ '" a m„ro or less distinct on this subject, but I findThat GoS l?n» •^^«^'°°'^«'l by the writers tion of them, and ha boautiS^fi J.»i l'^'^" ^f^ ^""^^ '^'^^crip. LivtSs%a£r7n"S";SBd" *"^-" ^T?.^^"' '^^^ ^ «-* -"^ scription oi^che ciliated bfdiVs If ^^ ''^f ^^ulity more than his de- trary to all past experience that f ITf '° '"^Probable, and so eon- the blood. The S of th« ni/ ^ ''*\?'^r''^ in on the folly of a rcentidsm 1if„H '''' '"°°'^'>'f *''"g^* «»« * l^s^on preconceived notions drawn f^^ on theoretical conceptions, and of bodies were seen n seven r.iT '^ ^J'^^'^'l .^^Perience. Flagellate one or two in a shde Thnf ' '^'' JP ^'l*' numbers, usually only often not more thtn half the^s?^'! '7^11 '^*° •'^^'^ Wood-corpuscles^ in one diameter to a red rnrn , , } ?P«''™en in one case was equal ovoid, orpearshaned the nrS' ^^'r^ T^' ^*- , They are round, instance contaS pi^t^ ?S^ hnely granular, and in ever^ rapid Brownian 1?SSVf" ^^^^^Tir^'n^'^'n^ often displayed uvemenis tir loss distinct by the writers :y full desorip. ipment of the . He has fol- detail than I len I first read 3 than his de- le, and so eon- aould occur in ht mo a lesson ptions, and of J. Flagellate , usually only od-corpuscles, ;ase was equal ley are round, and in every ten displayed '6 variable in t specimens, r three times tly tapering, (xistence of a No, 4, 1886. small terminal knob, figured by Laveran. The movement iS exceed- rtttdrivrfwiv . "^'°« o/ the W filaments may be sulStf; strong to drive away the corpuscles m the vicinity. The undulatorv movement caused by the play of the filament over the surface of a fees"'the cnr'Thl^lr'^'l '^' '^''r'^'^^. "^ the observer before he sees the cilia. The motion does not persist long; in none of the specimens which examined, for more than half an hour In one instance, the llagella disappeared in the short interval between two observations, but I could not determine what became of them, I have not seen the free-swimming cilia described by Laveran, but Dr. Conn- beeT abr« ^o^^r ^^'' ^'-^^ '°°'''f™'"^ ^^'' observation, I have not been able to d scover either nucleus or vacuoles in the flacellate organism Slight, irregular changes in outline occur, due to slow movements in the protoplasm. (ri) Small round, pigmented bodies, from one-fourth to one-half the size of a red corpuscle, were not uncommon in some cases (Fig! 12) %D S Fig. 12.-.SmaU free pigmented bodies, some of which show amoiboid movements. Usually, they remained unchanged, but, in several instances thnv SeT.^Jl^T^?^'^ movements %he smaller onesTbout equ 'in siz^ the products of subdivision of the rosette form laHof 7£nrv,r'n^ *°/"f"^,« tl^e '^'^tu'-e of those bodies and their re- lation, I will brielly refer to the conditi«n of the blood-corpuscles, alrldv dicrZr Th'^""'''^ "? f''" notable alteration save that airea ly aescribed. The pigmented organism evidentlv destroys the Zf'Xf.T'-'T'^'^r?.^^'^'''''^ t^« aflected eel become pale, often spherical and, finally, are reduced to the condition of mere shells; except m cases of pronounced anremia, the variations of the corpuscles in sue and outline were not great. The colourless cor puscles were in some cases increased in number, and in very many instances contained dark granules. In several specimens, they^ere observed to contain the pigmented organisms. In Case 40 a creslent had been included (Fig, 13). and, in Case 51, the process Vinu on Fig. 13.— A colourless corpuscle containing a crescent. ?Fi^^°if''^%re"'^'^, ^°'^'^' ^"^ ^^^''^^'l "ii^Dg h^lf an hour [iig. 14). The blood-plaques were, as a rule, scanty, even when the anremia was pronounced. No pigment was seen in them. Types of Malaria Studied.-Oi the seventy ca^os examined, a ma- i^H -r "I-'® '"^'.^l^f « of ordinary intermittent fever, chiefly quotidian and tertian, with two quartan cases. There was one case of remittent tever, one of comatose pernicious malarial fever, «nd the remainder were cases of malarial cachexia or chronic paludism, with occasional outbreaks of fever, with or without chills. In all of the cases, with found iShTbkor^"' °°^ "' °*^°'' °^ *^^ ^°''°'' ^^°^^ described was matim of the Forms to the t^arieties of Malar ia.~Tho pigmented Zf^'^ K*"^' M r\ ""'* ^''^ i"^ ^"^^ '''^'ite and chronic caTs. but tney may be said to be specially characteristic of the more acute mani- f . ( i ^1 !i t i I,: 1 liiiilli s forms were almost invariably prei'rtir™.^''''^^"*''''-''^""'^^ detail to the cases in whiTtLrZ^not fZ^.^ V''\''''V-''''^y '" pigmented forms, and the vlr^^Uo^Lf- .»onnd. The hyaline non- m the acute cas'esTindeerthte ttZ^ '°^"^ ^°^'''' *'«'""=^"r tions noted in several instances Thn, ?n p' ""'o^ ^^^ only altera- was admitted to the PhilSt'jo w ' K^^^T ^^' * «»»" afted 48 chill. HehadLiap^Svt?endfv?E'f'^ September 27th: in a malaria several jeavF^rSBlv rll ^!°^' *"^ ^-"^ '"'^'^^^^ with hot stage showed no pigmented bodies b«t.°^rn*"'°"'''^ •^"^i"^ t^« toining the vacuoles shf wn in FiS 5 and 6 tT^^^, corpuscles con- 28th, 29th, 80th, and October l«f.' .^5 v^^*'¥'*°''^""ed on the fully examined, wfthout finding othe?boT«^ .^"^ ^1' ^^°.°'^ ^"^ <="«- oles or hyaline spaces On O^tnCi J.v **• *^*° *^o«« i° the vacn- of aninine twiceWaV 4?ch w ' ooA?'' ^''}T^}>^g<^'' ""'^^ *«» grains chill after October 7st On thl 5?h lif°"* '^"'" ^^" ''"y- ^e had no numbers, which peSednntU the 27th "^^ ^t^•''^l" *?'^ •mmation. ® ^''''« "»e date of the last ex. some time. OreigS ^sesTn wlvfflh ''''" ""''" *^««*™«°t '"' there was a history of LfectknkstinJ^frn^'^- ''''■' r^'"*' ^° *^«1'« In many, the cachexia warSkeda^/Z ''',''''^' *° f'^ '^*"»ths. In six instances the aWack^ S reclt-unlT«^'''ll'°^^^^^^^ every one of these cases axiiniZ ^.aI .1^ * "lonth ; but in crescents occurred alonTfnthrblo„d?K«.T>. *'''''°- ^' » ™'«' th« in which the pigmented aracBSL^- ^t'" "^'^ •=»««« "^served flagellate organl^s were aTsfprltnt i^M\Tf /T' ''"^ *^« K^r* ^^^^^ °^ -^-"tU^feverihtcirdtVb'eVnTnr cZ^: aTXt"in"^to*cLtTof •iLh'^tr"*^"^ - -•- bodies. Case 31: tertian a'^e exam n\ ■% °™'?''°''^ intra- cellular cine. Case 33 : quSan for' s'en days'" Cas Vr""''^ %"? '"I'" SIX weeks, amx-mic, and had a large sE • + t • ^'^^^idian for Case 39 : quotidian for seven days^ Casl 68 • aSi^f '"'"^ """""/^y- for SIX weeks, then stopped • now dafll -fifji'i ^"°tidian, on and off, quartan for three weeks iLIcZ..^JI^^'^K^°^ * "^^^^^ Case 60 : not been much stS' and as Got '1*^'^? ^f^^I' ^ ^^^^ f«™ has important connection 'with the ^fveCl^.'^'rl*" ^'''^' *» '' »" was only observed in acute cases whiphv,^«^f l^ *''' P^'oxysm. It The flagellate organisms w«r«^. t^- °°* ^^'° "'^'^^^ treatment, were chronic forms^^andTne In acute .?»« '? .t^'" '"'?' «'^ "^ '^hich The small free pigmented boTi^ ^ *^''' "^"'^"^ they seemed more affiant in the chrjf. V'^ ^"'^^^^^ >° "^"^bers ; Belati^ of those FoZTlthTpar^y^^^^^^ ""'^t''^^- were made with a view of determiW w^'fT I? """^ observations any definite relation t^ ?L remSkabl! Si ' \.'l organisms bore terise acute malaria. For thknntnnl! P^"°'^'? ^ttacks which charac- were made in the hitemls of in^Phff' '" ^^^J"^^ '=*«««' e^^aminations paroxysm. The resS may' T hus Jteted S ""''' '"'^'' "'' '""^ particularly if recent, in which tL»r^K^^ *^^''® ^^""^ mstances, more numerous and a°ger before 1H^°''^ organisms were decidedly the intervals; there Tre otC in wM^i? /f' paroxysms than in chill and hot stage was so sman f),J "^ *H' °""'^'' ^""^S ^he find ; in others a^inT slides tXn bSl ^'""Pir' ^'^ ^^^^ ^"'^ *« stage were negative and vet in -1 «« attack and during each were present in the blood I tHnk'"^'T'°t V'^^'^y'^' the bodies bodies in the red corpuscles are S« n, *''' ^hoK**"** t^« pigmented attack, but the diffeSTby^T Tear TriSr an"? /= re^ uotidian or tertian eboid intra-celliilar fer subsequently in The hyaline non- bodies, also occur ■e the only altera- !8, a man aged 48 ember 27th, in a i had suflfered with mined during the us corpuscles con- ills occurred on the le blood was care- hose in the vacu- an with ten grains days. He had no icenta intolerable ie of the last ex. ore chronic forms der treatment for >resent, in twelve M to six months, greatly enlarged, month ; but in As a rule, the e cases observed tte form, and the 3nd the crescents not been under occurred in six id intra- cellular ttack ; no medi- • quotidian for uinine one day. m, on and off, eek. Case 60: is this form has I ascribe to it an paroxysm. It nder treatment. Bs, six of which ks' duration, le in numbers ; cachexia, ny observations organisms bore I which charac- i, examinations t stage of, the vere instances, were decidedly cysms than in ler during the ' very hard to id during each ns the bodies the pigmented nd during an id I have re- peatedly had to search long in slides prepared during a naroxvsm fnr a single example In acute cases whrchLvo laSome weeK and have had no medicine, the amcrboid bodies have seemed to be n'S as abundant at one time as another. Nor havo I hp«n .hi» * ^ special diffeionce in the form of tho boEs jult before or during 'th^ Sl n 'u;"!,tmet.rt InY 1 "" ^"^""^ ^''^y nia/be^mall""!^ it' rXred fn^lho »i ' "■^'"J^'^ may present, as in Case 29, already T).« r ^' '^\ fPP«"'»'"=6 of vacuoles containing small solid bodies «f,Tl ■•emarkablo segmentation of the rosette form was in each fi i five ?al"a set?^/'^lP"°'y^'"' ^""^ «°^«' claims to havTtracei ague-an attempt was made to follow Tese changes wfthlhetlloT ZXt for S«r"'l*' ^ l'^ °V'.' ''''^ "^'^ maS,Tn and off: for a' year, butfor three weeks before admission the chills had been recirrin^ cT n Srr ^H °" ^"^''^^y- *^« ^'^' tl^« blood was IxaSd in hf J li- ^^^ '^^ corpuscles contained many large pigmented hnHi«a o'LVh'Vtrand sT rr "T'T'- --y - P-oStbdi^sfon! a'm^S^i^rtt^S^^^^^ rc/Ty To^J^TlT:!!-; Fomented intra-cellular bodies. They did not™eem more numerous On the o'thlL"^^'^-"'' TZ' T^'l °^ '^' «■"''» bodies in he field On the 10th the note is : "No free bodies, all intra-cellular tolerahlv numerous; no rosettes ; no segmentation." On tL 1 th iaUx aminations were made, and the note reads, "absolutely noAe lave nig mented forms m the red." On the 12th the slide at 8 fw showe^d irrfngern7h«°/P»°i?'l>'"^'^^' ^"'"^ ^^'^^ the granules irregularlj arranged, other with distinct rosette. Fever began at ll a m fo^°,"l''°"^*^^P'ryr' hourly examinations werf made rosetl; the ordlZw °'^'°*' """^ «^g«»e"tation active. On the 13th and 14th? the ordinary forms were present, and in the paroxysm of the 15th thp Knnll ^^^''l ^'" ^^"'"^ «««°- The de^velopCt o pneumoSl interrupted the observations. It is worth noting that in this carthe onset of the par^'xysms was marked by an outbreak of the most in Certainly the segmentation seems associated in some way with thn The crescents appear, as already stated, to be confined to the ir,nr« chrome cases, or to those which have had treatment They mavTer sist for weeks or months. Thus in Case 56 -a patient had SregSla^ montn---for three weeks there was fever without chUls the temn«r blood contain* the parasiteH ; but in reKions where malaria in p.e/ai .ut mph experiments are not wholly free f.om objections. / neru s of n./aiivo observations on undoubted cases of malaria would L ■ ■onvi.uinjr 1 lav no special stress on tho three cases in which I did not find t)'fl parasites as the patients wsro not followed from day to day >vith 'lo aocuracv necessary to give any value to the observatiois, 'it must bo borne in mind that ha-matozoa are not uncommon ;„ laimals, and, as in the rat, do not appear to interfere seriously u u- .ao health of their hosts Under these circumstances tho association of a specific form with a Uehnite disease in an animal makes it all tho more probable that the species 18 pathoKenic. A furthei- study of the mrra disease is par- ticularly to be desired with the new light which Evans and Crook- shank have thrown upon it. The conditions under which tho disoajo occurs, combined with its paroxysmal character, are so similar to those of malaria, that a ful explanation of its pathogeny would have a very direct bearing upon tho p:esent question. To my mind, two facts in connection with these hrematozoa point signihcantly to their etiological association with malaria, ij'irst tlio positive anatomical changes which can be directly traced to their action, changes upon which one at least of the most marked symptoms of the disease depends ; I refer to tho destruction of tho rod blood- corpuscles, which can bo followed in all its stages, and is as well- defined an alteration of tissue brought about by a parasite, as any of which we know. The second fact is the action of quinine upon the parasites. 1 ho simultaneous disappearance of tho symptoms of the disease and tho hiuraatozoa suggest that the specific influence of tho medicine IS upon the parasites, though it may be urged that the nui. nine, wlnlo curing the disease, simply removes tho conditions which permit of their growth in the blood. Fraclical Cuimdcmtiuns.— Aa interesting practical point is the diagnostic value of the presence of these bodies. There wore six or eiglit cases in which tho examination of tho blood proved of creat service in determining the existence of malaria. Some of these are worth mentioning. One of the first was a man aged 37, who had been under observation on three or four occasions with anicmia and an enlarged spleen. He had had three atUcks of h »sitp Kvory Hliif{o of tldH procem, cnn lit) rendily tracod, and thoHO (.'licrvafioiiH boar ?'"ir m\"^° •'""*'""' ^'''"''* "" "'" ""«'" °^ *•'« I>i(^iiient in the blond tHulf. Tho i)iKni(«ntary doKencmtion of tho rod rori>unfles nnfired loiiK a^o by brorichs and by KoIhcIi,'" wnn no doubt th» hbiiio an hero doHonbol. Tho gradual accumulation of tho gr^uuleH in tho si.leen, hvor, and bone-marrow leads to tho characteristic nidanoms of thono organs. I sought carefully for evidence of active interference with these parasites on tho part of the white blood-corpuscloH, but on only Fig. 14,— A cnlonrlcM corpuscle Btiidled for an hour aihI « air ,i„,i.,™ .., i. two or three occasions was this seen. Once a crescent as found inside a colourless corpuscle (Fig 13). and again, as sho« at Fig "4! corimscle gradually enclosed two free pigmonte.l bodies The Kreaier portion ot the pigment resulting froa, the destruction ol :he nonaK piokodoutby thecellsofthesnloouand bone-marrow, , hie also no Joubt, as in health, remove tiie elieto rod colls and tl. .r omua'nts inownTH^'^T' '"'^T'' """"K** ^hon Stewardson'^ wrote s welt known article has now become very rare in I'hUadelphi,. In theso cases. Marchia ava and Colli have found tho capillaries 0. tho vaous organs hllod with corpuscles contaiuing pigment-grains ^^ uch appear enclosed in a hyaline matrix. Councilumu Ind Ab1,ot'^ h« ' descE the same change and I am indebted to Dr. Councilman L the speS men from which the accompanying sketch was taken (1 - 15) If represents a small brain-capillary filled with corpuscles, . ' many of which are pigmented bodies which stein deeply, and, so fa aTcan be Fig. 15.— Sketch of a cipillftry vessel of grey matter of brain. Case of per- nicious comatose malaria— Dr. Councilman. The red corpuacles art seen In outline, and in five there are pigmented bodies. ascertained, are identical with the pigmented organisms met w th in the red corpuscles during life. Only one instance of fatal m.i laria came under observation, a man aged 70, admitted to Dr. Mu "ier'a wards on October 25th. He had been on the Isthmus of Panam;> and in Georgia, and had chills and fever in both places ; last chili was three days before admission. He had also had haematuria. He was very anfemic, the spleen was slightly enlarged, the temperature, 101. .3°. There wa« great stupor, and he was roused with diflBculty ; the tongue was dry. The temperature became subnormal on October 27th and 28th. 18 Areliiv. d. I'hysiologie, 1875. 1' Amtnican Journal 0/ Mtdical Sciences, 1851. '^0 American Journal 0/ Medical Sciences, 1886. ^: f >» i . ;i H ji ^ ^',; '■■■." n,m,m„ Of ™k, m»j, be treated without I «*»" 'n i6 Examination of the blood showed many pigmented bodies in the red corpuscles, numerous free circular forms, a few crescents, and several flagellate organisms. The stupor deepened to coma, and he died on the night of October 28tb. The spleen and liver showed typical pigmenta- tion, and the bone-marrow was also very dark. The spleen-pulp con- tained free pigment and many large cells, some of which were filled with dark granules, while in others there were bodies identical with the small pigmented forms so abundant in the blood during life. The marrow jiresonted similar changes. The number of red corpuscles con- taining the pigmented bodies was not great, nor wore the capillaries of the liytr or the brain stuffed with them, as in the instances of pernicious malaria just referred to. Probably this was an instance of severe malarial cachexia of many months' duration, and scarcely should be grouped with the pernicious comatose form. To my colleagues, Drs. Curtin, Neff, and Musser, I am indebted tor the privilege of examining the malaria-cases in their wards; and to my resident physicians, Drs. Donohue, Albertson, and Westcott, for sistanco which materially lightened my work. London : Primed by the British Medical Association, i6ia, Strand, Vf.C~ "-.'«v«r\,«j»;-:(-.^:»VTi:T,r,.;;-----;-- 'CXYVII \, Strand, W.C, tofir 1<\=,' I ANTIFEBF A FEW months ago Drs. Cahn and Hepp announced from Kussmaul's clinic the dis- covery of a new antipyretic, which they named antifebrin. A full account of their observations has more recently appeared in the Berliner Klinische Wochenschrift, Nos. r and 2, 1887. The drug is known chemically as phenyl- acetamide or acetanilide (QH.C.H^OHN), and is formed by the action of heat upon aniline acetate. It is a neutral body, and in this respect it differs from all other anti- pyretics, which are either phenols, like sali- cylic acid and resorcin, or bases of the chino- line series, as thallin, antipyrin, and quinine. It is a white crystalline powder, insoluble in cold water, but reaaily dissolvmg in hot water or alcoholic solutions. The taste is not un- pleasant. The dose is from 8 to 12 grains. In larger amounts it is not poi.sonous, though it is advisable not to exceed 30 grains in the day. Usually 8 grains will be found an effective dose. It is conveniently given in spirit and - ■ 1:1. . r... .1.;, J . of-OT 'iHT? I ol'9or 5^A\ 3.TniT?jodui9i oq; '-wv 01 ;b 'pez am UQ -SBpdis^ja q]iA\ pajtoenB «BA\ aq qjoz aqj uq •?! XannuEf icjidsoH Biqd i^P^IRd "! asBasip pioisniu joj psuiqdaj^sHM '1? paSB'^H •J--(-An.iBqD) TIIAX asv3 •sanoq aajq; oj omi uiojj ui ^L o-\ ^t' luojj ajniBaadiuai aq? paonpa.! sA^p aAissao 10a' = 99° I. Rei most md Case IV. (Char ning usii admitted Novemb-- ministral the 4th the temper, in threq date until the 13th- sions a | At 8 p.m. on the temper in si.xt occasio time Wc was 6| the foi Case X XVIII XX., 7f ten houj In sel was una! and XII peritoni sipelas. j Thee - _ ncnallu. J_ j 9J3q:i puB'ponS scm uoiiipi-. I 'ssauiiijqo jqSijs jo paujB' ! aAjaMj puB uaAaja naa.AAiagr j Aq puu 'asu oj ueSaq 51 '' j SBM ajnjBjaduia} aqj -wk", ' SSnjOjd q}lA\ 'o? JO|[BJBSE ' ifg "uaAiS sBM 'iitA uS '" ■05C 1 o.)'- " '-^^^-^^^^^^t^^^^f^ ) } I I c f \\ w '!l ^-xy VII ANTIFEBRIN. A ^^^ """"'h' ^go I^'-s- Cahn and Hepp r\ announced from Kussmaul's clinic the dis covery of a new antipyretic, which they named ant.febnn. A full account of their observations i^W/ij. Wochenschrift, Nos. r and 2, 1887 The drug is known chemically as phenyi- acetamide or acetanilide (C„H C H OHN^ and is formed by the actiL%/hea%on amlme acetate. It is a neutral body, and in this respect it differs from all oth;r anti- pyret.cs wh.ch are either phenols. like sali- ylic acid and resorcin, or bases of the chino- mesenes as thallin, antipyrin, and quinine. It IS a white crystalline powder insoluble in or alclor ^"V^^dily dissolving in hot water alcohohc solutions. The taste is not un- pleasant. ThedoseisfromSto 12 grains In arger amounts it is not poisonous, though it is Usually 8 g,,.„, ^i„ be found an effective aose. It ,s conveniently given in spirit and sweetened water. During the past three months I have used LdaTZ u ''"f ^Philadelphia Hospital and at the Hospital of the University of rheZ. '''= P'«"nsy, x; peritonitis/ x ule s'^'lT' ' = '"^^™'"-' fever, x. ks a re, 8 grams were given when the temuera- «rc .0.C above xo3|^ and hourly observa- tions were made for six or eight hours in -eralc 3of phthisis 4 grafns^'eTgiv ZnnJr '""" ' '^y- ^^he maximum 10 F? r "• "V ^'"^ '' ^"'"« i^-^- be roteH . '^' '^' ^^'''' °f the drug may J^ted under the followin.. h.-,.i. . ^ ^ I. J^^^uc/ion of T,mperature.~Th\5 jg the most marked and characteristic action, begm- , nmg usually within an hour. In eighteen ad- I '"'"f'-anons the fall was over 2° in this time- ! >n three instances a fall of 3°, on two occa' I sions a fall of 4°. In thirteen instates the i temperature was reduced 4° in two hours •n sixteen adm! .istrations 3°, and on fou; occasions S . The frrpatpcf- Hr -^u- , . Hm^ • V. greatest drop within th s time was in Case XXIV., in which the fall tT? r ,1 ■ • '^^^ ^'^^^^^^ reduction was in tne tollowinc • Case T so ;,, c 1 rase Y r■^o■ r ' " ^^^ ^OUrs ; vvtt; ' i ■'" '"'"""^ ^ half hours; Case X\ III 71 ,„ two and a half hours ; Case ^^A-, 7 in seven hours ; Case XIX., 73° ,„ ten hours. '^ In seven administrations the temperature was unaffected by the eight grains. Cases VII and XIII., both of pneumonia ; Case XXIII ' peritonitis; and Cases IX. and XVIII erv' sipelas. ■' ^' The duration of the reduction was variable usually from three to six hours. The follow- ing cases illustrate well the antipyretic action ' ot tnis drug : Case XI. (Chart I.).-Man, aged .2 ad m.tted to the drunkards' ward of the Phil^del-' Ph.a Hospital. A fewdaysafter admi.ssion he was noticed to be a little short of breath, and ' on examination of the lungs, there was dulness' \ \ with rales and feeble blowing breathing at tS \\ ngh base. On January 3. at 5 i'.m., the tern i '' perature was 1051°. Antifebrin, gr. viii was given, and the fever gradually fell, as the chart ' shows, until midnight, reaching 100- By x A.M.ithadrisentoxoxr. At 7 p.m.' on (he 5th the temperature was nearly xo4° and an good etr' ^'^ ^"'^'^" "^^ ^'-" -'h ^1 .'V IN 1 1 r r^ D i\ 1 i\ . ^^-^ January j. Jan. 6. Pneumonia ^ Cask IV (Chart II.).— Rachel C, aged 21, 1 was no collapse. The thermometer did not I ^'^"""^'^ November 3 with typhoid fever. On ; again reg. .er above 103!° '" her case. '"( the 4th the temperature was 104°, but from this | Case X. (Chart III.).— J. B., aged 35, with date until the 13th it did not rise above 103°. | chronic phthisis and high fever. The chart At 8 P.M. on the 13th the temperature was ' shows h(nv r::pidly the antifebrin in three sue- II i^ ^ Cask IV. November 13. November tl N.-v. ij. a 't vo CO o\ e- 0. St N in CO fo ro -> ! .^ > 1 1 i i .„s° ^ 1 1 1 ! i r — / 1.1 jO - / 102" - »t 1 \ / \ A 1 1111° . /"^ r V r \ 100° H / \ /\ / V r,n° ■■ i \ 1 / V ,,8° - 97" - i : ,., 1 1 ^ i -— L ■ ! Typhoid fever. ;04-^". Antifebrir, gr. viii, was given. By I ten o'clock there was a fall of 5°, with profuse sweating. At ii p.m. the temperature was 1 97°- At 12 A.M. it began to rise, ■and by 2 A.M. was 99.4°. Between eleven and twelve I o'clock she compiained of slight chilliness, but the general- condition was good, and there cessive days reduced the temperature from 4° to 7° in from two to three hours. Case XVIII. (Chart IV.).— F. H., aged 31, was trephined for mastoid disease in Philadel phia Hospital January 15. On the 20th he was attacked with erysipelas. On the 23d, at 10 j A.M., the temperature was io6|° ; at 1 1, 1051". Jaiiiuiry j. Pneumonia. t II.).— Rachel C, aged 21, j was no collapse. The thermometer did noi er 3 with typhoid fever. On ; again register above 103^° in her case, iture was 104°, but from this I Cask X. (Chart III.).— J. B., aged 35, with ; it did not rise above 103°. | chronic phthisis and high fever. The chart 13th the temperature was ' shows Iiow mpidly the antifebrin in three suc- Cask IV. November 13. NovemU-r i -,. X'v. 13. * •*. '■ '^ »•'■ '■o !:'• < < < ■- -it, n f >o 00 c> -• - - n in M to rn 'r II ! ! ! 1 j 1 r aJ / , A 1 /^ ' V \ / 1 \ t- /j \ A / y v_ / v : . - ,. 1 jWi J 1 - . . . i Typhoid fever. IOmeter did not her case. B., aged 35, with ver. The chart rin in three suc- ''^^t7^/fy?\t^i. — \OaiTJi\ '^e g^rs \^nh WA(/iy\ He was g.ven ant.pyrin, gr. xv, and quinine, gr. XX. At 3 P.M. the temperature was still above 103", and a second dose of antipyrin S,^'7; ^^5^.M.,quinine,gr.xx.'He had had also qu>n,ne. gr. v, every four hours. At 8 P.M. the temperature had fallen to iool° at II P.M. to 99°, and at 3 a.m. to 98°. 0„' vrintd '"" "" ^^^'" '^°5°. and anti- pyrm and qumme were given, with a reduc- fon of 4; in five hours. On the .5th anti- anTeffec? 'i ,"" ""' ^"'" ^^'^^"' ^^^out cal t^rl' f T '^^"^^^^'•'■^'^J to the medi- cal ward, and the antifebrin was used as hwn by the chart. The last dose caused a all of 7f ° m two and a half hour= The oa -ent subsequently did well. The chart is of merest, as it affords a comparison between the^act.on of antipyrin with quinine, and that ! This pa( fever dj ; dayfronj ' a second ; the first i XI. and In ty : prompt j young n I temperai i the dru, '' and afte ! 3° to 5°, I more sti In th) each ins In ph usually I ^y?^'f -^m "frfl vr/r, without ) i I I c I j tm I i if m {',\' ■> Cask XXIV. j He was given antipyrin, gr. xv, and quinine, gr. XX. At 3 P.M. the temperature was still above 103°, and a second dose of antipyrin was given. At 5 ,...m., quinine, gr. xx. He had had also quinine, gr. v, every four hours At 8 P.M. the temperature had fallen to iool° at II P.M. to 99^, and at 3 a.m. to 98°. On the 24th the fever was again 105°, and anti- pynn and quinine were given, with a reduc- tion of 4° in five hours. On the 2Sth anti- ipyrm and quinine were twice given, without any effect. He was transferred to the medi- cal ward, and the antifebrin was used as shown by the chart. The last dose caused a tall of 7f ,n two and a half hours The pa tient subsequently did well. The chart is of interest, as it affords a comparison between the action of antipyrin with quinine, and that i lof antifebrin. | In several cases the dose of gr. viii did not jseem sufficient. In seven administrations little or no effect followed. This was particularly noticeable in the pneumonia cases. In Case AUi., with almost complete involvement of [the right lung and affection of the left base aL^n'^f '''"'' ^'°"^ '^^ 5th to the loth ranged from 102° to 105°. Antifebrin was o'ven Six tunes, thrice without effect, and on three occasions it only reduced the fever a aegree or a degree and a hair Thallin gr •V, twice brought the temperature down 3° Y»a 4 ; but the most effective agent in this ■^e seemed to be the cold pack, which re- "Ced the temperature from 105° to 98^°. I 1 his patient had delayed resolution, and the fever did not subside until the thirty-ninth , day from the initial chill. In other instances ! a second dose repeated an hour or more after the first produced the full effect, as in Cases I XI. and XVIII. , In typhoid fever the action was usually prompt and satisfactory. In Case II a young man, aged 25, with persistently high temperature and marked nervous symptoms the drug was given on fourteen occasions' and after each dose there was a drop of from 3° to 5°. In the milder cases the effect was more striking, as in Case IV. In the erysipelas cases the action was in each instance most decided. In phthisis, with high fever, the drug was usually given in a single powder of gr. viii when the temperature was above 103°, but in three cases the plan was tried of 'giving gr. IV four or five times a day. This did not seem very successful, and the patients did not feel so comfortable as with tho single dose. In a remarkable case of quartan ague anti- febrin in 8-grain doses given before or during the paroxysm seemed to be without effect ; , One curious circumstanne, \...,.,evpr i- «---.' ' mentioning. The lad had always with the fever the most intense general urticaria, which the antifebrin seemed to prevent, much to the patient's comfort. 2. Action on the Circulatory Sy stem. -AJ^x^^Wy with the reduction of the fever the pulse would ^^"' ^"d a drop of 20 or 30 beats in two or \i ft tfH % %,« January, 1887. tlirec hours was lrt(]Ufntiy noted. Th Case II., with a pulse rate of us, 111 the severe and the 1 1} tempt perature at 105^ the pulse fell to «4 m four hours. In another case the pulse fell from jjo to 90 in four hours. A marked increase in the pulse-tension was observed in several cases. Kven with a rapid fall of from 5 to 7» in two or three hours, there was no evidence of heart-weakness. Slight cyanosis, which IS mentioned by one or two Cerman writers, did not occur in any instance. 3- '^«''^fl/%— Aswiththallinandantipyrin the action of antifcbrin is almost invariably accompanied with profuse perspiration, whirl, IS often the first effect of the drug. Repeat- edly I have seen the forehead beaded with sweat half an hour after the administration o 8 grains. This is sometimes a most un- pleasant feature in the employment of the drug, and is the only one of which the patients have complained. In several instances the 'Irug was combined with atropine, but without much effect. It does not seem to increase the ! night-sweats in cases of phthisis; indeed ■ under its use, one patient, who sweated much ' with the afternoon dose, had drier and in consequence, more comfortable nights. ' In i per minute, stopped iti weaken the I 4- On ih was a marl of the cas« , of the inci 5- The , seemed ui often folic istration. themselvei this mattei There w which we s pyrin and vomiting ; there was IS so comi These of Cahn that we hi erful anti from unp tage also I have u wholesale I ' u. ) i. 1 ) 1, \ t' ' 1 1 \ \ \ 1' \\ %\ ^^'--MM-;-;:;,-^-— ::^^,..no.„„... hn '\ WH .nT.^ : ^ P"lse.rateof ,,2 per minute and the temperature at .05°. the pulse fell to 84 m four hours. In ar^other case the pulse fell from X30 to 90 in four hours. A marked .ncrease m the pulse-tension was observed n several cases. Even with a rapid fallTfo^ S to 7 ,n two or three hours, there was no evdence of heart-weakness. Slight cylnosis which IS mentioned by one or twn r ' writers! HiH r.^^ "^° (merman writers, did not occur in any instance I 3. Sweaf/n^.-As with thallin and antipvrin Ithe action of antifcbrin ,s almost invSr; laccompanied with profuse perspiration wh'h Is often the first effect of the drug. Repeat tdly I have seen the forehead beaded wUh Iweat half an hour ifff-r ti,^ . If 8 ^rain^ Th • ^ administration easant?. . ' " ^"'"^^'"^es a most un- asant feature in the employment of the f rug, and is the only one of which the patients ave complained. In several instance Thl iiucn eriect. It does not seem to increasn th« Kh the afternoon dose, had drier and in 1 onsequcnce, n,ore comfortable ri'^h's' In i ^ weaken the paS„r '™""« '"™'"° .v^■ata:tut:^-J,^^r^^"«— ' onje cases. ThisTp'rl^' rdirrru o( the increased arterial tension. hl^f 1 " P'"'"-'iiral patients e;''''-*-t''herst whIrhT ""' "°'" °' ""= lisagreeabie effects ;r.t:rtr,!rVh:i°''°"'''"^"'-" :-it,„, d,:i.hi^?,:-,r--' -cr„r„ff-xr"---- of cS ""J",^ ■"'servations confirm those ,h=, . ""''. ""PP ""'I °'1>"S, and I think ful an, rn ■ " ""'•'''"'" » P'O-^P' and po„' from ""=''"" =««'. easy to take, and free . «aZrr"' '""'" " ""' "- advan! whoteale '• °"'^ ""'■ «"'» - <"■"«. ;i I mmm ^XKy/// • f 144 was not roducod .„ I,,, tlnn 9. t. ''' '"'' *''^ Pnlse-rate "- "-' 1".. This patient suf ^^ ^^ ^^ :!"""^'"' -O'n, between -soles especially in the lin.bs 17 1 '""'"' ^"""'- '•^" ^'- — "-' absent, but returned if 1 ,1 * f"'; T'^"" ^'"'^ '^-"'- P-vf ". strength and feels well w dl t "" 'f '''' «''^' ^-s in. iH'en takino. one-,,uarter of a .rain e . f ' '"^' ''• •^''^' '"'■^ '.,>w I .i^ave spartein for periods ;■'" ''"'"'•^ ^"'- ^^'"^ '"""ths. f''b- ...antities of oue-lhirdt" :" I ^:;;r' '''''' '^ ^ "'-^''s in ;lo.se was continued in one case for n " "'l^''' «''»"^^> the latter large !-^i-> with one-sixteenth ofT^j '^^ P'^'' ^^^fit. U is best ^ '"-ease up to two grains, if n^^ arr^i, h"' '""^' '"'^' ^^-'"^^% -•eulat.on is obtained. When t e do o '' ^T"" '''''' ^^ t^'e '•-■It does not seem so good ; son.e L^" ^'7" '^"^^ ^'-i"«.tly the '-iuced without loss of em.;. T^^Jn 7'" '^' ""^' '" ^'-'"''"v J"' f ^- --•^''- "- palpitation'",^, ;:";■■ ''. — '"ation. Th^ "< '"^'l' tension, and a feeling of .nv- \ve ^'""' """''' ^-^l*'^ I'-J'^e _ ^••artein begins to act in about't lil ""''• '"" ''''' '"'"'^^^-^^l ^^y [^;? '-:"th, and its actio,;tL tn Zit 1 ''''' ' '^'^ ^-" ^^^en '•'^!-l.ty of action, at first consistin- , 7 , •' '" '''' '''^"••«- 'i^''- -■'--!' t..nsion not occurring mil i •; H'^"" f ^^''^ ^«--^' --.f ^^i;:"-ten. in a.s,-stolic conditions o val u . T'' '"'""'^'^^^ ^'^^' "- <^^' '■ft'et ,s desired, giving it superioriv ot T'' ''^'''' '^ ^I'^^^dy ^" these conditions,^ too ! ^^1 d Tlf^''^^ "^'^'""- ^'^ugs. t-"tl. to one-quarter of a t n) i;!: ^''^'f' '^^ -Ployed (o^^-six- l"7-f;'Hy to stinn.Iate and g 'te The" '"\'?" ^"'"•^-' -- a«er.al tension, perhaps not nlr Hn " ""'^ '^" ""'^^'^^^ '•-'^ of "f '"creased cardiac force. " '^'' "«""^^^ accon.panin.ent j;;^;'.'...ofthesurf.eel>nh:c;i:::^:;;;^- ^^ '''- 'r-- after a.lnuinstration in „u.st cases. ''''" ^*"" '" ^^^o l'o"rs THE CAHDIACRELAXrOX. OP CHORE V -— . cu.... ,„!^:;:^:;;;^;^ Os.K., 3I.I,, ) I c i'M M -if ,^ 1 f ' ' i p ■B l\ ":'n 'if • ( I': I ! i 372 OSLER, THE CARDIAC RELATIONS OF CHOREA. a deatli. By far the most serious fact in the clinical history of the dis- ease is the occurrence of endocarditis ; but here the danger is renidtc, not immediate, and lies in the changes which an acute valvulitis may initiate. A satisfactory study of the cardiac relations of chorea must embriic(! the condition during the attack, and the subsequent heart history after a period of years. The first (juestion has engaged the attention of man v workers, and an attempt is here made to work out the second on a scale not hitherto attempted. I. Condition of the Heart during tiii; Attack. Oftentimes the extreme jactitation renders the examination of a clionic child difficult or even impos.?ible. I make it a rule to examine the bare chest. Auscultation through the clothing is not trustworthy, as soft murmurs, readily audible with the stethoscope, may easily escape detec- tion. It is a good plan to let the child lie quietly on a lounge for some time, and make the first examination in the recumbent position when the heart's action is less rapid. Subsequently the eflfect of exercise and of the erect posture may be tested. In chorea, as in rheumatism, the evidences of cardiac disease must l)e sought for, as it is rare to hear complaints of either palpitation, pain, or other symptoms which would direct attention to the heart. The cardiac disturbance is indicated by the presence of murnuirs, alteration in the rate or rhythm of the heart's action, and by pain. A nuirmur at one or other of the cardiac areas is by far the most common sign and is present in a considerable number of all cases. Of 410 cases in the records of the Infirmary for Nervous Diseases, tlicre were 120 which presented a heart murmur at the time of examination. In at least 40 cases there was either no note or an imperfect one, and in very many the exigencies of out-patient work prevented a very tliorouirli examination. It can safely be said that in over one-third of the cases a heart murmur Mas detected, and I have no doubt that this number would have been much increased had each child been stripped and special attention given to the auscultation of the heart. Of the 120 cases, ll;3 presented the apex systolic or mitral nuirnuu', in 7 a basic, and in '.] both apex and basic. In 15 cases the heart'H action was noted as rapid, and in 6 as irregular. Pain was not a fre- quent complaint and was noted in only (5 or 7 cases. It is commcm experience that the special indication of heart trouble' in chorea is the i)resence of a soft systolic bruit, heard best at the apex or over the })ody of the ventricles and not often propagated to or bevdml the mid-axilla. Basic systolic murnuirs are usually associated with auffimia or debility. Diastolic and presystolic murmurs rarely, if e\ci', occur in acute chorea. CHOREA. had almost coaso.l „,:, ! t "S;;];!" V--"-»i- Tl.^ ,^:^;,:;^ 40O post-mortem records il i^t re "l ?;,:^ 'Y^'r^'- • '^'''^ *'"'^"l''^v ^ J'.vpertrophy of the heart, s ew at I ? ^V''^"*^^^ «''»^^- '«'" ■<^1M t nu,rK.v,,,sirreguh,rwartv -e-Si ;, r '"r' Z"''™' ^'"'f^'i-'^ ^n Two ot the aortic se'' ^^^O- -'i a ''«n-t murmur. About the '^Otli of ?t ^^'"\„^^" rheumatism. X «'«ce and on March ;Jd he 4 in l"^ » " j;;";-}' ^^^^' '^^^ ^^-^ - '•ecur- Br. Molson. About tlie JOth he it'^" I ^''"^ ^'"''■'''^' ''«spital to see -stless. On ti.e Hth the tem^rV !""{ ^'^'^^'^^ and' extreme , I'ame comatose TI.p l«tv „ '"P*''inne rose above 104° J^' .,nri i.^ i ' were constantly tJll^i^. "Suhn'tK"'^' ^''^ 'i' ' -''' ' W fl'e K'th. The autopsy showed vV. H'' ^hed on tl,e mornin-^ of vegetations large, soft, gray?^ hten ?,?'''' V" '''""' valvulitis, lie il'e brain and membranes he-ilthv , -1 1 '^ ™any recent in^ircts e..^'Hosf>!'d, mldrDJrS:!,.:^!:^";;^?^^^^' ^^ "- ^f-t-al «on- -n There ..is no rheumatS;;^^;.^ die" m! ^f ^?/^J" ^''^^'^ «f ^^^J-^us- y verylaryenun.heroffat'. H^ f- V ""' ^"'*"' ^'^" '-t.s.n to ph,ce heside these ii..,re "7 ' ""'"■'"'' '''•'^'- -so prone to endocardial eonmli^t , , ' 'm " '''" '^"'^ ^'^^»«^' this respect. Dh-ldnson has' ^ h^ r ""T"'"' "'^'^ ^•''-^" "> "•"■i" -- not rather Jtu^^^rT "■'"■^''-- ^'-- ^-.l^ of defect, and Stnrges holds tin tl '" ''" '''""' "^" ^''^^ ^''''vular i"«an.,nation o^the endll^.^^ '''^X^ir ' 7^^'^" =' ^^^ "ot, I think it mnst be conceded that thll • '"«'""-'alion or -llyns nell as nnu-roscopica Iv Ji , "" '' "''"''■^''^^' n.ieroscopi- see it in other diseases ' ' "'"'''' '"' '''''>■ -^'ocarditis as Ive -• Tho character and loeitlon nf fi, i".-her af^ctions has tau^ir^a ^:ZZZT "' '■''''''- ■>"tnil segn,ents. I speak of the a,ex t '"""""""f"'" "^ M'e ^'""■Id be so gencraliva.sociatc7.itM '^''•'^"■""""•""•'•- ^^hy this -arty vegetations Just" wit h^nt^-u \ ^'■''™'' "^" ^^ "'"• "^' ''""^" - ->.,Id think, irion : ^; :;^;: ;r!-f "^l^'- -rtalns, not, to be solved. The condition crrfai2 doe T "":""''^' '^ '' l"''''>^-» ->d the bruit n.,v perhaps as ht b > " "'''^^^'^''^'^ »-^'g".-gitation, t'"e roughened facJ of thfCJ::,'"" "'«^^'^^^^^- '^ "- to friction of ^uii^rnif ,:t: crer: '■' "?---- <- ^^^^ nu,st acknowledge that the bnu .nu f 'T,"'' '^"' "^'"'- ^'^^^^ "'^ -cossarily accompany n,U,.;l " ..^J^'t 7"^' '"^-d' ^oes not >'PO'i this, and there have been f«. . ! ' '''''"■' "«"' '"■"'•^ted of chorea in which tl ve- ' ■ t « V' T"V" """^■"'^•^' ^^•"''-' --- -n.u;ation tuiied to .::^r;:::s:;:; r^r''-^""',^!^*' --^^^ give .'iuggest that manifest even b we fl,im., The facts which J si Jiiay .luring tiie attack h lal! ■:uhse( juently trouble. The d rheu siiiull inatisni egetati y a Tnurmur, but which has laid the found ■ 'appearance of the apex ni ave an endocarditis, not iitionof futu too — has been iirnuir of d\oi\ re ions, thi.s is a natural •ei)eatedly followed, and if a— and of sequence of the cb m caused by the i'es w hich go oii I ) i I I c I' s A 9 w ■ * 1 i!l ll'l 37(3 OSLKR, TUK CAKKIAC RELATIONS OF CIIOIJKA. i ;!' I ! ■ '1 ... I .IM in tlioin. At tir.-'t a soft granulation tissue, they become in time firnici, smaller, and ultimately sniootli flat elevations mark the spots. It is not imi)robal)le that if we could follow accurately the auscultatory i.istory of a valve affected with acute endocarditis, we should find iu many ('a,«.(> that the nuirnuir of the fresh attack disappeared, to reappear when the changes, which it is the misfortune of the acute disease to initiate, have reached a point of interfering with the competency of the valve. 4. In its sequel the cardiac affection of chorea has been sui>posed to differ from that of other disea.S(>s, "as none of the injurious after-conse- quences which attend endocarditis in its other relations . . . are found to ensue here" (Sturges). A study of any large lunuber of choreics some years subseciuent to the disease tells, as I shall show, a sad tale to the contrary and proves that the primary heart trouble is, in u majority of cases, at least, endocarditis. ir. TiiK Condition of the TIkaut in Ciioukk' r.vTiKNT.s SOMK Years aktku tiii: Attack. Owing, doubtless, to the difficulties inherent to such an investigation, this line of inquiry has not been followed by many workers. Indeed, so far as I know, Dr. Stephen Mackenzie's paper, at the London International Congress, is the only one which has dealt with the subject, and he lia> examined thirty-three patients at periods from one to five years subse- quent to the attack. Postal cards were sent to all the jhoreic patients, in sets of twenty-five, who had been in attendance at the Infirmary since 187(5, asking them to return for the purpose of having the heart exam- ined. One hundred and ten came back, a luimber much exceeding our expectations.' All the more recent cases in attendance at the clinics have been excluded— all, indeed, after j\Iarch, 1885, so that tlu; stu.ly is based upon 110 cases in which the examination was made inore tint ii' I in, years subsequent to the attack of chorea. In each case, as it came, reference was made to the original notes, questions asked concerning subsequent attacks, and rheumatism, and the heart examined in the re- cumbent and erect postures, at rest and after exertion. The results summarized, are as follows: In 4:3 cases the heart was normal, in ')4 there were signs of organic disea..e, and in 13 there was functional disturbance. Tne tables which I have i)rei)ared are too full for publication, but the following abstracts of the cases affected will be of interest : 1871 (sixteen years). Two cases. Case I. — Laura C. K., aged twenty-five. Several attacks subse([iient to 1871. Never had rheumatism until February, 1887. No note of ' It spciikB wfll for tlio stiibility of the artisan class in I'liiiiulclpliia that so many of the iiostul cards reached their ilestination. Coiiiiiarutively few were returned from the VoBt-oHice with tlio coniinent- Semoieil; cannot find. CHOKEA. ski'd coneoriiinf,' mined in the re- "'""■■■"""-^""- '-■-".,.. „.,„„,.„,, iioiirt condition in prcvio.,, uKm-I.- • 'Ml . -..„. -...(M.isi; IS i„n.||,|.. i!"P'''"r'^^"^"-'^l><>Hne.sMof |)r(...fl, '""■r ri^ I-'*""'- r"'- : « s::.:;:;n-t ■^'" ' *"' ' I't-Miui jfit accen- ^'" liean aniTfion. l'^"2 (fift,.e„ years). One ease. m4 (thirtoc-n year.). Three oases ^li'lness. .Second fr '•"''' ^''; '" I'^lmcarv a va V^- '' '^''^""^ '31-Lona Jen accentuated. "'.^ aiea. ^No increase in 1875 (twelve vears^ T,,-.. K yeai,). luo cases ; one norma). attack very severe ; -^0 note of heart in """•-"•• Loud aclentuatidt-oni IT"'" ^'"■'" ^ -"^'' l-iSt ^^.Ce^venyears). Eight cases : one norn.al. "j ^^«^, >^o ^eumitiLnr^^^^SK"- ^'r '''' three attacks last «,■««; impulse feii","„ tS"T""'-' ^ "*'«'" ^'"l" '« ft' r ) i I t c .1 I' 3 .;f •^ / 378 OSLKK, TIIK CAUDIAO HKI.ATIOVS OF OiroKKA. <'xerti(>ii loiKlor. Botli very *7(!. Is'd rh.'iMiiatisiii. No note iif iicart in I'S?'.'. No symptoms. St,ihi.-< jinisni..- : Beat i'orcihle; dnlnoss increased. Lund a|)ex systolic imirmnr, iicani at angle of scapula and very distinct alon;; lel't marjfin of sternum. .\i aortic cartilage a .--oft systolic hrnit. Second left 'inging and acciii- tiiated. Cask XFV. — Jennie A., aged twiMity. Second attack in 1M7><, lliinl in l-'^7!*. Xo rlieumatisni. In I ^7!), sound, stated to l)e normal. Shihi^ prie-vHs: Impulse not forcible, no apparent eidargement. In fourtli let'i space a rough p'.osystolic murmur; iimiled i'l ari'a. At a|)ex a systolic bruit, traiismitied to axilla, and lietird at iMigle of scapula. Second li It v^ry accentuated. Sounds at apex booming. No symptoms, always good health. ("ask XV. — Annie L., aged twenty-four. Two attacks since, last one in D^I^'I, when for the first time she had rheumatism. No note of heart. Stutu'^ pni.-ifii.-* : A])ex an inch outsidi' nipjde. Impulse forcible. No thrill. I'r .systolic murmur, not rough, in fourth space; apex systolic, heard in axilla and r' angle of sca|)ula. Loudly accentuated second left. Has had palpitation and shortness of breath on exertion for three years. Cask XVI. — ]\Iiriam C, aged nineteen. Two attacks since. Never had rheumatism. Has had heart disease for some years; is now in bed with it. 1877 (ten years). Seven cases; three afected. Cask XVII. — Andrew G., aged twenty-one. The attack followed acute rheumatism. In 1878, a soft systolic murmur. No symptoms. Stnfits pncseiM : When recumbent sounds clear. Erect and after exer- cise well-marked a])ex systolic, not transmitted. Second left ringing, accentuated, and reduplicated. No enlargement of the heart. Case XX. — Mamie L., aged fifteen. Rheumatism (acute) four weeks before onset of chorea in 1877. No attack since. In li^77, " mitral murmur." Xo symptoms. Stutux pnrxeit^ : Impulse forcible, beat out- side nipple line. Transverse dulness increased. Loud apex systolic nuir;nur, ])ropagated to posterior axillary fold. Second left very accen- tuated. Case XXIII. — Rose ]McF., aged twenty-four. Attack in 1^77 pro- longed and severe; none since. Ko rheumatism. In 1877, a faint apex sy.stolic murmur. Statux j)rcE-'*e)h'< : Heart's action violent; impulse for- cible ; apex outside nipple. INIarked presystolic thrill. Presystolic nuu'- mur in fourth interspace. Systolic murmur in fifth space, and heanl as far as posterior axillary fold. Second sound accentuated at the secniiil left cartilage, and al.so heard loudlv in axilla. Patient is at times very short of breath ; has attacks of palpitation and has fainted. 1878 (nine years). Two cases ; one affected. Case XXIV.— Minnie C, aged fifteen, Attacks also in 187!l, 'f<0, and '8"). Rheumatism in 1885, never before. In 1878 an apex systolic murnuir. No symptoms. Status /^rffw»,s; Imi)ulse forcible; apex out- side nipple-line; transverse dulness increased. Apex .systolic murnuir ;':::<;'*>-- '•■ ■■a^.-. ».; .J;.:,,:,: '■ '""' H...,;,,.;,;,. i^nuishut t'J^f'iv "'^T!'-- ^"'•'""' "•'"'•'< in l«.s.> lln- t^ .. Nopreviuus not.M,nu.art ,.;„£'' u'V-TT' ^'> '•'"•"'""- I V^ 'T- Jr-l'^Nt'lM- (lllllicss IIKTl'ilSt'd. l>"ii,ir|i pmsy.^foiic! tlirill. \' '^7i'"*^^*;:Jv A'>''f'*- '^'""..Is ll,.|ILT '^ '"^^ Hm.nt.,a...,l a..,| ,, iiiniii f t''^;k. Khoun.ati.s,„ i„ 1^5 w il .i ' .' '' '" ","":"'="T ^vi,!. a s.v .rJ l'>i.x lmx systolic hrnit |.n.|^a!^t il f ' /''^'^l'-^- ^^"'"^'■^^ i'HMvas<-d. No note of heart in ^(^ u'^^l'T^'-'^T^' ^^^> ^•''-"atisn. "Yl'.and at tin.es severe pa, Tl'^t' ^''I'V^^^P'^'^tion, shortness of a Id tore.ble; dnlness increased pt V .'.^'^^/'^r""''"-^"-' ^^ction rapid i;H.^h presystolic nu.rmn)^ Sok sS'l "'" ■ '"'''^ "" •»^'^'- ""tral am 1^ - loud but not speciall V a een^ nt ,] F ■'"'• ''''}'^^^ ^V^-- '^oeon 1 er a course of iron and a 5 ic v iV,/f 'V'"'';' "^^'i" ^"■'H' weeks 'ainnursunehanir..d. ' ''''"'' '"'^^ •'olieved the anaemia- ^ <^Asi.:XXXIli._An.rek W ., i • , {r;t i" 1880. Xo rhe,Si^,i: fti:^]^']^^''''- f "'^^^^ ^'^ t'- I increased on <'eiitiuue( ASK exertion; not altered ! xxxrv Vvx systolic, heard as f >y position. •Fl ii'\as middle axilla, and '^■••ond lett a little at f-thcatt;;i:.-i;,'?S;;; "^■a occasional attacks of pal tl jipex a little out, but •Pjice B., aged twenty. Ill an a vlieuniatisni si.v months ptx svstolic murmur. Uas 1 pitation. Sfdfu. ad •pncscns: Impulse foreibl =inice ,' •-"^■iJ« our, out nosoeci'il o.>I.,,. "wi^«««.- inipn heard well to n.iddle axilT M,,?. !i' P'"*-^"*- .^P^'-^ ^^.V^^ 'ul '11a. Marked accentuation of second left, 10 murmur, ( i I ) 1 < ) I ) i I V D 1 I I' ;< ) n w ! I 4 380 OHIiER, TFFK OA I! DF A C H K I, A'l' I O NS OK (UIOUKA. t ■• I I n IMMl (six years ). Sixteen ciiscs ; nine atlected. ('asi: XXXVI. — Ltiiiis ()., iij,'eil sctventoeii. Al least live attaekr^ siiieelSSI. No I'lieiiiiiatisin. Nu iiole of heart. Xo svinjitoiiis. St(ilii,< jiiiiMrn/<: .\|iex l)eat in ruiirtii space in iii|i|)le line, lieaviii;; ami Hh- cil)je ; (liiiiK>s iiiei'en.sed. Loud systolic miirimir at apex iieard to po.- terior axillary fold, hut not ahove Coiirtii space. Wlieii reeurnhciit it i- lieard in st'cond and third spaces as well. Second left very accentuated. ('asi'. XXXIX.— Frank N.,ai;-ed thirteen. A .second a'ttai'k in l.s,s|. Xo rheninatisiM. Ileiirlsaid to have heen normal in 1M84. I'or some time has heen very short of hreatli, and L;cts tired on exertion. .SV-(/((,. jmiwHn: Preeordia hiilues. Inipul.se diliii.- symptoms. Slalii.-< ;;/vr.sr«.<; J)itfu.- clear. Iie(Mind)ent, distinct ajiex .systolic murmui' transmitted alun- anterior axillary fold. In third and fourth interspaces doid)le murmur. the diastolic not rou;;h. Socoml left very nnich accentuated. ('A«r, XLI. — Jose|)h .M , ai^ed thirteen. First attack January, iNS] ; second, Octoher, 1881. No rheumatism. In 18S1 asoft svstolic nuir- nnir. Ifas had vertigo and rushes of hlood to head. Slu'tiis /)riiniii'< : Impulse iiot forcible; dulne.ss slightly increased. No thrill, hut loud shock of first sound. Kinnhling j)re.sy,stolic muriiHir, maximum in lifth space in nip[))e line, is \\. 11 heard to anteri(U' axillary fold. Louilh aeceninated .second left. No systolic murmur even when recundient. C.v.si XLIL— Carrie B., aged . Second attack in J S84 : third in 1881 i, all severe. No rheninatism. In 1881 heart normal. No .«ytu li- tems. StdfiDt /mrsrit.^: Visihle, sonn what forcible, pulsation in tliinl. fourth, and tilth spaces. Erect postui'e.no murmur; recumbent, sv.stoi' bruit at .-second left, localized. Second soun. Pains in knees in 1882, and lately in shoulders. Heart normal in J.^sl and 1882. Srntas pnvxens: Soft apex systolic murmur, not heard iu axilla. Second left accentuated. No enlargement of heart. Has at times pal|)itation and shortness of breath. Ca.sk XL IX. — Jessie J., aged nineteen. Three attacks since. Blieii- matisin with attack iu 1883, and again in 1885. Heart said to he (!|[()UKA. "Kl'lllill ill JiSrS,") V // "'"* """•'• I'ainai tinu.. and is pu lit tht' licart," liiiiK short ofhrcatli l^"»^' .««>,,,„). Tl,i„,.,.„ ,,„.,,, „.„„„,„„„, ; ~" ;;':;;:;i:.'r- ■, ''^"■' '■' "'-"i" ^^^'^tzir- '"t. / • ""J'tiJ.M' forcible. Soft Kvs(,,li,. I " '/" ■\^ "' 't'>'ii-s. aSV«//(,,v vvASK LIV . — Iji.ssic I' ... I .1 • •I^MndMh^;^,,;^;,;!;;;'^^^^^ >.. HKHinnaisin. Di,,] ..n^art !" 1^«4, ;:;f"^J;;j";;^ Ji^;^pt^loven. Secon.l attack i„ Ins;] n.ird 'Finf? rftliis year Zrl,^;- "-?' ""'l""' A socomi ,V„H •.tti.k i„ *l : ill I i Jl iijfi .,^^. n 382 OSLER, THE CAKDIAC RELATIONS OF CHOREA. I; :, .f 1 increased. Feeble j)resyst()Iic tlirill. Loud a])ex systolic niuriiu'.r, pro- pagated to axilla. In fourth space just within nipple, a riimhling pre- systolic nuirnuir. Secontl left very accentuated. Has had at times severe pain in heart ; no shortness of breath. 188;> (four years). Fifteen cases ; eight affected. Cask LXII. — James G., aged thirteen. Second attack in iScS"), third in 188(). No acute rheumatism ; ])ains in shoulder. In l8(S(j a systolic apex murmur. Status pne.'le line. Dulness increased. No thrill. Loud apex systolic murmur transmitted to angle of scapula. Just below and inside the nipple a fajl presystolic bruit. Second left much accentuated. In December, \XX{), the child had a sharp attack of cardiac dyspnnrsni.^: Beat at nii)ple, in fourth si)ace, Transverse dulness increased. Feehle thrill above apex. Kough presystolic murnuir in third and fourth spaces; heard also along pectoral fold. Just outside apex a suf't systolic. Loudly accentuated second left. Is short of breath on exertion. ' Case LXXIV.— William H., aged filteen. Still has twitches at times. No rheumatism. No note of heart. Status j)r(V-'<('us : .Apex beat in nipple line. Dulness increased. Feeble presystolic thrill at apex. In second left interspace a loud, rouf/h, systolic murmur. I:; third and fourth spaces a softer bruit. Distinct presystolic ruinhle above apex beat. First sound reduplicated at apex. Second left iniicli ; H O H E A . '^'^l^^'^/'^^-^-n ease.; ten .ffectod. ( 'heeks iire E ■second loft. Xo palpit-iTion""' ,/^'"'/"3' ««^^'"itiiate(! an apex systolic bn,it propaga^ 2 ^ Cf! -"^^ >!> enlar.en>ent. si^ "H'nnur at second left space t f '°'" '^•^''^''^'•3' f-l't .\vniptoms. ^ i^oiully accentuated left. P^-^n^i)^l^r'£;^^^^^^ ^0 otker att inent. Soft nno^- .„.,*.,i:„ , .! "oiinal. ,S/a//^9 Systolic Ha.s no r, ;. " '^^O-*. Heart Tlnrm.,! t.'j J "-"wj .ULUCK. ii'K .'>'ent_. Soft apex systolic hndt'T ^M"^ prwsr,,. ; Xo enlar-e Case LXXX.-Xclli. M ., ■ , «•<'- '■Iml systolic faintly one inch outsic^3- nippie i;;r-"S;;j-^^<;;^ble ^P- ^^^at inlfth";'::" 'oonung and echoing. I„ third m, 1 /•"',''•.. ^^^ ^P^x first s'un •nnt; feeble at secMul left cil' '^'^ '"^^ ^l'*'^'^es l,>„d ' "'' heard in mid-sternun . \r /^ ' 'f ' "«1 "/''lil'le in axilla symptoms. ^^"^'' accentuated ..econd left. ir... tiS^T'""' Lnpulse j„.t within ,dpp^ ^;;;k "'".'•"""• "^ l^"^e. tlinl At apex a rund)lino. prcsysto p > '^''^"^'t" '"ereased. Xo audd)Ie at apex. At fourth left^a.';''';''''"":; ^^" 'y'''^^'^' »>H.it fold." near s roeumhcnt a soft systoi nil>P'e line. First sound at aj)ex b *r„„„,. .¥;„ri^:ffr:,:':™r "'. r-" -..i .iiis i.* -::Sx^{!ii«"iri-?"!':'-i loonuni"'. spaces "'»i'"ial in 1««4. AW,/ i)ft. long, ape '"I'd spaces. Di , aged twelve. No rlie mp>^,r.^i,^,n<< : No onl X systolic nni '•"iiir, not hoanl i'l-gement. \\'1„,„ .iimatisni. Heart and in axilla recumbent ^appears when erect. Second \J ! ,'"' '," '"'•""' "»' acr./^.,,) ......i, "^^'-^Jnd (lull aiK (iiK ii,.f „i '•"'ging, like second riirht md loud, not sharp 1 I ) J ) I c ; t '1 > : ri : 1*1};, h 381 OSLEK, THE CARDIAC RELATIONS OF CHOREA. Case LXXX VII.— Fannie P., aged ton. Second attack in ISHf). Pains in wrists, but no swelling. In 18S.") ai)ex nnirnuir, prcsy.«tolic ; .soft basic mnrnuir; hypertropliy. Stiitii.'< pnmmii: Forcible ai)ex beat in liftji space, outside nipple. Feeble thrill. Loud, liigh-])itched apex systolic bruit, transmitted to scajjula : and, in fact, all over left chest. Presystolic bruit. At aortic cartilage a rough, svstolic muruuir Second left accentuated. Has palpitation at times. _ Cahk LXXXIX.— Annie T., aged thirteen. Several slight returns suice 1«84. Ilheuiiiatism three months after the chorea. No note of heart in 1884. Statiti^ pniwiis : Action rapid, apex a little out from nipj)le line. Dulness increased. Loud, rough systolic l)ruit at apex, transmitted to scai)ula. Second sound verv accentuated at third left cartilage. Has " spells" with her heart ; has fainted. Is short of brcaili on exertion. 1885 (two years). Eighteen cases ; five attected. . Case XCI. — Lizzie E., aged fifteen. No attack since. No rheu > tism. No note of heart. Sfatun prcenens : Impulse strong. Thr''i ,r, upex. Localized systolic murmur at apex, not heard in axilla v^r ;.>; third or second spaces. Loudly accentuated .second left. Case XCIL— Alice N., aged ten. Xo rheumatism. In 188.") loud mitral systolic. Stain.-' j)nrsens : Apex beat diffuse in fourth and ti ft h spaces in nipple line. Transver.se dulness increa.sed. Apex .systolic murmur, lieard beyond mid-axilla; intensified in recumbent posture. Marked accentuation of .second left. Case XCVIL— William R., aged nine. Xo rheumatism. Heart in 1885 said to be normal. tStatua pnescns: No enlargement. First soiiiid not clear, and on exertion a soft systolic murmur at apex; heard also two inches beyond nipple, and as high as third rib. Loudly accentu- ated second left. Has no symptoms. Case C— Georgie G., aged thirteen. Xo rlieumatism. In 18,s:) a basic systolic murmur. Sfatus pnmenx: Impulse diffiise, forcible ; apix just outside nipple line. Dulness increased. Thrill. At apex loud svs- tolic bruit, propagated to posterior axillary fold. Second left dull, thud- ding, and accentuated. Heart's action irregular. Has palpitation niid shortness of breath. Case (T.— Jennie X., aged nine. Second attack in 188(), in wlurh she had rheumatism. Heart in 1885 normal. In 188() loud ai)ex sys- tolic murmur. Stutn>< pra'sciix: Impulse forcible, apex in nipi-le liiic. Dulnc-s increased. Apex .systolic transmitted to axilla and an^dc of scapula; heard also as high as second rib. Second left loudly accvulii- ated. Has, at times, throbbing, palpitation, and pain. ( )f the 43 cases in which the heart was found normal, 1 2 had h;i(l three or more attacks, 8 had had two, and T.\ a single attack. Tliero was a history of rheumatism in 8—/. e., 18.() per cent. In (5 of these cases the rheumatism was acute. In only 2 cases had there been a iniir- mur noted at the time of the original attack. From the cases presenting abnormal physical signs, 1;> may be separated as exam])les of functional trouble. They are cases without signs of enlargement of the heart and with localized or variable iiiiir- murs. Ten presented soft apex systolic bruits not ])r()pagated ni CHOHEA. vai-ml,lo „i,|, |„„ii;„,, i„ „,^,j .>»coii,I left imhmmyy sound l,,„ r ,1 ""'ontiiali f ,|,„ '" ""™-' 1—'^. i'--tic„ia;a'„o,„i„,; "J :, T :;;■ ;;"■"'" '."'"'"«" osaiiHiiatio.1 of „1| ,||„ . , ' . '" I""' "i tins ]>„i„t „ (|io '" -Lioh the pulrnonarv sound w dW .cth^'T "T '' ""■""^' ^^^^ in some instances mluplicated N, ,t ^ f'" ''"'" ^''^' '""•^'"^^ »"'l often developed in the re^don 'of tlu 1 ' '"' "^' ''" "'"'■'""■•«' «'> •i'>" ""'J "hich are ex.ro.n v J"''"""'''''.^- artery during respiru- oases the sounds in U' Z, :'"";" "! ^''--''-ted d.ild.^n. „ 2 --"bent position .-s::;:':; ^ d^i LT ti ':r'' ^-^ - ^^- was aocenluated, and in one the -17 r ] ' *'^' ''^'^"^ «^>i'»^l In a third ease there was a sof sv' oil ' ■' "'"^"'^'^^ '"-"^^^^d- ^I-s in the .ecu.bent ^S hi tV:;;^::"' ^^ ^?-"^ -''' third "'-'"ary sound and the apex hea o M ^^ '^^"'uafon of the p«l- tl.- there n.ay have hee or ' u e cl l ' 7''' ''"■• ^" -'"' «f ■> '>-t to exchuk all doubtful^'rs '" '" '" ''''''' '"'^ ^ ''-'"^d i"''^::.::;^ ;:,r;t:rr^ ^^'^^^ ^1'^ '-- -^ -•- disease. Ti.e..ets.e,ardin,z;:;;;i: ::;:::::t'7 wat., li.ere Mas s,i„„ l,i.„,„, , "."■"'"•-• '" ^'^ ™aes, 40.7 ixa- '■""'I«'""S tlio frB|„cuov of rl„.ui„.,tic ..fli-f" ■™"'', ■'"'''■ "" """='"• o™..,-viei, ti,„, i„ ,1,0 ,„.,„ „„x f! :^^"'; -;■;'''''*•'■■""'>•-'''■■ I- t" 1> of 4;l „„n„„| „,„j, J. „,.'''*■■'" !»'■«»«., or will, tlic *-o corcisos i„ ,.,.„<,„e;„, n,^';:!,::", tir; "Vo"„:;""r'" "■■■' <'h' larger proportion, oD..^ per cent nf H " • ^^' ^">^\"evcr, ^•'"'^""atic trouble. Of th M " "' ": T? "'^''""^ ""•^' '''^^orv of attacks of chorea, only 7 hadTheu^'i^;!" '"' '"'"" "' "-- ^^•th.eference;o^hr:.;!; :^'::;::^';-^-.of-- --« of uncon,plicated n.itral affee iL Id 4 """' "'""' ''''' ^^ aortic and nutral disease, h- •>' ili^Hh; ^ " "'"? "^' """'^'"^d ">'"•; i" 17 a distinct presvstolL Z •?' '' """'''^ ^^>''^"''^' '»"»- --"y -ith a systole ^Q ''r'"' 7^''';^''''''''t a thrill, and rented a soft aortic direct n u-nun "' ,^'"""^ ^'"^^' ^"^'U- I"'^' adouble aortic n.unZi:::^2 Ti^;::^'^ Tt ' ''''' '''^^■ ^"'■^'"'f --tio and antral dis^^ cl > XXX h" '^''- ''?' ^' aaa.ual combination of an aortic d hV l ^^^ l»''^^«^"tcd the — ur. The overwlKdnunV ;,' : tf '"' '' -'f ™^ '^^^■■^^'«^«'- '« what we might expect f^Ln '-''^^cs, w.th nn'tral lesions, endocarditis of ;henn,S. ^:^J^::::^^ ''"'' f'' ''' ^"^^ NO. cwxxvni.-ocTOHKB, 1887. ^""'ea attacks these valves ' I ■ I )'■ i 1 V C 1 f i i s ■• ^ .!j 1 i k H : illl. •it 386 DANA, HEREDITARY TREMOR. There are mjiny points of interest in pliygical diagnosis which these cases ilhistrate, but I am only concerned now with the clinical problem of the frequency with which organic heart disease follows chorea. Not many of the oases had subjective symptoms of cardiac disease. In 14 instances there was complaint of shortness of breath ; 16 cases had attacks of j)alpitati()n, and in 6 cases there was cardiac i)ain. Two cases had died of heart disease, 1 was in bed with (•ardiac dropsy, and in several others there were premonitions of heart failure. The miijorily illustrated the important clinical law in valvular disease, that the symp- toms do not result from the lesion, but from failure in the compensatory action which for years may eciualize the circulation and obviate coiu- pletely the most serious mechanical defect. A study of these cases justifies, I thiidv, the following conclusions : 1. That in a considerable proportion of cases of chorea— much larger than has hitherto been supposed— the complicating endocarditis lays the foundation of organic heart disease. 2. In a majority of the cases the cardiac affection is independent of rheumatism, and cannot be regarded as in any way associated with it; unless, indeed, we hold with Bouillaud, that in the disease "chez ies jeunes sujets le coeur se comporte conmie une articulation." 3. As the presence of an apex systolic murmur in chorea is usually an indication of the existence of mitral valvulitis, as much care should be exercised in this condition as in the acute endocarditis of rheumatism. Rest, avoidance of excitement, and care in convalescence, may do much to limit a valvulitis, and obviate, possibly, the liability to those chronic nutritional changes in the valves wherein lies, after all, the main danger. HEREDITARY TREMOR, A HITHEHTO UNDESCRIBKD FORM OF JfOTOR NEUROSIS.' By C. L. Dana, A.M., M.D., PRESIllKNT OF THE NEW TOnK NEUKIU OIIICA L SOCIETY, VISlTINa I'flYSrCIAN TO BFLLEVIE HOSVITAL, PltOl-ESSIlIi OF NEUVOl'S AM) JIENTAL DISEASES, NEW YOKK POST-UHAUUATE MEDICAL SCIIOOI,. Thk object of this paper is to call attention to a peculiar hereditary motor disorder whic'i has heretofore never to my knowledge been systematically described by medical writers. Definition.— The affection in question consists of a fine tremor, con- J I am under Rreat obliRations to Dr. Henry Hoyiiton iind Dr. Fred. T. Kidder, of Woodstocit, Vt., and to Dr. Couluid, of Cruttleboro, Vt., for assistiiuco iu eecuring datn for my Listorieg. ^X,KK I nosis which these ! clinical problem ;)Ws chorea, f cardiac disease, breath ; 16 ca.ses rdiac pain. T\v.) •diac dropsy, and ix>. The majority ie, that the synip- the compensatoi'v lud obviate coni- g conclusions : •ea — much larger ocardit.'s lays the s independent of Bociated with it; lisease " chez les )n." :;horea is usuallv auch care should s of rheumatism. :;e, may do much to those chronic the main danger. CASE OF [TRO.SIS. nPllF.VlE HOSPITAL, KAUUATl: uliar hereditary knowledge been fine tremor, con- ler, of Woodstock, Vt., iBtories. CHOLESTEATOMA OF FLOOR OF THIRD VENTRICLE and of the INFUNDIBULUM, BY WILLIAM OSLER, Md PROFESSOR CLIN. MFn . „„, ' • "*■"• 'NIVERSITY or rpvvcv,., -^ NHRVO.S O.SR^SHS "'" """'"^- [Reprinted from The Journal ok Nkkvous a.h ^T XIV., Nove.nber-D::e:Lr, :8S;.5-''''' ''""'^' '°'- NEW YORK; 1S87. I ) J I M C u s 'A ,1 5 CASE OF CHOLESTEATOMA OF FLOOR oF THIRD VENTRICLE AND OF THE INFUNDIBULUiM. CLINICAL SU.\LMARV-._n' A r » lad, had vi„]c.u licadnclics vv'l.ir I, l ^^^ ^^' ''' quent about the eigl,"™th v n T"'" """' '"- several attacks „f .ra„,sientb , s^ („ i'"'!' ""\''"- when a si:,„le„t, had trouble with I "i u' ', '"•""' >"■ ••">J would frequently faM alee, ,:' "■"*"''" graduated in ,S;g, ,„:,, be,,", ,n ette'"'; T '''>'■ "" loss of power and sen.sa.io.rin e a™ ;,„ V''""-'','"''''"' tuined in an hour ^■'...rtk- \,, ''".",'"«' '<=e. which re- vonming. Afte an ;, ' l^ ,""'■ ""'""■ >"'=">^^'=l'^ with ".aniaca? outbreak F, „' Ir^^tTi. '' '"" " ^'-■' ache, von,iting, and great dro, 1 ", "X^l ,",'"" '""'■ hours. Pulse often as low as twen^' . 7'"''' ='=<-'P '"any tervalsof several days bLvee.ul "'".T,*' f "^ !'''"^'' ''- was at times incoherent, .an^ lo all e ?i " ""°"'" wife and faraily. SLdu nn ch Hil u f °"'"" "' '"^ d.p.opia ; one sb^ht e;i',ep;rr„ c™ :: sion" Tl ''''\ ""^^ "-.-e about, thou,\ji;:\-,x''rVclr:ra;-in;:;.! ) 1 ) { I I' r I If I 'T 4 WILLIAM OSLER. vals, and the constant tendency to sleep persisted. Gait staggering. In March, double optic neuritis was deter- mined by Dr. Duller. In beginning of July, another severe attack of headache and vomiting lasting three days, followed by a severe convulsion and prolonged sleep, from which he awoke quite blind. From this time rapid re- covery oi health, and for five years was able, though blind, to manage a drug business. On June 3d, 1885, return of attacks of headache, vomiting, and prolonged somnolence. Remained unconscious until August 27th, when he awoke at 4 A.M. quite suddenly. From this time pain in the head was the prominent symptom ; no further loss of conscious- ness. Death suddenly, April 25th, 1886. Anatomical Summary. — Cyst at base of brain in posi- tion of optic chiasm. Infundibulum greatly thickened. Small solid tumor in anterior and lower part of third ven- tricle. Dilatation of the lateral ventricles. Atrophy of optic nerves and tracts. Numerous pearly bodies scattered in the lining membrane of the cyst, and throughout the solid parts of the tumor. The full account of this remarkable case is thus given by Dr. Duller of Montreal, and by the patient's brother. Dr. J. L. The early history of the case, as related to me in a letter from the paticr.t's brother. Dr. J. L., dated March 22d, 1880, is as follows: " My brother began to complain of his eyes about the beginning of the year 1877, and all the fol- lowing summer he complained of more or less pain and un- easiness, but they did not give out until near the close of next winter. He was then in his primary year as a student of medicine, and found great difficulty in writing for his examination. His visual troubles continued to increase until about the month of May, when he went to Toronto to consult an ophthalmic surgeon, who pronounced his con- dition retinitis albuminurica. This diagnosis ! never ac- cepted, for it seemed unreasonable to me that he should have such advanced symptoms from a constitutional dis- ease without having any of the physical or other symp- toms of that affection. <=^Sli OF CnOLESTEATOAfA. course of studies, n^ev fs' ^ n V''^" '" '""^'""^^ '''« he was first sen by Dr ^^^^ }"n\'''''' "'^ ''' ^'^^ ^''^e His vision had x\2^!\ '"' '"' Ciiristmas time. ,878 -^'.du.•tiu. d fti ,r fll'^P^^^^^'-'^t he u-as able ' t i» the sprinc. o s '0 ,;. "'""I^'^'^^' '^'"^ ^eciical studies whole ^'nt^ 'l^^t H^unf l^'^^ "^^"^"^ ^-'^'' ^h he commenced the ^^ac ^of ^I "'f "^ "^ '^ ^'^^^-ee. vill^'ge, and all went we 1 „! T"^''?'""'" '-^ ^"""try same year, when VZ t Lf," i"'^ "^^^^ ''' '^- headache and nausea wth occ^^^^^^^^^^^ ^^°"tal tnuied for about a fortn Ir^^r °"V''"^'= '^''' ^°"- tude and inability to nrle ^ "'^'"'"' ^>' ^^'"^'''^^ '^ssi- e'fort for hin. to tv st He h J '''f'""- '^ '''^'^'^ '''» to Ottawa for nud ol .d • "''^' "P ^^''^ '^'"d to ^o conveyance that was to Inv: hi i^ '•'"""'^ ''"^ "'<= "^leep for a short time and ^,,1 " "" ""^'^ '"' '''" dchrium, with com, r^r '" a "..lent attacic of (or »bouUwe ,7h H .ur?T;°" l" "''"=■ "''-" '-"^d a'xl the next dav he 1,^, f / ^['^^Vrgo set hin, ri(,-ht, a. ™y house the ame Ih" fH; ", n' "''"^^ '^^ '"^'^'^ that he had been vomi i £ hi, ,7 '' ''"= ^^ '"'"'ioned his arrival here. T was i' ; 1''""'=™' ''•■>>'^ before The second night af r , ati '',1'hf "' "'? ''"' *'''5). severe, accompanied bv, „tn, ' . P'"" ''"came very eighteen hours ^ sivera r'T"^ 7™'""^ '""^ ""»"' "f pain and vonntinlnow ah ' J'! '"^ ''="'='"'='' ""••"='<'' and prof„,„,d sleep Su'n ?^^ aggravated after a long would fall in frZencv ; !h ;7 r '''' "' P''""' '''■^ P"'- even to twenty-eigl", !,nd ' t "T. ^f^ "^ '°''>-fi^"'' """ "ot increased. (Probablv ^ V """P-^'ature was would have been no ced bv th'^ ' ^''T' "=■"!'""'"- had existed but he doSl^^^t^o/ulVilV"''^"^' wou!rrt:;rh:':vr,r::t'';:!!,'.-^-^'p'^-'^'^-^ppet.te prov.ng. The first treat the first m SIX leeches and week here while suffe freely and ent he got so pparently be im- ine time durinj a blister which crave nng dreadfully. I applied '-t.the leeches had hardlyta^rUeThf':,:!"" in s pulse began r ) 1 I' c J I' 8 A 3 , .. / I ! t , (• fi ■'B '] f J WILLIAM OSLER. mi to rise, and in less than twelve hours lie was pcrlcctly easy. " This condition continued with very little variation for about three weeks, when the attacks became milder and the ink rvals longer, but with a steady decrease of wei,i,dit. I applied blisters repeatedly, always with marked benefit. I also applied a scton at the nape about the fourth week. On one occasion, about the fourth week, on attempting to stand up to pass water he was seized with a slight spasm, and I think if he had been kept in the upright position it would have developed into a convulsion, but immediately on his assuming the reclining position it passed off, which made me think it was from deranged circulation on ac- count of his having suddenly assumed that position. About this time he complained of a loss of feeling passing all over his body ; it used to alarm him very much, and he used to say, ' I cannot feel anything but my poor head.' It seemed to be a numbness lasting only for a little while; it occurred several times, sometimes all over the body, and sometimes only on one side. He never suffered from paralysis of any part or any organ with the cxcei)ti()n of his sight. The special senses were all perfect the last time I saw him, about four weeks ago. "About September 28th he began to show signs of men- tal failing, evidenced bv slight loss of memorv, and at times it was difficult to arouse him to perfect conscious- ness ; he would mutter on being shaken, but you could not bring him to himself. This would continue fcjr some hours, when he would wake up quite bright. This was his condition at intervals for the last week befoic I started to New York with him. The pain during this time was not very bad, and there was not much vomiting. " He complained continuall}' of feeling a sensation, in dif- ferent parts of his body at different timeS; of the touch of what he called a pebble. He would describe the size of it as that of a pigeon's <^'g^, with a rough surface. Of course he knew it was only an illusion, that it did not exist, but he had the sensation, and used to say he had a lump in his brain and that it was the size and shape of the i)ebble, CASE OF Cllor.F.STF.ATOMA. btif the fact. „f his knowin.r the (Ii-,.rno.i« ^ -•[''•''--nmcientrcasonM/hnn f L^^^^^ and .'" '"-''- n..l re„,aine -rt; ^^^if, "J' f^'- ^^ clay m«r„i„.r. He kcut nir, ! it 1 . "'''' "" ■^•""'■■ o. su"day.;.hich w^s' h I ,^ ',t: d;";"'^' "'" •',':" was then well et.oni;!, t„ ,nve the ,',1, ■> "'">'iy. He C.-.SO, bnton SnntlajMtit ; : b™ 'li "'"■^^ "' '"'^ and for the next f„,,r ,,r five ,?n ' ''•"" •'«■""• and„.a,,atti,,,e,,nrLM:s'':,{:e;Li;;;;r:,r;:::;:''' profouiK V so 'i■ «'»''. eoveraNc in a y ,art , ,!■ I od' """7^' "' "•""'""" "- I'is complaint; is able to .rive a ,a. '>e early stage of life ; close qn stion . do ; ,1 " "^"'^"l"'"" "' ^^P"^' sible venereal origin" ,,"","■";"""' "7" ' "'"- thongiitbesttotn lh,wfr . < ?f' ' ''■"■ '"'"'ever, rapidly as the stomach would be-rrr.,' '"'''T^ '' this was commenc.rl n,. !'.../'''' 'J' ^'-.^^^'' ^'"'"ted : Montreal. On March -Gt P. Howard, who second da}' after 1 n he wa.^ s ex- gave me the following notes ins arrival in amiued by Dr. R. I 8 A ,\ i lO WILLIAM OSI.ER. ■■ "Heart sound, normal: pulse, 65; presents no pecu- liarities;, lungs health}', but respiratory sounds weak; \;j rig-ht side of chest flatter than left, and lower respiratory movementson this side markedly less excursive than on leftside; shows an amioying restlessness under examina- tion ; has a papular (? iodide) rash on body and slight coryza ; body emits a peculiar musty odor, which, however, is probably due to external circumstances. Is now taking iodide gr. xxx. thrice dail}-, preceded by a small dose of hydrocyanic acid a few moments before the iodide is ad- ministered. Still has hiccough and morning Inadache." The condition of the eyes was not placed on record \intil March 27th, but had not in any way changed since the 2rst. It was as follows : Pupils equal, in ordmary daylight about 2y< mm. wide, act sluggishly both to light and ace, V = l [J and Hm /^- each. The ophthalmoscope shows well-marked double optic neuritis — choked discs — not neuroretinitis, the swelling being little wider than tlie normal disc and quite steep. With hyperopia — J,, at macula, the surface of the nerves is best seen with + 10. Veins dark and tortuous, but of normal size; arteries a little smaller than normal ; vessels only here and there hidden or obscured by the swelling of pai)illa ; no hemorrhages, and only a moderate degree of white striation, and the papilla ai)[KMrs rather reddened ; macula regions entirely normal. There is no contraction of the visual fields, no defect in perception of colors, and the muscular system of th.e eyes presents no abnormality. lie remained in Montieal until Api'il 3d without any material change in his contlition ; some days feeling a little better and others suffering more from headache (always frontal), occasionally vomiting, was taking pot. iod. gr, Ix. three times daily, when he returned to his home in Perth. Oct. 2ist. Came to Montreal again for the day in order to have another examination of the eyes, having now be- come entirely blind. Continued taking the iodide in about the same doses all summer, but for the last three weeks has omitted it. Vision failed steadily from the time lie CASE OF CHOLESTEATOMA, II left Montreal, but could still see fairly well nh,M,f .1 1 headache and vomiting which lasted son.c three d s .nd -hn,na ed ,n a convulsion. This was followed ^'^^ ound sleep from which he awoke cntirelv blind wlid; has continued up to the present time. Sine i.i ' severe attack his general health has steadiK- n oJed Has had no headache to speak of since the end of n s 7 -'y n ht.le occasionally just on the top of the h ad 'feels ance has ^^Mx-. hve.ns and arteries much diminished in si"e n next seen by me „„ June .41!,, ,SS.;carae ..naeeoun,; an aente catarrhal otitis n.edia „( the left ear, whie i, s cat.sed h,„, a considerable deftree of pain for the a te, ays. otherwise his health has been ler,- good s S i ."'e, afford!, rir""'','"''^' ""■"'"'" "1"'--' -"•" l-'e b c »; W I ■■' ^'''"'""■■'' "' "Si't since the rlav he became Wn„l, I he e.ar tronble yielded readilv to tie br ir,T;'1"'":H'e':;'""''-''v^?-'«^-"''''>i^ trouble -H, ■ , "■'^"^'''■'""l Porlectiv fnmi the ear SS- ,:;"""?' "■""• -'i°y"'i' K""J ■:i\ 1 i> 12 n^/LLIAAr OSLER. up and took his dinner at the table, and remained well, with the exception of slight attacks of pain until Nov. 15th, when he was seized with a terrible stabbing, pierc- ing, unendurable pain in the head and his face flushed crimson. This gradually passed off, and he was able to walk to the post-ofifice. From this time he was up and down, one day well and several days in pain, but there was very little vomiting and no disturbance of the pulse. He slept well when not suffering, " During the last month the intervals of relief were very short, a day or two at most, and the attacks of pain longer, and for the last fortnight the pain was nearly constant ; he has to have some person sitting beside him to keep him from falling asleep ; if he happened to fall asleep, in a few minutes he would wake up frantic with the increased suffering. The Thursday before he died he was down-stairs enjoyed his meals, and he looked quite well, and likely to be so; he was always so cheerful and bright when free of pain and suffering. He passed awav without any struggling or any particular warning of the approach of his death. He had peculiar attacks, the last three weeks before his death. I was at his bedside (jne morning, and he called me in distress and complained of a strange feeling in his head. He said his head was all drawn up, and that his face was also all drawn up, al- though showing no indication or appearance of any change in expression. His hands and feet were extended and rigid, but could be flexed by force. He appeared greatly alarmed and distressed, and his appeals of distress and alarm wi^xc pitiful. During the attack, which lasted half an hour, his pulse never varied or changed ; it was perfectly normal. The attack lasted about half an hour; it returned again several times during the day. Another expression he used, 'xMy inside is all drawn up.' He used the word ciraivn to describe the sensati(jn in his in- side, face, and head. He had several attacks of this char- acter the last two weeks before his death, and it was fearing an attack like this, and feeling it comino- on, that he called his mother the night of his death: he saiti, CASE OF CHOLESTEATOMA ' I ^ ''Mother, mother, I am ^om^ to have onp nf f^ raise ,ne up." He then s^icr^TI" ,ik-. f '?-'"'''^'' me a glass of water I • He tr ed to <1 - 'j'^"/'?'"^'".^^' ^et back, his head fell forwarc^::d l^pa ^^.l l^^^l '^ "- moved ajjain." F'lsbcu aw ay, and never Dr. Eraser, ol Perth, Ont h'i< nl^n UM-Jff i"g account of the pat ent's V ;/ i 1 1 ' V'" '"'''■^■^^■ corresponds ..th tile abol^dl;!;!:^^''^'^^'-^'"'^^''^ ^-ei"^::;^:;;^-:.^:r^dir^:^- case on several occasions with ]> B ' ^ , n^'"'^' sented to ,o to Perth w.th Drs. Bul.!> ' , w'^t^JoT"" ston to make an examination ^ ■^°^"- temporo-sphenoidal lobes Vo o.ii • ^ ^ ^^^"^ but the infundibuhu "is ^^.^T^^ '\ ''^^^-^• u-ith resistance 'Lt \t. ,. f ^ thickened, and cut body ' '^^'"' "^ J""^^'^>" ^^'ith the pituitary translucent and ■, ". ' f ■"'""■ =-"'• '^"mewhat the plan a ; C, b snil t""",r"" "'" ""'•'=''«' '" The mass occunlll Zl'^t.'^l "^'"""^■"■'.■s in thickness wiiich can be jpies the position of the chi.- seen. two millimetres Ti le o isma, no trace of in diameter ptic nerves are atrophied, only ■"- y in color, and were at- irra i ( ( ) J I I c 1 t ■I ■S'-? !f' 1 1 3 r i !^ 'J '! i •i'l 14 WILLIAM OSLER. tachcd to the antcro-cxtcnial an Pons normal. Fourth ventricle and corpora quadri ireinina nrespnf ^^,^\w,,.. _• ■ -.,, . ' iiuanri- ina present nothintch a?ter sect on " the groove between therestiform bodies and th. ^ . nor column on the right side. ' P'''^"' msro/ogtca/ examination.~Th^ tumor consisted chieflv o ■ (.) a matrix of densely interwoven fine fibres wit S :T:iTr^Tr- ^" ^'^^ inf-Kiibuium ^d ; ' • wall of the cyst they were more closelv <;pf fi.. • . softer mass within the third ventricle ' " '" "^' (2) Spmdle and branched cells which were found in nil emmes prolonged into delieate filaments (Fig. , ,,,d b). Some ,>f the branched forms were the larees id most beauttful structures of the kind which I fve ever net w,th ,n e.tl.er normal or p thological grow hi FiJ witn me camera. M- ny of the processes were pr„lo„..ed ar beyond the margins of the held. The protoplasm was asarule dehcate, with but few granules Here ,d l were noted crious elongated no„.,ucLat"d ee 11 v h a' hyahne, homogeneous stroma (Fi. t m !i1 ! X -KK II ««-cee., rro™ .H<^,,.^,_^^,. ,^^^, ^^^^^^^^ ^^ ^^^^^_^ _^^^ HEREDITARY ANfilO-XEUROTIC (EDEMA ■ J^Y WlLiJVM OSLER, M.D. Till. INHIIMAIH ruB NBRVOI'I CISEA^a,. 1" various .v,io„s of ^dj!:! r^:^;:;^ '::: e'^ ''-udden o^ct extent, and of transient duration vi . ^ ^"^'^ ^""'^^'l "' length in text-books I ^ di- ttrr ''^'''' ^" "^ »">■ very uncommon, as Di..i.ei;d' ""^ number of ca.es fron. the litem;,, o ^ O • ,^",'"'':'^.' '""^ ^«"^^^^^' '-^ the subject in ^f>n.f.|.efieJ^^X^U^"''^: '''' ^""-'f -ferrcl to of Ldmburgh. has uritten on the subject and GralamM '' good aceount of the disease. Ki.hr' Falcone" ^. r IT ^"^'" ^ recently reported cases ' ' '^^'•"^'«ff.' Matas/ have andVls U,i:tSJj:4r:.r ^^^^ ^^ -r ^-^ generation, lowing report : ^ ' '"'*' ^'"^^ ^P^^'-'^l "^^ercst to the fol- Briefly summarized, the affection Jn fi.« ^ m has the following chumcter'sUcs "^ ^ ^' '"^"'^ ^ '"^^" ^'^^'^^ 1. The occurrence of In swt.i];n,«. ;„ iace, ha„*, „„„,, ,„,, go„i.a,s .l^/: JZ^-"^ •"' "° ""^^^ po«ib.yi„ «„ ae„,K ,.,„.ed ... ^ ^ud^n i' ,^„ ^ »™ ■""»-, 1. Associated with the fpHpm., fU^ • i ./'^"""fw. i~.o..inal disturbance: „ i.-^l:, *"° " "T '-"""Wy Sa„r„. 3. A .,™,g.v „„.ked lier^ta ; d^5i:;''^"'J™"''T''™■ .ffectedmembe,.oi•thcfa,,,i,yi„«;ei,^^S^„°: "■" ''""'"'^ '""'°» Anieniberof thf'familv Mro pt j^ to the Infinnarv ibr N iCiifea^rl^rT'^V;/^^^^^ "as admitted lowing notes were tak.n b^Dr Burr 'fhe^ ''"^'','^'.^.^^"- ""^ the fol- Medium sized, well-noukheAnnw. '^''•''''■''''''''^" ^ Bvn>pton,s. Has' been ma d two ^ea «'' nTu '''''\ neurasthenic - has hee.:;ul^t\^ -K--„ - -§,;;^.he .^^ \ Dil";?'' ";.'■ .^'"'"-""P'"" Nouro,o„c«l Socletr. • IJiukelaker : Leber aiiitno ii'.i„n. x „ ' "";'" ■■ *''»*^"'' i" Lon Mo.,. llcorU, l)„c 1887 ' '''""""'"' P""'""™", I880, FalcuDo : Oaz,.Ht« dogli Ospltali, Feb. 24, W8f, ' Matas : K . Orleaiie Medical Journal Oct 1887 ' ^"■"'''°«' 1^°^ ^3 Matas. J I ) } ■J X t I 3 ^r 1 '■ ^ i, 1 ' ^H ; fl ill . J a 1 ^^1 1 ! i 1 1 f i : ^1 2 OSLER, HKKEDITARV ANG 10- NKU ROTIC (Kl)KMA. hands or fingers, knee cap». elbow.-!, buttoi-ka, urni or lliigh in fleshy parts, fiice, or more ofU'ii I lie lips alone. The Hiifiers luive been so swollen that it was inipo.-^sihle to move them, and onee the rin<,'-fin<;er was so greatlv enlarged that the ring had to he filed oH' to prevent gan- grene. The nderlip has been swollen to such a degree that the mouth could not be opened, and milk had to be poured in from above. A slight redness and itehing of the pail is first notieed, or a sensation of heat; the redne.ss is not always juesent. The effusion may take jilaee with great raj)idity. She often ha.s red spots on various parts of the skin, or irregular lines of redniss witiiout any swelling. The duration varies from one to four days. Tiiere is not imu'h iW'hing, partieularly when the swelling is great, but a sense of distention an.l stiffness. When fully out it does not pit, but does so when going down. The attacks may come on when she is feeling (piite well or then^ may be slight indis- po.^ition. In all the severer ones there is abdomimil pain, described a.s colic, with nausea, and often vondting. There is sometimes headache; no fever. The attacks have no relation to the menstrual flow. She rarely l)asses two weeks w ithout an attack. She does not think that food has anv influence on her ease. She remained in the hospital three weeks, during wliich time there was no severe attack, but she had numeroii.>- wheal-like eruptions on the chest and sides of the thighs, with very slight swelling, aiul the day before she left there was a large si)ot of local (wdenia on the inner aspect of the left thigh. Dr. Morton dilated a very narrow cervi.K, and she went home much improved. She had not passed three weeks without a severe attack for a long time. I saw her again on -lanuary 10th. She had liMiror five bad attacks on the hands, feet, and thighs, since leaving the hospital. From 'Slv. T., my i)atient'8 grandfather, a venerable old patriarch of ninety-two, with unimi)aired vigor of mind and body, I was able to obtain a tolerably clear history of the affection as it has existed in his family. First Gi:xeration. — The disease first appeared in his mother, Mtr- (/(ini A., b. 1762, d. 1834. He thiid^s it began with her, and feels sure that had it been in her father's or mother's family she would have known of the fact and mentioned it. She was twice married and hud two children by the first husband, and three by the second. She had the attacks from an early age in the hands, feet, face, and neck. Ho had fre(piently seen her in them, and on one occasion she nearly dird in an attack of shortness of breath. She had colic with them. After the age of forty-five or fifty years she was not so much troubled, hut her constitution was nnich weakened by the strong medicines which she had taken. She had evidently, from the account, been badly salivated. She sought advice "verywhere, but in vain, and, according to my patient's mother, was brouL.it to Philadeljjhia, to the Pennsylvania Hospital, to see Dr. Rush or Dr. Physick. She died at the age of seventy-two. Skconu Generation. — Of the children, all boys, four grew .p; Samuel, Stacy, John M., and Allan. Samuel was not affected, but his children have the attacks, and one of them. John, died of the disease in Salem, ]\[ass. Particulars could not be obtained. StacAj was never attacked. John M. suffered i'v .ra his youth, and had frequent attacks on the (K 1) K M A . attacks on the hill OSLER, HEREDITARY A NO ,0-N E U ROTIC CEDEMA. ;!>; an,l privates. Ho h,., ,;,„r duUhen 1 ''III, aj.(.,l iiiiiofy-two V iviiiK, of wlioiii A//< "Illy one Ih Itii^.andHtillahro to wAlk fi fllCll an a tice. at thf ivn< „f ,,i,ri|f t'iWM, a hale, vi ,">r()iis man, with [XMfccf ""•^. ...u m,n 11, ,0 to v.'iilk five or six .nil .s i ,|,,v r .' ', chih . K(Mno.Ml.ors that tl... ..ff,.„L.: i . .. '''>•. "^ ^^"•■^ ''i-'»l'l 'It the attack.s hcoaii while I hv valw of a iiiDiiti •'liii or iiiiiotee f rei|iieiit. Tl ii or six weeks. A few Tl ley liave recurred 10 was an apjiren"- tio last attack was two week the first symptom, and in 1 years n^o they i)eeame I ks a''o. Tl lit int<'r less commonly affected, less oflen tl iS:;i. ;".ir;;.: ";'!•;■■;" '""iirva.., ;;;.., Itch in- precedes the onset. The (ed 1*! trunk, and never the fa "',-\velini;r is nsiially Ik' parts CO. f,'.r> in an attack are ^. so thick and slilf tl etna conies on rapi( sometimes 'y, and th(! La, tiu. coiaTiVf;;;; h^cz^ CZ:''!^ ^'"^;^ i^ impossiide t;; n.;;; are felt in the al.(l.,me. m » ' ' • " ^'"t"'^' <>»y- Colicky pains usually with reliiV 'EVc .ndh.:; ."""T 'Y ^'"""""'^ ''"''" "^ l.il.^ luul to come np hofW^l^t' i^^i! ^ :^:'!;'-^ ''-^j--<' i^ 'the; poes down before the sickness Vom7 in i« „ f ' •'"^'"'"^' ^^^'uerallv attack. The entire duratio.Hs KT!^ > t h ee da;::''''^!''''"^^ "V" headache, and very exceptionally diarrh.ea W, v l. . i V '"■''''■ '"'•' to cold, and imliscretion in diet: we e .V i ^ '' "'"'''' '^^•^'l-^uro thiuks determine the attacks 1 ..he ?s ""/v^ e.rcu.nstanees which he apnarent caii.se. ' ^ ""'^ "'' '^^^^" '-'""'^' «•" without any second wife, are affected. '"""^'' '""' '''^ ' there was oedema of the II viilft Laudon had in ]„s own case swelling of the pharynx. Cuntz^ desc i es a case in which the patient awoke one night with great dyspna'a aTd a sense of suffocation, which passed off in a few houis In one of Riehl's cases the patient had three attacks of angina with <1 ffio Ity of swallowing, and great breathlessness. In his second ca e also, the man is said to have had inflammation of the vocal coTvlS had produced symptoms of suffocation. ' In several cf the cases there was a remarkable regularitv in the ^:zz \:'^r'''' T''-'.'^' ''' seventi^:;i:ui The hereditary aspect of the disease, which is so well illustrated in e family which I liave studied, has been noticed by thre o ' n.rs In Quincke s« first case the man had two children, one of whom Vl 1 ged one year, had had, from the age of three months, attacl^' ] ",' c^ema,^often precede by a red and marbled conditi.i of 1 sklrol ^^:^^^:^i^. ^ '"^'^ «^^^ ---^' '-' "^ - ^vho suffered In Falcone's case,' a lad of seven years, with well-m.rked attacks the li^t:; been aU'ected. but the grandfather had been aS t most distressmj usually requiring morphia for its relief. It ' lioc. cit. ' I>-'ut8uhe niB'!. WochBiisohrift, 1880, N,) 17 ■> UiKlon : Berliner kli„, Wocl.oiiaolirift, 1880 ° Loc. cit. 7 T •> ' Ijdc. cit. symptom, is interesting to note that • Loc. cit. 5 Archiider llcilltuinlc ' Loc. cit. B.I. XV. ( i i 1} i 1 3 b e f 1 b- } 3 ■1 .■) 3 II V c il V 1' s 'A ,1 3 J' J J i i i • 1 J; ' 1 * ' i J OSLER, HEREDITARY ANGIO-NEU ROTIC (EDEMA. there is a disease in children characterized by painful cedomatous swell- ings about the joints, a purpuric or urticarial eruption, and most intense colic. There may be hemorrhage from the bowels, but the skin affection and the colic are the prominent features. The attacks may be repeated at intervi.ls for many months. Gouty' lias given the only full account of t!ie disease. Henoch'- has also reported four cases. I have recently had an opportunity of seeing a typical ease of the kind with Dr. Dunton, of Germantown. A boy aged six, has had, during the past ten weeks, three attacks, each one extending over many days, of purpura, with urticuria, swellings about the ankles, and intolerable colic. He has also passed blood in the stools, and the urine contains blood, albumen, and tube casts. So far as I can gather, none of the members of the T. family has had purpura, nor have there been painful swelling of the joints. Some of them have had urticaria, and Mrs. H., whi'e in the Infirmary, had very characteristic wheals on the chest and thighs. The colic is, in all probability, due to oedema of local regions of the intestinal wall interfering with the regular and uniform progress of peristalsis. The colic of horses is, in most cases, the result of hemor- rhagic o?dema — infarction — of a limited portion of the intestine, due to embolism in association with the common verminous aneurisms of tlu' me.«enteric arteries. Quincke has termed this condition cmgio-neurotic oedema, and regards it as a vasomotor neurosis, under the influence of which the permeability of the vessels is suddenly increased. That it has close relationship with urticaria, a skin disease of unquestioned neurotic origin, is shown by the frequency with which in the reported cases we find mention of the affec- tion preceding or accompanying the local a?dema. The condition re- sembles in some points urticaria tuberosa, and Juler,^ in a very abk' article, describes a case of u. porcellana which evidently belongs to the affection under discussion. In our present state of ignorance of the factoi-s which regulate transudation, it seems useless to enter upon a theoretical discussion on the subject of nervous oedema, and we may conclude with Cohnheim,* "that we have to do here with clinical facts and observations which urgently call for scientific solution, and that we possess at present but extremely scanty material for an adequate explanation regarding neurotic oedema." 1 Gftzotto Ilebrtomiuliiire, Win. - lU-iioch ; Jii-riiiuir kiln. Wudionsflirift, 1871. '•> Cinoitiniiti Liuifot and Observer, 1878. ♦ Allgeinuiiu' I'lithuloKit', Hil. 1, p. 500. EDEMA. lomatous swell- id most intense B skin affection ay be repeated ly full account . have recently th Dr. Dunton, past ten weeks, purpura, witli !. He has also , albumen, and T. family has 3 joints. Some Infirmary, had regions of the rm progress of isult of hemor- ntestine, due to leurisms of thr ui, and regards le permeability lationsbip with s shown by the on of the afl'ec- le condition re- in a very able belongs to tlu; norance of the • enter upon a \, and we may \i clinical fads ition, and tliut )r an adequate t: i 9 )I y i I •I I u s A i W I II ■ II I / .« Lxxx'iv I ' The Medic VOLUME III. NUMHEK 4. A 1 THE DIAGNJ '^y WILLIAM O.'i l-ROFESSOR („.■ CLINICAL MFlj The MEDICAL Standard (March) has ' tonally outlined the present subject, and in necfon with this editorial discussion the fol .ns-bncf notes may prove of interest. I„, "nset of ,he di.sease the difdcultv of dia.r "'a.v be very great, even ^vith u•ell-de^•el nausea and backache. Mistakes arise in niajonty of instances from the occurrencl certannnitial rashes which in so„,e epide. are very common. In the Montreal epidem _>874-,-6. they were more frequently met ^ ■hanm the recent outbreak of iSs/.e Svc ham refers to them in the following wo, The aforesaid smailpo.K breaks out someti N^rthefashion of erysipelas; somet,:: jeasles From these they are difficult tc «,.j..shed, even by the practiced Zs Hed t at he goes by e.xternal a pJa;: W- f hey have been well studied by 3 t-anphys,, ,ans. Bartholow observed then^ >™nnt,. The fullest description in E iJ£li'£ll...in an uvt'n-],^ i.,i,,„u , d aqi 3.1L' Asqj ajsqAv sjKipD oiui sppno puy .oqB puuojSuazojj puB soi 'a\ous avfl Xq juiBiis I ui ppn suuoS astjastp pui? sasTjS uiiav uapiq ' U3.UI13-J1H punoa.Sjapun 3\\\^ 'uosiod pooiq j 'pjoj itsij o; 3np 3q sojoj s.uau jo ssoj aqj jqiaq.tt 'pay.-iAi; oq oj si anssi \v.-\v} v. }\ luamiBsaj AisKwp 'jduioad 'uiuyaD puBiuap asaqx ''^liotid ;o iSuijsissj pai^ uoipunj jo sso] SuiXuudiuoDOB |;i mi.w sissjBd Ti JO sfsaq^odXq aqj uo aiqBOjid 9S small pox departmei*' '^^'■'■ pital' did death occu most careful inspec papules. In three i place on the fourth i was beginning to api prevailing, there is r nosing this so-called lated cases it may t rash do not develop The prodromata (A. acteristic and of gre early stage. I saw diagnosis in pur| year-old child was t ™ "^"^ , , FOR DIS- great pams in the I second or third day skin. The nervouj^j^j^ j there was retractior, , the limbs. The cur ''*^"' more abundair anc^' ^"*^ oneof cerebro-s,;'n; He Jr and years 1 of a le has The term "WintJan to relic of the time Ivania "Black Measles," j only the-Back" and sir, invented; terms as a« are the theprjes ently, ilso to i^s: Is ins of er his The JO paiuHduioDDB aq pinoA\ aaqif legs ft ui jnoDO Abui -j „09 jo v . . " arnes 0;BUJII:> 3[qBUBA A[31U3J1X3 s'p U: SB J3;UI.\\ UI 3SB3Stp 3qj 04 .)■ "*"^ qDB3'siiqBq A|UB3]Dun pire p3si feels 'sSuipiinojjns Ajjiq 'saouaniilone, TjSUB i (W 3ABU S7 I); r s n e h ;e i< t; b e ii s )i a :r tl a h. •a t( e . :i The .DM'ME III. Nl/MBEK 4. Medical Standard. I APRIL, I8S8. THE DIAGNOSIS OF SMALL Pox, ^CmCAOO: <■ P. ENGKMIAUD&CO. the MEDrcA. Standard (March, has edi- onally outlmed the present subject, and „. U,n vvuh this editorial discussio;,,',: .^' br,ef notes „,ay pn.ve of interest. ,, L ^to^thed,seasethedi,Hcu,tyofdia^:.' m be \erv ,^.reat. even witi, vvell-developed Usea and backache. Mistakes arise ^the '-'"'.nty of instances from the oc-urrence o ;rta.n ,n,t,a, rashes which in so„,e ep cic ,i.^ -ery-o„.n,on. m the Montreal epide,; n~,~0 they were more fre<,t,ently n.et with P 'c ers to them m the followin^. words=. :u^aforesa.dsmallpoxLreakso„timet^ ; ^^^ef..h,on of erys,pelas; sometimes ^ me.Meb. trom these ihpv .,r„ ^tc , *„,ui.shed evenbvt. '"^^ ^' ^^'"'^ ^^^ >^e ^VK^d that hr,oes Iv "T T' '"•^■"'■'■''^"- I ., ,,,, '^ '^"^-^ '^y external appearance 1^ I hey have been well studied by Ger Physicans. Bartholow observed theni I ""-t.. The fullest description in En " .S?3 ^d^:^ t"/"'^'''^ ^^•'"''h appeared m aS, f' '"'''"'' "" observations nmde in Montreal General Hospital, and in an Irticle 'r. Seymour Sharkey < '-"title ""i"t.''?:fr""'^"™^'"^he'nitial nrst. ihe hsmorrhamV uh.Vh 'recautions to hp t=i. neces- >, , , '° "^^ taken even before rhp -crashes n'theeruralo-^;'^''"'^"^ f^nnff from thJT f ''■""^'■>' ^"^ngles, f--softh?d;seas^™"°^^^"''--^e ^™n^J.-The erythematous rash, which may r"' ^^'"'^"''■^n, Society, Vol r „ "ospiial Reports, ,882. be diffuse and s.-,,-i.,,- r ^'--uralandte^'::/"^'". •''•'-'•-' to '•a.se it is usuilK '■'■■''^'""■'' '" ^^•'i''''h havehearr;:;t,r;;::;::;:f'^--'^'- ^ this varietv of r-,sh '■'"''' '" ^^'^''^f' ^Ha.nosis:ft;:^;:::r'':«,-^b-.iedtoth.. '"'H'd .scarlet fev./' , '''''^e^ "f com- '- the older wn\:""' ^'"f"P'«. described ture. ""'''^^•^^'■'■'■ITobablyof thisna- Third.-^-Thcmaculou.s^rmcaslv ,-,sh i ■'^"'■ommon. [ i,,,,.,-. ^ ,' ' "^ ""' ■■""Pleofit In , ."■" ""'>■ ""'^.U-odex- -h papules , ■-•'■"»-■- a m.ottled ra.sh. >-n,ln'i^;,' ',:::'''---• If-'Klone ^vitb distinct snvd I '"''"'^ '■"''''"'""^ ra.sh, "-.'^-'^"-i-ia;r;:tt^ri:r '^'••^^ to his home n ■"'"'de. and .sent u-ns .,k . ''"^^ "'y '''''■'^'^"^e a child was also admitted with nie-islp;. v./ these cases took smallp . , [. , ^'''''"- "^ J saw at the Citv M , "''' ^''''^' ^^^i'-h Dr. Laro que "^;f r^'^'f '" ™"--'tation with and papu r ns ' ' ".'''■:'''"'*^- ''"'^^' "-ttled -yot!n.m::t::rth:;;:p^^"7- I"c-a.sesof hc-emorrha^ie smallnov th^ r the svmptoms do not differ snl,lT"'";'"' of h.mon-ha,ic scarlet f.Z 7 Z '' P--pura-the morbus macul„us We,S'"r IS rare, however, for cases t^ I u ' '' fourth day, and e^en wh^Tt ,e sk.nis T '"^ Purptiric. the papules „,ay t ," ""'^°r!^' about the wrists. In only^ne- of [J rmv"'"'' ^ of hemorrhagic smil, p.. ^^^-:- f^ •Canada Medical and .Surgical Jou„ul, .875. L-Xxxiv^ \' if If 'I ii 98 THE MEDICAL STANDARD small pox department <.f the (.eneral Il-.s- pital3 ditUleath occur on the tlurd day. Ihe most careful inspection failed to detect any papules. In three cases in Nvhich death took place on the fourth day. the charactenstR- rash was beKi.minK to appear. When an ep.denA.c ,s prevailing, there is rarely any difliculty ^^^ chaR- nosiuK' this so-called black small pox. but m iso- lated cases it may be impossible, if a papular rash do not develop before death. The prodromata of small pox are very char- acteristic and of Kreat service in diagnosis m the early stage. I saw only one case of mistaken diagnosis in pu-ptiric small pox. A f"^"-- vear-old clvld was taken ill suddenly with fever, great pains in the back and head, and on the second or third day petecchia. appeared on the skin The nervous symptoms were marked; there was retraction of the head and rigidity of the limbs. The cutaneous hemorrhage became more abundan' and the case was regarded as one of cerebro-s.^^ial meningitis. Ha-matemesis occurr.;d and death followed on the si.xth ,l;u The child had not been vaccinated. At ih autopsy, the papules could readily be detcrt,, 1,1 the deeiilv ha-morrhagic skin, and this lac with the absence of the lesions of cerebro-spr nil IKM the meningitis, led to the postmortem diag of small pox. which was confirmed by mother taking the disease, of which she unfnri nately died. In the pustular stage it would scarcely s.« possible to make a mistake, but 1 had one i;,. sent to me in which diagnosis of small i>(.x hs, been made. The history, the distribution (clmi! on trunk and covered portions of limbs, sparin the face and hands), left no doubt that it was a unusuallv well developed pustular syphilulc. The diagnosis of small pox from varicella not always easv. In 1885, the Chicago™ which conveved the disease to Montreal, wa regarded as varicella and not isolated; an im which was directly responsible for one of li most fatal of modern epidemics. nv t.; The term "Winter Cholera" isa misnomer-a relic of the time when "Break-bone Fever. ••Black Measles." ' Winter Fever," " Spine-in- the-Back" and similar nosological terms were invented; terms as vague in meaning, very often as are the theories of the fathers in medicine and theology. Whether this term originated with some newly-fledged graduate of a moss-backed Chicago or Eastern medical school, or with the cut-and-dried remnant of other days in Egypt or Kentucky, cannot be determined. At any rate, it is not a proper designation for a disease whose pathology is so comparatively well-known. ••Choleraic Diarrh.ra" perhaps comes nearest to filling the demand; of nomenclature; the qualify- ing phrase, " of w.nter." " of summer," " of the Chicago River." "'of the Mississippi ' would clearly designate the disease "CHOLERAIC DIARRHCEA." WHEEI.l'.R JONES, M. D., DANVILl-E, ILL. followed by numerous cases of diarrhoea, assu: ing all the phases and types of the summer d order, from the simple •'biliousness" of a s!^ "ague" to the collapsing cases and rice w discharges of true serous flux. The predisposing causes are similar m seasons; the vitality is reduced below the of successful resistance, which reduction is complished as readily by extreme cold » properly applied, as by excessive heat. The sisting powers of the constitution being thiii feebled from whatever cause, improper food congestive disorders easily induce intes fluxes in all grades and forms of action. One very common source of malarial d bance in the country and in country t which is generally overlooked, although ;tj duces much diarrhoea of special types,' jarly designate the disease. presence of those former reservoirs calledc The large majority of cases depend nn. pre e, .^^^^^^^_^ ^^^^ prudence in diet and malaria. The processes of food fermentation, the ptomaines and the germs of zymotic diseases have to answer for most of these diseases in summer and winter. The only differences are such as would necessarily arise from seasonal iniluences. Dirty surroundings filthy homes, debused and uncleanly habits, each and all, predispose to the disease in winter as in summer. In this extremely variable climate where a variaticri of 60° F. m.-^y occur in 24 hours, I have often noticed that a few days ex- tremely cold weather would be accompanied or From thes-^ arises a steady influence \vhic| duces a toxaemia in the inhabitants abovej" fested bv many odd forms of disease ojI phcable'on the hypothesis of a paresis with accompanving loss of function and resisting c^ pacity These demand certain, prompt, decisis treatment if a fatal issue is to be averted, whethc the loss of nerve force be due to heat, cold, ' blood poison. The underground air-currer. laden with gases and disease germs held in straint by the snow, ice and frozen ground abu find outlets into cellars where they are the p THE MEDICAL S VAyDARD U ()( the r.cneral Hos- r on the third day. The :tion (ailed to deti't any •ases in which ileath tooV: lay, the . liaracteristic: rash u'ar. When an epidemic is arelv any ditTiculiy in diaR- blai'k small pox. but in iso- •c impossible, if a papular before death. ,f small pox are very char- at service in diajjnosis in the only one case of mistaken ,uric small pox. A f"i>'-- aken ill suddenly with fever, ,ack and head, and on the petecchia- appeared on the s symptonw were marked ; . of the head and rigidity of aneou.^ hiemorrhage became I the case was regarded as d meningitis. Hit-matemesis occurred and death followed on the Mxthd. The child had not been vaccniated. At h- autopsy.thepapulescouldrcad,lybede^cc. in the deeply l^^^-m.-rrhagicsku, and th.sf.ut, with the absence of the lesions of eerebro-sp,n„ nieningitis, led to the postn.a'tem d.j^n,.- of small pox, which was conhrmed b> t„e mother taking the disease, of which ^hcnnlnn.^ natelv died. In the pustular stage it would scarctl> v possible to make a mistake, but I had one sent to mc in which diagnosis of small poxl>.. been made. The history, the distribut.on (cbir, on trunk and covered portions of limbs, sp;m,; the face and hands,,leftm. doubt that n was. uuusuallv well developed pustular syphilid. The diagnosis of small pox from varuc- „, ,Kvays easy. In ,885. the Chicag,. .. ,vhich conveyed the disease to Montr.al. re^ard<-d as varicella and not isolated; an. which Wis directly responsible for one ot most fatal of modern epidemics. 'CHOLERAIC DIARRHd'A." HY C. WHKKI.K.R JONKS, IX Cholera" is a misnomer— a when "Break-bone Fever," • Winter Fever," " Spine-in- lilar nosological terms were vague in meaning, very often, 01 the fathers in medicine and ;r this term originated with I graduate of a moss-backed 1 medical school, or with the uint of other days in Egypt or DC determined. At any rate, ■r designation for a disease so comparatively well-known, sa" perhaps comes nearest to ; of nomenclature; the qualify- nter," " of summer," " of the "of the Mississippi" would he disease. ,rity of cases depend on im- nd malaria. The processes of , the ptomaines and the germs M.D., D.\NVII.1.K, U.1-. followed by numerous cases of diarrhcea, ass: ing all the phases and types of the summer order, from the simple "biliousness of a .. "ague" to the collapsing cases and rice « discharges of true serous tlux. The predisposing causes are similar m, seasons; the vitality is reduced below -k!! of successful resistance, which red." uoii complished as readily by extreme .old properly applied, as by excessive heat. sisting powers of the constitution being 1^^ feebled from whatever cause, improper fooi congestive disorders easily induce inte rtuxes in all grades and forms of actu>n. One very common source of malarial u bance in the country and in country! which is generally overlooked, although duces much di.arrhoea of special type. presence of those former reservoirs called. From these arises a steady influence whid duces a toxemia in the inhabitants abou f.«ted bv manv odd forms of disease^ ollowed on the sixth day, been vaccinated. At tin- ,.„uld ri-adily be detc tc>! ■hauic skin, and this In: tie lesions of cerebro-si>in;.. :he postnioitem diaKiio-i^ h was continued I'v tht sease.of wliidi -^'i'^ unlnri • jj^rc it svoulil scarcely s"" Tiislakc. but 1 had one . ..- di.-iyjnosis of small \)n\U ,t()ry,thedisirilintion(chif'; ;d portions of limbs, span';, , left no doubt that il w a< .^: l(,ped pustular syphilii!.- small pox from varia In 1885, the Chicaijii . ,e disease to Montrt'.-il. . la and not isolated; am y responsible for one i<\ rn epidemics. U.I-. rous cases of diarrh(i-a, a and types of the summer ,imple "biliousness" of a oUapsinR cases and rice w ; serous tlux. ng causes are similar in lity is reduced below 'in stance, which redmuon •eadily by extreme cold as by excessive heat. Tr [ the constitution beiiitj thr atever cause, improper fooi )rders easily induce inte les and forms of action. ^ imon source of malarial d :ountry and in country i lily overlooked, although 1 iarrhoea of special type?. ;e former reservoirs calledi ,es a steady intlucnce whic la in the inhabitants above, ■ odd forms of disease « A'^^.«W/>.,„,TM.JouRXA,.o..N,.:,no,.s.vv ^^5? " M«..sr,A,, DisKASK, 4/.,,,/,, ,g GLIOMA OF THE MEDULLA OBLOP NGATA. ^y WILUAM OSI.EK, M.D., MOPKSSOR OP CLINICAL MEDICINE IN ,,.. 1887. He was 1 Lu \ ^"^ ^^'^ °^ ^arch, gave a very good account of r"''r' ""•""'■'" "'^"' ^^^ knew little' fnotir;7L-f.^nrfH7 '''I'''''''' "^ ^11 hi-s brothers and^sfster^ H ' h.d T' " """"^ ^"^ ago, with secondary symptontf W , .,"'''' '^^° ^'^''^''^ verysevereattack of heir with, •' "'^'P^"" ^' ' been well until six or ZlT v ""''' *" '^^^ he has have fits, for whi^h e f ^ f, ^f^' "\"" '" '^^"^" *° Hospital, where he ren^a;!; d ' :S' Att t'l^^"?:!^^"''^ one or two attacks a week ■ now Z ^^ ^^^ °"^y and he has had three inl^; " " V ."T '"^'^^"^'>'' feel a little uncertain on hilfeet "'^ ' ^' '''^'"^ ^^^° ^° Condition on the 6th. when fir«f .» intelligent and answers t. 'stLs" ^pir^ C^^r^^ "^ '' headache, unsteadiness m, w^lkln/ZT ^' ^^^'P'-'^''^^ of body, and fits. There snir^V ''"'^^''°"^ ^^^'^ J^i^ grasp of the hands itL'I' "''''"^' "° P-'^'^y-"- The unimpaired. He co^; f; ^i:?; ,'^^-"'- P--^ of legs muscles of the back of the nee - .nd n T '"^ P^''" ■" ^'^^ the head and back stiffly, butirnthe^hl'"^^ ? !?' ^^"'^^ to side. He walks Jtl . ^"""^ ''^^'^y ^''^ni side •'drunk.'-andheten St TlrT" 'f ^'^^'^ ^'^ ^^^^ and with the aid of an assis ant'.' ^'' '^^' ^'"''^ ^'°"^' scone .no,. ...„.:_ f '''^^"^ ^ ^"" ^vent to the oohthalmo- t 1 3 (1 8 9 l| 3 S II i E I S a Uf !| Hci n scope fully 100 feet off. Th ! f i||l e co-ordination in hands ill ] ! i - . ! IMAGE EVALUATION TEST TARGET (MT-S) // 1.0 !r Hi^ IM I.I 45 50 t 1^ M 2.2 IL25 ill 1.4 2.0 1.6 Pnotogrdphic Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 \ iV ■1>^ \\ '^ jf^ ^ ^ WILLI AM OSLEK. is impaired, he does not grasp objects quickly, nor can he rapidly touch the tip of his nose. He gets out of, and re- turns to bed with great deliberation, like a man with lum- bago. Sensation is everywhere retained ; feels a pin-prick rapidly. Complains of m-mbness, tingling, and cr eping feelings in the hands and feet. Says his legs " feel as if something had laid upon them and put them to sleep." Has also sensations of cold in hands and feet, and, to use his own words, " they are warm, but they feel so cold." This was a very frequent complaint. Sensation in region of fifth nerve normal. Special senses unimpaired ; he hears the watch well at either ear ; no affection of taste or smell. Vision good. The eye-grounds were examined twice ; no neuritis ; veins looked full, but there were no special changes. The head- ache was not constant, was chiefly occipital, and he did not seem clearly to be able to separate it from the painful feel- ings of stiffness in the nape of the neck. Reflexes are present ; patellar somewhat exaggerated. In the fits the movements are bilateral ; he froths at the mouth ; says he does not lose consciousness. This is probably a mis- take. He fell out of bed last night in one and knocked his head. They last from five to fifteen minutes, and he comes out of them, as a rule, with the mind clear. The appetite is good ; he vomits sometimes ; bowels reg- ular. There is a loud apex systolic murmur, transmitted to axilla, and the pulmonary second sound is accentuated. Pulse fair in volume, 90 per minute. Urine clear ; no albumen. Taking into consideration the fact that he had had a chancre two years ago, the lesion was thought to be syphi- litic, and he was given large doses of potassium, iodide. On the 7th and 8th he was better, but the pain in the back of the neck was severe. On the 9th the tingling and numbness of hands and feet were not so distressing, and he had less headache. Had a severe convulsion last night. There is increasing difficulty in getting in and out of bed. Pupils are dilated to-day. He talks clearly and says he is improving. On the lOth, at 12 o'clock, he was given a dose of the ioJ.de and immediately had a sort of fit, but he did move , nor can he t of, and re- in with lum- a pin-prick nd cr aping 3 " feel as if sleep." Has • use his own This was a 3f fifth nerve le watch well Vision good. :uritis ; veins ;. The head- id he did not ; painful feel- ^gerated. In .t the mouth ; obably a mis- i knocked his and he comes ; bowels reg- ransmitted to tuated. Pulse ) albumen. e had had a t to be syphi- , iodide, e pain in the tingling and issing, and he )n last night. i out of bed. nd says he is a dose of the did not move GL/OMA OF THE AfEDULLA OBLOA'CATA. the hands At 12.45 I came into the ward and found him t the foilowmg condition : Is unconscious R. . slow, three, four, and five in ZZZl ^''^''T''" ""'''' ;7f.-^.ft;expiration'r:::,„:;:^'^t;:r;:::- 08. fair m volume. At 1.3.55 the respirations had fllleHo two m tne minute, and pulse stopped somewh suddenly No heart-beat or heart-sound could be detected af er 12 ^' Last mspiration at i o'clock. ^^^" Autopsy. -Twenty-four hours post mortem. Old scar, on orehead and arms. Calvaria normal, perhaps a 1 i t tt hick is lline o? f . YT ' ^'"—y fun-on either sio. there ear ah. ^'^ff^.-'^^'^/^^ pachymeningitis. Arachnoid is clear at base. Ve.ns of pia dilated and full. Parts at base present foilowmg condition : Olfactory and optic nerves sma, but h,,e normai color. No effusion in interpeduncular spac ' Vessels of crcle of W.lhs contain blood ; they are not athe romatous. The third, fourth, and fifth nerves look nlna ' and those emerging from the lateral part of medulla ha;e a natural appearance. The crura were cut. and ce.ebrun' removed separately. Vessels on the cortex very fu "ay ■natter of p.nk-red color. White matter in section l^T moist and glistening; no foci of dis^k'^Thf ;,;:,: contam a shght excess of fluid ; linin. membrane norm Crura show no change. Pons normal. The fourth ventHct -s d.lated, particularly in the lateral recesses. The Falbpian aqueduct not enlarged. The floor of the ventricle looks noT mal above the level of the acoustic stri., the right of whTch are not so d.st.nct as the left. A large vein curls ov r he left margm of the medulla at the level of the left stri^ The lower part of medulla ana beginning of the cord are occupied by a large growth extending from below the call mus. projectmg more on the left than on the right sid ft is everywhere covered by pia. On the left side it'has a redH.U sta^l" jr T^""''' °" *^^ nght side the white sub- stance of the medulla .s apparent. No trace to be seen of restiform bodies or of posterior pyramids. The olivary bodies are v.s.ble, but wider apart than normal, and tne lower pa i ( II r r i' 1 h e I t: b e ir 3 s >i 1 r 1. .s b< l,v 3 ( i i ■ f ' ■■ '■ ; ■ i :'r 1 i 1 i 1 !l WILLIAM OSLEN. absorbed. The growth retiches to within 7 or 8 millimetres of the fissure separating the medi'.la and pons. The cerebellum is a little compressed just above the tumor. Fig. I. — Section tliroiigh the Tumor below level of Calamus. Natural size. Fig. 2. — Sectior. through the Olivary Bodies and uppermost portion of the Tumor. No other changes. The upper part of cervical cord is soft and the postero-lateral columns have a very translucent aspect. The central canal is somewhat dilated. A cross-section just 1^ Fig. 3. — Section at the edge of tlie Growth, showing the gliomatous tissue and dis- tended Blood-vessels Nos. 7 and 3. below the calamus has the appearance represented in Fig. i (actual size). The tumor is an inch in breadth by three- fourths of an inch in antero-posterior diameter. In fully one- half of the circumference it is in contact with the pia mater GUOMA OF THE MEDULLA OBLONGA TA. aid fl . ' '," ^' *■"' ""^ '^' '''''"'' ^''^h the compressed and flattened columns of the cord. In the medulla it does not reach above the middle of the olivary bodies ; Fig. 2 repre sents the section at this level. The tumor was firm of a r'ed- brown color. w,th recent hemorrhages into its substance. The large lacunae represented in Fig. i were filled with clots H.stolog.cally as shown in Fig. 3, the tumor is composed of a troma of nucleated fibre-cells supporting blood-vessels which m places are so closely set that the appearance is that of an angioma In other regions the gliomatous tissue is more dense and the blood-spaces less numerous rh.>?\'r'''°" °^ '^'" '"'^°''' pushing aside and compressing chiefly the posterior columns, explains the disturbances of feaTurerofTh' ''" '"7-°'^^'-'^^-" -hich were the prominent features of the case. It is probable that the central hemor- rhages, which looked recent, caused death by increasing the pressure and disturbing the respiratory and cardiac centres which lay just above the growth. Gliomata of the medulla are rare. Sokoloff has recently 1 Wure ^ '"'''* '""^ ''"' '^""'''"^ '"''"" '"''""'^^^ ^•■°"^ ^he ♦ Deutsches Archiv. f. klin. Medicin, B. xli., H. 5. ,887. H Mi i ir ■ • 1 t C( la n le t h . ■ i i ! le i( * t: - i t 1 b 'fi 31 .i Is f ^l &> i# i IE 1'^; ti w h. -f ' H " ' , i IS tissue and dis- a< 9< ir CI IK n le 36 it: er •0 01 la' 3E tl ai i: I'' TYPHLITIS AND AI^: By WILLIAM OSLER, M.D., F Professor of Clinical Medicine in the Univ (Reprinted fnyin Tub Canada Caecal and peri-cmcal inflammations are descrihed under the various tern.s typhlitis, peri-fcyphlit,is, para-typhhtis, peri-cecal abscess, and appendicitis. I think we may clinically, and for practical pur- poses distinguish two groups of cases, to the first of which the name tj^phlifds may be restricted, and o the second appens w;is i'([ual, and^ • luitc well. He hi' weeks iM'forn. Sucl'*'' whatever the niorbi'^ they po.s.scss feature*" the next group. ^^ Appi-ndlcilis.- ~h\ ' lesion proceeds froi ti( which is liable to inflammation, catar obliteration of the i i I tube, and perforatic lodge in it, and fa'c become hardened an enteroliths. In a recent repoi, «th, lS88)Igaven. bad mot with ulcer connection with pht ^ er never met with for ■ it er )o m 3a On one occasion tiv me as having been the tube, in a dissec , of the cases in the p es treal General Hospi ' acting as Patliologi, presence of six or eii of a man dead from blance of the small quently leads to ern Inflammation anc vermit'orniis (so long may produce no de iJe the most extensi' bo completely oblitc dlMhMition, without Kigns of abdominal c If the appendix is., ulceration may go (i tube forming attach exceptional. More the perforation lead: ation of which will !f i i in i.K)iX V au TYPHLITIS AND A f>PE N D IC IT I S.* Bv WILLIAM 08LKR, M.D., B'.R.CR, Loni... Professor of Clinical Medicine in the University of Fennsylvuniii. (Reprinted /rein Tin Canada Lanort,) Csecal and peri-cneca! inflammations are described treatment, recovery is fl„. rule Local applica under the various ter.ns typhlitis, peri-typhlitis, tions-tho ice-l.ag, turp.nCno stupes-are usually para-typhlitis, peri-ciecal abscess, and appendicitis. found sutlicient to ullay pan, To break up the I think wo may clinically, and for practical pur- fu'cal masses, large i..j..,t,„ns should be usod poses, distinguish two groups of cases, to the first Purgatives may be administored, but I prefer as of which the name typhlith may be restricted, and a rule, to rely on largo injciions to the second appewiicitis, or, perhaps, better, as Dr. Fitz suggests, perforative, appendicitis. Typhlitis. — By this we understand inflammation of the caecum. The term has also been usad to designate inflammation of the contiguous parts as well ; but it may be limited to the cases in which the caput c^eci and tiie adjacent portion of the ascending colon are involved. Unfortunately, we know nothing of the anatomical condition described under this term. 1 have myself never seen a post- mortem, nor do I know of a report in which the disease was confined strictly to the walls of the I intestine in these regions. The cases are commonly met with in young per- jsons, particularly in young males. The attacks lare very often asso iated with errors in diet. In [the majority of e s( , there is a history of consti- pation. The symptoms are very distinctive. The patient complains of pain in the right iliac fossa ; Ihere is constipation and often nausea— sometimes Vomiting. At first there may be no fever, but lubsequently the temperature rises from 100° ' 102°. On examination, the patient is usually Pund with the right thigh flexed on the abdomen, there is slight fullness in the right iliac fossa ; Vderness on pressure, and, often, dullness on fercussion. In the majority of instances there is ptinct induration, which may have a rounded ■UUine, so that the expression "sausage-shaped ^mor " has l^een applied to the condition. Such 'ses are extremely common, and are usually re- ferded (no doubt properly) as the result of fsecal npaction _ typhlitis stercoralis. With proper [The Bubetance of remarks made at the Toronto Medical J^pciety. December 26. 1888. Attacks of this kind may repeatedly occur in the same patient; I hiivc known of four or five recurrences within four y.-a.s. There can be very little doubt that this l..,ul inflammation is due to fuical impaction. Tlit; iiitla.Niiiation is confined to the intestinal wall, and rarely extends to the tis- sues in the neighborhood. Itis true, that occasionally there may be more serious disease of the c«)cal coats. I have put on rotord two instances of round ulcer of the caecum, in both of which per- foration occurred, with the production of peri- ciecal abscess. It is ([uit.. possible, of course, that inflammation may exteiul to the loose connective tissue behind the ciecuni - when that organ is attached— and even go on to suppuration. But, with the exception of the .uses of ulceration, 1 have no personal kuowlod^'c of instances in which there has been peri-ciucal al)5cess apart from dis- ease of the appendix. The opinion has been exprt-ssed, and is I believe widely held, that tlie casps such as I have here described are also in reality due to appendix dis- ease ; that typhlitis and peii typlilitis mean in all cases tubal affection. 1 confess there is often great doubt as to the true nature of a case, but, clinically, I believe we can recognize a stercoral typhlitis. There is at present in my wards at the Philadelphia Hospital a case in illustration. Lad a-t. 22, admitted 22hd, with temperature of 102", a furred tongue, constipati.jn and abdominal pain. On examination, there was tenderness in the ri 'ht iliac fossa, the thigh was drawn up and everted • the right iliac region was dull, tender to the touch,' and presented a distinct induration, without defi- nite outlines. He had nausea and vomiting on admission. Stupes and poultices were applied '/ ^ ml liirgf cnomata wore j^iven ; no opium, us the iaiu was not excessive. The injeotiona brought way II miiiilier of hard tWal masses. Tlie tern- pciatiiif (111 Ihe third day was normal, the indiini- (if)ii .111(1 ttMidcriiess gradually disappearod, and on iIk! sixth day the stmse of re.sistance in the two • 11 •J ^ides was o(jual, and the patient said that he felt |iiite wt'll. Ife liad had a similar attack six u(>pks before. Such cases we have all seen, and svliatcver the morhid condition may be, I th-nk I hey possess featuies which separate them from I lie next ;,'roup. Appmikilis. -\n the second group of cases the lesion proceeds from the appendix vermiformis, which is liable to various affections- -catarrhal inflammation, catarrhal ulceration, obliteration, obliteration of the proximal end, dilatation of the tube, and perforation. Foreign bodies may also lodge in it, and fieces moulded to the tube may i)ecome hardened and calcified so as to form small enteroliths. In a recent report (Med. and Surg. Rep., Oct. Gth, IJ^HH) I gave notes of eleven cases in which I had met with ulcers in the appendix, usually in connection with phthisis or typhoid fever. I have never met with foreign bodies in the appendix. On one occasion fivo apple pips were brought to me as having been found in, and removed from the tube, in a dissecting. room subject ; and in one of the cases in the post-mortem books of the Mon- treal General Hospital, Dr. Sutherl«ind (who was acting as Pathologist in my absence) records the presence of six or eight snipe shot in the appendix of a man dead from Bright's disease. The resem- blance of the small enteroliths to date-stones, fre- (juently leads to error. Inflanniiation and ulceration of the appendix vermiformis (so long as it is confined to this tube) may produce no definite symptoms. There may be the most extensive ulceration, the lumen may be completely oblit(irated, there may be extreme distention, without the patient manifesting any signs of abdominal disorder. If the appendix is quite free, it is possible that ulceration may go on to perforation, without the tube forming attachments. This, however, is very exceptional. More commonly adhesions form and the perforation leads to localized abscess, the situ- ation of which will depend upon the position of this extremely variable structure. It is n\08t commonly situated in the right iliac fossa, and is either within the peritoneum, when the appendix is entirely surrounded by this membrane, or it is behind the peritoneum, when the appendix (which is rarely the case) has only a partial serous cover- ing. I have seen peiforation o(;cur with the for- mation of localized abscess, within the pelvis in the neighborhood of the broad ligament ; in ano- ther instance immediately upon the sacrum, the tip of the appendix lying to the left of the middle line ; and, in a third instance, the abscess was high up behind the mesentery upon the psoas muscle. I do not think that sufficient stress has been laid upon the fact, that this local inflammatory process almost invariably precedes the graver man- ifestations. That healing may take place at this stage, is shown by the occurrence of an obliterated tube closely adherent with fibroid thickening and much pigmentation of the surrounding tissue. Once perforation has occurred with abscess forma- tion, the course is extremely variable. It is within the experience of almost every physician to have seen the pus appear anteriorly in the neighborhood of the groin, where it may open spontaneously. The presence of gas, or even small fragments of fieces, may shov,- that there is open communication with the bowel. Two such oases I saw with my preceptor. Dr. Holford Walker, of Dundas, in 1866 and 1869. One of these cases made a good recovery ; the other, with much more extensive abscess formation and perforation in several places (through which gas discharged), succumbed to sep- tic fever. That the tube of the appendix is not always obliterated at its caHJal end before perfora- tion occurs, as is claimed by some writers, is shown by such cases. The pus may burrow and appear in the lumbar region, or it may pass down and appear in the peritoneum and form a peri-rectal abscess. A more favorable event is, when the abscess perforates into a neighboring viscus— the colon, the crecum, the rectum or the bladder. In a recent report of a case in a French Journal, in which the abscess perforated into the bowel, the characteristic oval enterolith was found with the discharged pus and fseces. Perforation into tli^ bladder is less common. At the Montreal Genera! Hospital, in the Summer session of 1882, IJecturcd upon two cases in which this event occurred with were fifiven ; no opium, as the sive. The injections brought lard ftocal masses. Tlie tern- 1 day was normal, the indura- Sjradually disappeared, and on ,inse of resistance in the two the patient said that he felt td had a similar attack six ^1 cases we have all seen, and d condition may be, I think {s which separate them from the second group of cases the '. n the appendix vermiformis, i various affection." —catarrhal irhal ulceration, obliteration, itroximal end, dilatation of the \m. Foreign bodies may also .les moulded to the tube may d calcified so as to form small ■t (Med. and Surg. Sep., Oct. »tes of eleven cases in which I s in the appendix, usually in lisis or typhoid ft ver. I have sign bodies in the appendix. 3 rpple pips were brought to found in, and removed Trc:" ting. room subject; and in one OBt-mortem books of the Mon- Ital, Dr. Sutherl«ind (who was 8t in my absence) records the wht snipe shot in the appendix B right's disease. The resem- enteroliths to date-stones, fre- or. I ulceration of the appendix I as it is confined to this tube) ifinite symptoms. There may Ve ulceration, the lumen may irated, there may be extreme the patient manifesting any lisorder. j quite free, it is possible that )n to perforation, without the inents This, however, is very commonly adhesions form and J to localized abscess, the situ- depend upon the position of this extremely variable structure. It is most commonly situated in the right iliac fossa, and is either within the peritoneum, when the appendix is entirely surrounded by this membrane, or it is behind the peritoneum, when the appendix (which is rarely the case) has only a partial serous cover- ing. I have seen pei foration occur with the for- mation of localized abscess, within the pelvis in the neighborhood of the broad ligament ; in ano- ther instance immediately upon the sacrum, the tip of the appendix lying to the left of the middle line ; and, in a third instance, the abscess was high up behind the mesentery upon the psoas muscle. I do not think that sufficient stress has been laid upon the fact, that this local inflammatory process almost invariably precedes the graver man- ifestations. That healing may take place at this stage, is shown by the occurrence of an obliterated tube closely adherent witii fibroid thickening and much pigmentation of the surrounding tissue. Once perforation has occurred with abscess forma- tion, the course is extremely variable. It is within the experience of almost every physician to have seen the pus appear anteriorly in the neighborhood of the groin, where it may open spontaneously. The presence of gas, or even small "fragments of fiBces, may show that there is open communication with the bowel. Two such oases I saw with my preceptor. Dr. Holford Walker, of Dundas, in 1866 and 1869. One of these cases made a good recovery ; the other, with much more extensive abscess formation and perforation in several places (through which gas discharged), succumbed to sep- tic fever. That the tube of the appendix is not always obliterated at its ca-cal end before perfora- tion occurs, as is claimed by some writers, is shown by such cases. The pus may burrow and appear in the lumbar region, or it may pass down and appear in the peritoneum and form a peri-rectal abscess. A more favorable event is, when the abscess perforates into a neighboring viscus— the colon, the caecum, the rectum or the bladder. In a recent report of a uabe in a French Journal, m which the abscess perforated into the bowel, tiie characteristic oval enterolith was found with the discharged pus and fseces. Perforation into tb- bladder is less common. At the Montreal General Hospital, in the Summer session of 1882, IJectun'd upon two cases in which this event occurred with ■,ure. It is most iliac fossa, and is i'hen the appendix [uembrane, or it is e appendix (which irtial serous cover- jccur with the £or- thin the pelvis in ligament ; in ano- n the sacrum, the ; left of the middle le abscess was high the psoas muscle, nt stress has been local inflammatory ies the graver man- take place at this ce of an obliterated oid thickening and urrounding tissue, with abscess forma- riable. It is within physician to have ji the neighborhood pen spontaneously, small fragments of ipen communication ises I saw with my :er, of Dundas, in cases made a good ich more extensive ion in several places ), succumbed to sep- bhe appendix is not end before perfora- ne writers, is shown burrow and appear lay pass down and 1 form a peri-rectal event is, when the iboring viscus — the or the bladder. 1 ii French Journal, in into the bowel, the was found with ihv Perforation into t!i ' le Montreal General nof 1882, IJectuivd event occurred with i-ecovery. I met with a fiurious sequel in a case of peri-cffical abscess which perforated into the bowels. The patient had for some years aftor and may s^lll have for aught I know, persistent enlargement of the right leg, due, undoubtedly, to chrome venous stasis consequent upon the narrow- ing of, or perhaps the obliteration, of some of the large veins in the pelvis. A third and almost necessarily fatal mode of termination, is when the local circumscribed abscess perforates the perito- neum, setting up a diffuse, virulent and septic mflammation. I have never yet seen instances of perforative appendicitis in which there were not attempts made to limit the inflammation. Even when the appen- dix has been free in the peritoneum, walls circum- scribing the abscess arr rmed by the adherent mesentery, retro-peritoneum and intestinal wall Symptoms of perforative appendicitis are fairly well defined. A number of cases begin with in- testinal trouble, constipation or pain in the ilio- caecal region, lasting for a variable lime. A mo-e characteristic mode of onset is a sudden, sharp pam in the right iliac fossa. This may be followed by collapse symptoms, or more usually by an ag- gravation of the intestinal disturbance. It is worth noting, that strain, such as sudden lifting or jumping, may be followed by an acute pain and may, apparently, be the starting-point of appendicitis. The local symptoms are rarely as well marked as in typhlitis Tenderness is usually present ; there may be fullness, or even induration but in my experience, these signs are more fre- quently , absent. The leg is usually drawn up thereby relaxing the psoas m uscle. Irritability of the bladder, as shown by frequent micturition not infrequently occurs. The fever is moderate' the tongue is furred, but constipation is not so' constant a feature ac in stercoral typhlitis Ab- dominal aistention (tympanites) comes on early and may interfere with proper examination. A rectal examination may indicate fullness towards tnc roof of the pelvis, but unless the whole hand IS used, the ordinary digital exploration is practi- cally worthless. Practice on the cadaver, with the pelvis exposed, shows how futile is the attempt to reach, even with the longest finger, those higher portions of the pelvis which the peri-aecal inflam- _mat,on usually afiects. Increasing tympanites diffuse i decubitus of the pati( tutional toms. Cases occur i peritoni accurately determine peritoni presents the picture the abf has started from soi; small in Treatment of per abdomii disease has made g saw, wi few years, and the tion of 1 Parker has now beci abdoniii but a most success board-li stated, there are m In a recovery, even whe sudden occurred. We all h not the *^*oks of this disease sion of i P®ar and the patie As I ha n^edical treatment i adhesioi spoken of in typhlit; in perso almost always to b localized constipation, large possible ^" *h6 early stage local ab! would hesitate to er sympton which moves the bo forated ; ^'^oe of the peristals; mischief when gen'^ral peritoi tion, tha ^'his method of trea onset of rational. A concer duration] ^^^'^^ depletion of tl also its € '^^'num to ca?cum, a vation of in these region, c ically inf In inf appendij all the s den agon gastro-in days, fact, tha present j are more nary typ also less j portion ol diagnosis of onset, vious his of hernia rence of f interstitial oedema which, chiefly, th. in the early stages should be directed t< tory process, and fa^ riera which nature ^1 i^ecovei;;., I met with a fiurious sequel in a case of peri-cjEcal abscess which perforated into the bowels. The patient had for some years after, and may still have for aught I know, persistent enlargement of the right leg, due, undoubtedly, to chronic venous stasis consequent upon the narrow- ing of, or perhaps the obliteration, of some of the large veins in the pelvis. A third and almost necessarily fatal mode of termination, is when the local circumscribed abscess perforates the perito- neum, setting up a diffuse, virulent and septic inflammation. I have never yet seen instances of perforative appendicitis in which there were not attempts made to limit the inflammation. Even when the appen- dix has been free in the peritoneum, walls circum- scribing the abscess are formed by the adherent mesentery, retro-peritoneum and intestinal wall. Symptoms of perforative appendicitis are fairly well defined. A number of cases begin with in- testinal trouble, constipation or pain in the ilio- cjfical region, lasting for a variable time. A more characteristic mode of onset is a sudden, sharp pain in the right iliac fossa. This may be followed by collapse symptoms, or more usually by an ag- gravation of the intestinal disturbance. It is worth noting, that strain, such as sudden lifting or jumping, may be followed by an acute pain, and may, apparently, be the starting-point of appendicitis. The local symptoms are rarely as well marked as in typhlitis Tenderness is usually present ; there may be fullness, or even induration, but in my experience, these signs are more fre- quently absent. The leg is usually drawn up, thereby relaxing the psoas muscle. Irritability of the bladder, as shown by frequent micturition, not infrequently occurs. The fever is moderate ; the tongue is furred, but constipation is not so I constant a feature as in stercoral typhlitis. Ab- dominal distention (tympanites) conies on early, land may interfere with proper examination. A jrectal examination may indicate fullness towards jthe roof of the pelvis, but unless the whole hand |s used, the ordinary digital exploration is practi- Pally worthless. Tr,M,ctice on the cadaver, with ^he pelvis exposec, niiows how futile is the attempt - rnach, even with the longest finger, those higher ortions of the pelvis which the peri-ciecal inflani- Qation usually affects. Increasing tympanites. diffuse tenderness on paljiaii,,,!, aggravated consti- tutional symptoms, indi.;,to the spread of the peritonitis. It must not i,,. forgotten that the peritonitis may be limited i,, the lower portion of the abdomen, even conii I to the coils of the small intestines situated uithin the pelvis. Such abdominal distention may i,,. extremely slight. I saw, with Dr. Musser. last year, a case of perfora- tion of the appendix with ji..iitonitis, in which the abdominal walls were flat and presented a hard, board-like resistance to palpation. In a considerable majorify of cases, I think the sudden on:et with sharp' intense pain, indicate.s, not the perforation of the appendix, but the exten- sion of an already existin- inflammatory proces.^^. As I have stated, extensive ulceration, distention, adhesion and obliteration of the tube, may occur in persons in whose history there is no account of localized abdominal inflaniniation. It is not im- possible that ulceration, loading to perforation and local abscess, nniy occur without exciting severe symptoms. I have so often seen, about the per- forated appendix, signs of chronic inflammatory mischief indicated by fihr.tiis hands and pigmenta- tion, that the process has certainly ante-dated the onset of the acute fatal illness of only a few days duration. Marked tendency to recurrence finds also its explanation here, in the temporary aggra- vation of the condition. Siu-oonshavereneatedly, in these cases of recurring attacks in the peri-ca?cal region, cut down and reniowd an adherent, chron- ically inflamed and even perforated appendix In many instances tlie diagnosis of perforated appendix presents great (iifliculties. Perhaps, of all the .symptoms, the most important is the sud- den agonizing pain occurrini.' either at first, or after gastro-intestinal .symptoms have lasted for some ^ days. Its importance may he gathered from the fact, that of 237 cases analyzed by Fitz, it was present in 210. Abdomin/ii pain and distention are more marked, and ocenr earlier than in ordr nary typhlitis. Induration in tho iliac fossa i.- also less common ; indeed, a very considerable pro portion of the cases picscnt no local tumor. The diagnosis in such cases rests largely upon the mode of onset, the development of symptoms, the pre- vious history of the patient, the absence of signs of hernia or of internal strangulation. The occur- rence of frequent micturition and the characteristic 'f ^'i'. decubitus of the patiint, are highly suggestive symp- t(jins. Cases occur in which it seems impossible to accurately determine the condition, and the patient presents the picture of general peritonitis, which lias started from some unknown locality. Treatment of peri csecal abscess from appendix disease lias made great progress within the past few years, and the operation devised by Willard Parker has now become, not only a very frequent, but a most successful oiie. As I have already stated, there are many instances of spontaneous lecovery, even when extensive suppuration has occurred. We all have seen, in the recurring at- tacks of this disease, the gravest symptoms disap- pear and the patient rapidly convalesce. The medical treatment is much the same as' I have spoken of in typhlitis. Opium, in some form, has almost always to b^ used to relieve pain. For constipation, large injections may be employed. In the early stage; I never use purgatives, I^ would hesitate to employ even a saline cathartic, which moves the bosvels with very little disturb- ance of the peristaHs. Not that I would hesitate when ceneral peritonitis is established, as I believe this method of treatment to be in a high degree rational. A concentrated saline purge produces local depletion of t'.e intestinal vessels from duo- denum to ciEcum, aad removes in great part the interstitial oedema of the intestinal wall upon which, chiefly, th.J paralysis depends. But, in the early stage^l of tt^ffthaflTection, our means should be directed tt^wards limiting the inflamma- ; tory process, and fa'«|oring those conservative bar- riers which nature! invariably sets up against extending inflammatio]^. I have been so much impressed with the fact, that in these cases the dangerous symptoms seem to originate by the extension of the disease from a localized peri-csecal abscess — the walls of which may be in part mesen- teric, or, as I have seen, intestinal — that I dread the disturbing influence of purges. The indica- tions for surgical interference are not always clear ; but my experience has taught me that the abdomen is much more frequently left untouched than it should be, and that an operation is too often deferred until practically useless. Local indications may be very positive, particularly when the perforated appendix lies behind the peritoneum, in the iliac fossa spine above Poupart's ligament. But when the abscess is high on the psoas muscle, or lies within the brim of the pelvis, or far over towards the middle line, these symp- toms are absent, and in such cases, from the gene- ral condition alone, the indications for operation must be gathered. We may say, as a general rule, that in young persons, in whom the attack has set in with severe pain in the right iliac fossa (whe- ther preceded or not by previous digestive disturb- ance), and in whom the constitutional symptoms, as shown by rapid pulse, fever and coated tongue, indicate a serious lesion — when tympanites and abdominal tenderness exist, it is better in these days of safe laparotomy to give the patient the benefit of any diagnostic doubt, even without the existence of local tumor, and to explore thoroughly the peri-csecal region. Still more urgent would such indications be, if the patient had had pre- vious, though less severe attacks. 4 , [int, are highly suggestive symp- n which it seems impossible to I the condition, and the patient , of general peritonitis, which le unknown locality. ' csecal abscess from appendix (•eat progress within the past 'operation devised by Willard (i»nie, not only a very frequent, i'ul one. As I have already iiny instances of spontaneous in extensive suppuration has lave seen, in the recurring at- j., the gravest symptoms disap- ; tnt rapidly convalesce. The f:;8 much the same as' I have \m. Opium, in some form, has ;? used to relieve pain. For 1>. . ■ , , . 'injections may be employed. f I never use purgatives. I |aploy even a saline cathartic, flv^els with very little disturb- Is. Not that I would hesitate liitis is established, as I believe liment to be in a high degree 'ftrated saline purge produces ,e intestinal vessels from duo- d removes in great part the of the intestinal wall upon paralysis depends. But, of tl^9ik.affection, our means |wards limiting the inflamma- oring those conservative bar- invariably sets up against extending inflammatioy. I have been so much impressed with the fact, that in these cases the dangerous symptoms seem to originate by the extension of the disease from a localized peri-csecal abscess — the walls of which may be in part mesen- teric, or, as I have seen, intestinal — that I dread the disturbing influence of purges. The indica- tions for surgical interference are not always clear ; but my experience has taught me that the abdomen is much more frequently left untouched than it should be, and that an operation is too often deferred until practically useless. Local indications may be very positive, particularly when the perforated appendix lies behind the peritoneum, in the iliac fossa spine above Poupart's ligament. But when the abscess is high on the psoas muscle, or lies within the brim of the pelvis, or far over towards the middle line, these symp- toms are absent, and in such cases, from the gene- ral condition alone, the indications for operation must be gathered. We may say, as a general rule, that in young persons, in whom the attack has set in with severe pain in the right iliac fossa (whe- ther preceded or not by previous digestive disturb- ance), and in whom the constitutional symptoms, as shown by rapid pulse, fever and coated tongue, indicate a serious lesion — when tympanites and abdominal tenderness exist, it is better in these days of safe laparotomy to give the patient the benefit of any diagnostic doubt, even without the existence of local tumor, and to explore thoroughly the peri-csecal region. Still more urgent would such indications be, if the patient had had pre- vious, though less severe attacks. Lx XX V III IX PUERPERAL ANEMIA, AND ITS TREAT MENT WITPT ARSENIC. UV WILLIAM 08LKR, M.U cases, amrinWperTif? Vf 'rT. t'^"'^^^'^ «""ilar appeared abounre\amftimfm^^ interest in this subject ' ' '''''"'^'^ ''^ ^*««"1' . The importanoe of this etiolomcal fiotor ;» •■lous anemia is shown bytlie tSmnfnf r™' observations collected bV EiclXopstlh '''*^-°"'^ in twenty-nine cases d^Lt I ■ ' *^'^ synii^tonis nreL'Danr^. -.f t^ t^eveloped m connection with who„ «. ccair-riJiy^ P^a^l-ol Sk 11 ! ii 1 f 4 ! i "■ ■ i . ' ^! i t i J ■ ^nt, are highly 8Ug ^n which it seema I the condition, ai of general peril le unknown loca I csecal abscess f r peat progress wi operation devisei ;>nie, not only a v f'ul one. As I finy instances of a extensive sup ave seen, in the the gravest syn int rapidly con^ ta much the san Is. Opium, in sc |i used to reiiev injections may I never use p I (>ploy even a sali (vels with very ] I 8. Not that I M litis is establishec bment to be in,£ itrated saline pu 1,6 intestinal vesa ftd removes in gi *of the intestim |) paralysis dep of tl?si».affectioi iwards limiting 1 'oring those com invariably sett these cases, three recovered ; of one, I aiu doubtful, as the patient removed to a distance and has not since been heard from; the fifth case T have here given in full, as illnstvative of certain important points in connection Avith the treatment of this coudition. , ■ . , Amelia T., a^ed thirty-five, domestic, was admitted to the medical wards of Philadeli)hia Hospital on 25th February, 1888. Nothing' of note in family or previous personal history. In October, 1887, she was confined of her fourth child — easy delivery. She was well through her pregnancy, but in last month had suffered with bleeding piles. She was up and about two weeks after delivery, nursed the baby, but was very pale and weak. She was dis- charged in about 'six weeks. She never regained color after her confinement and had many spells of fainting, once or twice having fallen in the street. After January 1st this condition grew worse, and diarrh-ea set in. When admitted she was in a con- dition of profound aiia'inia, and had severe diarrhrea with irregular fever. She was placed on Tr. perchl. Fe, gtt. 20, t.i.d. She remained in bed and had not im]i.'oved ; and when I saw her first on ITtli A]-.i-il she was in the following condition: — Profound anaemia; face and general cutaneous surface has slight subicteroid hue; fat is fairly well retained, though the arms look thin, conjunc- tiva^ pearly, tongue extremely blanched. She is unable to sit up on account of the fainting. Has three or four movements of the bowels daily. Pulse 120°, small, jerky. Periiiheral veins not very full. Apex beat of' heart at fourth interspace ; visible pul- sation in sidx'laviaus and carotids. There is a rougli thrill with first sound. Cardiac dulness from lower border third rib. On auscultation both sounds heard •A at apex with much edio; loud systolic^ innrmur, propagated to axilla ; also heard very plainly idong left sternal border. Distinct systolic; inurnur at aortic cartilage. Second sound much accentu.'ited. Lungs normal. No enlargement of sideeu or liver. Tenderness on ])ressure over alxlomen. (ilands are not enlarged. Fever range of 2 or :i degreea daily. Blood very watery; red corpuscles per cu.mm. 1,170,000; percentage white to red, 1 : 484; color by Gowers' ha'moglobniometer, about lo-18% ; corpuscles extremely irregular in size and shape; considerable proportion of larger ones are oval. There are many microcytes. Several nucleated red blood corpuscles were seen. SheAvas ordered Fowler's solution, five minims t.i.d. for a Aveek, and then to increase one drop each (lav until ten minims were reached ; opium supposi- tories for the diarrhoea, and in a few days enemata of dried blood. Blood count on April L'Gtli, 1,480,000 ; color percentage, L'O. She took the arsenic well,' began to improve in color, and on May 10th blood coimt by Dr. Henry Avas as folloAvs : Red corn 2,800,000; haMm)gh)bin, 40%. ^ ' Patient improved rapidly through the simimer, the diarrhoea stoi)ped and she gained greatly in Aveight. When I Avent on duty Sei)t. Cm\ 1 did not recognize the patient, now a large robust-looking Avoman Avith excellent color. The apex systolic nuirmur i)ersists. We have in this case a 'history very similar to that Avhich is met Avith in the majority of instances of post-i)artum anemia. It is interesting to note that the patient, prior to delivery, had suffered Avith hemorrhoids, and had lost from this source consid- erable blood. She never regained her color after confinement, but remained very pale, and after dis- charge from the hospital she had many fainting '■1 If m If hS^^' ^"^de" int^'stmal hemorrhage in an apparently ^^^Ithy person, which tends to recur and produce a pro » Am^ir' ^I'^^'^^f^' Awl, May, and June, 1887. > rS'^'^iir'""™,^' ■ '-= ^^dical Sciences. 1888, i. Canada Me al and Surgical Journal, March, 887 ,^nt, are highly sug ,n which it seems i the condition, ar ;j of general peril :,ie unknown loca i. cBBcal abscess fr J-eat progress wi jpperation devisei |)nie, not only a \ |:ul one. As I sjjiny instances of |n extensive sup ave seen, in the , the gravest syn mt rapidly con> a much the san 8. Opium, in sc '. used to reliev injections may I never use p 1 oploy e _".. i«i sail wrels with very 1 18. Not that I M» litis is establishec braent to be in t ! trated saline pu ,e intestinal vess ad removes in gi ) of the intestinf 5 paralysis dep of th^affectioi ■ iwards limiting 1 'oring those com ' invariably sets spells. The coiiditioii in whioh I i'<'"iin several occasions the sickness of the stomacli was aggravated, and the medicine was interrupted for a week. By the 19th of May she was able to sit up in bed, her appetite began to improve, the corpuscles had more than doubled in number per cubic millimetre the hfemoglobiii had risen from 15 to 40%. Rectal injections of dried blood were, for a time, employed, biit had to be stopped on account of the irritation they produced. . ^ m I did not see this patient from the end ot iMay until I went on duty Sei)t. .Srd, at which time I did not recognize her. She had grown stout, her color was excellent, and she looked in robust health. 1 he patient's recovery may be attributed to the arsenic. / X fdiinil lior was , lip in l)f(l witli- ; vomiting, \vitli t t'Xpct't her to ) typical ns vc- scl«''S. TliP por- ;)W('V('T, rediii'od iidt't'd, tlu' indiv- ui'iuogloliiii was of instances ol is good. ,nt point in tlie Miis patient had IV. ot ])eri!hl''ride 'b. iJoth to Apr. [y regulated, ami check the diar- vith five minim ii, time was well icreased, and the •al occasions the ravated, and the A. 3 to sit up in bed, e corpuscles had cubic millinu'tie, to 40%- Kt^ct:il I time, employed, of the irritation the end of IMay which time I did [1 stout, her color bust health. The ed to the arsenir, and 1 believe that if the iron had been continued slie would have failed i)rogressividy, as she did dur- ing the six or seven weeks in whidi it had Ixsen administered. This is by no means a unique liistory. To Kram- well, of Ediidiurgli, tlie profession is "indebted for pointing out the almost sjiecitic action of this drug in certain cases of pernicious aiuemia. Tlie statistics collected by Tadl-y i a few years ago show forty-eight cases treated without arsenic, of whicli forty-two died. Of twenty-two cases treated witli arsenic sixteen recovered, four died, and two improved. Within the past few years, numerous observations liave sliown tlu^ powerful effect of arsenic in certain cases. Unfortunately, we do not yet fully under- stand why, in some instances, the drug siiould be well borne and prove successful, while in others the patient continues in the progressively downward course. That the cases which we group as pernicious anaemia are very varied is now recognized by all writers on tlie subject. It is not to be expected that when the gastric tubules are atrophied arsenic can be curative. We need a careful study of those instances in whicli the drug has jiroved successful and of those in which it has failed. To judge from therapeutic test alone there must be a very deep-seated difference between the two (dasses. I know of nothing more remarkable in practical therapeutics, nothing so resembling specific action (unless we except iron in chlorosis and quinine in agiie) than the rapid recovery of profound aneemia under tliis drug. As a rule it is well borne ; and should ' Lancet. 1883. il. i if ' I I ' M^! til ^j il uZT^' ^"d 8 much the san a. Opium, in sc used to reliev injections may ||i I never use p aploy even a sali wels with very 1 18. Not that I M litis is establishet bment to be in i trated saline pu .e intestinal vess ad removes in gi hof the intestint ) paralysis dep of tli^affectioi iwards limiting I 'oring those com ' invariably sets a W given, as liramwell advises, in increuHing doses, Ix'ginning with live niiiiiniH, anil rising gnulually to twenty or thirty three times a day. I'lirtiness ot' the eyelids, (edema above th« eye- brows, vomiting or diarrluea, indicate that the drug should be suspended for a time, or the dose reduced. It is interesting to note that the existence of vomit- ing or diarrhoa does not, however, contraindicite the emi)l()ynieut of the medicine, as in the case here reported. These symptoms seemed tf) improve, for a time at least, when the arsenic was first given. If the Fowler's solution disagrees, arsenious acid may be tried. I have known it to be well borne when the liquor arsenicalis disturbed the stomach. The drug may be given hypodermically, but in these instances of profound anaemia the tendency to hanuorrliage is so marked that the punctures may become hemorrhagic. I have known considerable subcutaneous extravasation follow au iniection. The point of the greatest importance is the fact that the medicine must be given in increas- ing doses, and for prolonged periods. I find practitioners express great surprise when they hear of doses of Fowler's solution, of fifteen, twenty, and twenty-five drops three times a day. There is, I think, but one rule in the matter : give the drug cautiously until physiological effects are produced. The tolerance of the system for arsenic, IS well known. I havt', never seen serious conse- quences from its careful administration. Youii.u persons, as a rule, take it better than adults. In an instance of pernicious amemia which I reporteil a few years ago, the patient took twenty minims oi Fowler's solution time timcR a day for/veeks, with the most satisfact'-ry le-.u't-s. / X ncrciiHing dosoH, rising f»ia(luiilly al)ovc tho cyo- iti! that the druj? he (lo8e re(hiCP(l. istenco of vonat- •, contraiiidio ite n» in the case smed to improve, [•senic was first In ixist-partiiiii ca-seH recovery is always slow. It may he many months before [ierfect health is restored. It is well to intermit arsenic tor a few weeks, hut the dniK should [n- ^\vn\ at intervals for many months, even when the health is aj)- parently re-established, as there is a well-i'eeognized tendency in these cases to relapse. i S .'-k.M m grees, arsenious n it to be well is disturbed the hypodermically, nd anaemia the narked that the c. I have known sation follow au 'st importance is given in increas- Ls. it surprise when lution, of fifteen, ree times a day. the matter : give Dgical effects art^ lystem for arsenic, fn serious eonsc- stration. Youuf: than adults. In which I reported twenty minims of i,y for^ weeks, witli hZT' ^"dde", intestinal hemorrhage in an apparently healthy person, which tends to recur and produce a pro » Am-!i'" H''"'"'''''f''/P"'' M''*^' and June, 1887. ~ . rf„ i ''xT^^^™.''' "'^'h" Medical Sciences, 1888, i Canada Medical and Surgical Journal, March, i887 1 ^ ^ r'' 1 H- I 1 M '■ii- J l)nt, are highly sug jH which it seems ,^ the condition, ar ) of general peril ,16 unknown loca I csecal abscess f r •eat progress wi .operation devisei ,>nie, not only a v :ul one. As I iny instances of a extensive sup ave seen, in the , the gravest syn ■nt rapidly com s much the san s. Opium, in sc ^ used to reliev injections may I never use p oploy even a sali (vels with very 1 Is. Not that I M litis is establishec jiment to be in £ ; trated saline pu ; ,e intestinal vess ^ ad removes in gi ) of the intestinf J paralysis dep ? of tl^»aflfectioi >wards limiting < 'oring those com invariably sets ^?^XX/ X In ON THE DIAGNOSIS OF DUODENAL ULCER. By WILLIAM OSLER, M.D., PROFESSOR OF CUN.CA,, MBmc.NE l^ THE UN.VERS. TV OP PENNSYLVANIA. Rtprintedfrom The Medical Record, A-ovemb,r 24. 1888. It has recently been suggested by Bucquoy' that the duodenal is to be distinguished from' the gastrk ulcer by certain well-defined clinical characters Dr W W Johnston, of Washington, has reported' an interesting case which seems to bear out this author's staSment I have expressed myself somewhat sceptically on thS point, although one of the nine cases which formed the Dr^Sl ""^''''"i ^T'^ ^^^ ^^g^^ded during hfe, by Dr. Palmer Howard, of Montreal, as probably duodenal on rnuch the same grounds as Bucquoy lays down ' Physiologically, the portion of the duodenum above the bile papilla belongs to the stomach. Peptic diglst on only ceases where the acid chyme is neutralized by he bile. When we consider how limited is this region, and how close to the pyloric ring many gastric ulcerf Se iJh not surprising that difficulty should exist in the dia^osi The points upon which Bucquoy lays the greatesfstress Src=.'^'T'!f:i' °^- '^^ ^"°^^"^1 "'^^^' ^'•^ ^^ follows : h^fi K ^"dde\\"testinal hemorrhage in an apparently h^lthy person, which tends to recur Ind produce a pro ' Archives Genorales, April, May, and lune 1887 Canada Med.cal and Surgical Journal, March, isS;. 1 'f Ilk ■?> : *^ ■ 2 found ansemia. Hemorrhage from the stomach may ])recede or accompany the melcena. Second. Pain in the right hypochondriac region com- ing on late ; two or three hours after eating. Third. Ciastric crises of extreme violence ; the hem- orrhage being more ajjt to occur about the time of these n.tt3.CiCS The following cases are of interest in connection with possible existence of duodenal ulcer. Case I. — Dyspepsia. Biematemesis and nicliena m 1870. Repeated attacks during the past eig/itcn years, with the exception of the three years, 1877-1880, J'te- quent attacks of heniorr/iage from the Ixmwls iviihout vom- iting; of blood. Sa'cre gastralgia. Henry C , upholsterer, aged forty, was brought to the Philadelphia Hospital by the ambulance, on January 4, 1888, in a condition of juofound exhaustion. 'I'he next morning he gave the following account : For a month he had had diarrhoea, and on several occasions had passed blood in the stool, without any vomiting. On the night of January ist, he vomited nearly two quarts of blood. On the 2d he remained in bed very much prostrated, and that night again vomited a large quantity of blood, " half a basinful," he said. On the 3d he had no vomiting, and on the evening of the 4th, when in hospital, he vomited three or four times and brought up clots of dark granular matter. On inspection, the patient was found to be profoundly anaemic and unable to sit up in bed without fainting ; his skin was like ala- baster ; pulse 130, small; respiration 20; blood-count, 950,000 r.c. per c.mm. Haemoglobin, twenty per cent. The history which he gave was remarkable. He had been healthy as a young man, with the exception of dys- pepsia. In February, 1870, he had a hemorrhage from the stomach and brought up, he says, two bowlfuls ot blood, and also passed blood in the stool. During the next two years he had several attacks, and suffered con stantly with pains. In 1873 he nearly died of hemor- rhage, and during the next four years, three months did not pass without a recurrence. In 1877, he was four weeks in tlie Pennsylvania Hospital, having ha*', profuse hemorrhage from bowels and stomach. He returned to France after this, and on August loth had bleeding from the bowels. For the next three years he had no hem- action with orrhage, though he was never free from uneasy sensations in stomach, and at times had attacks of severe pain. In 1 88 1 the haematemesis recurred, and since then he has had repeated attacks. In 1883 he was in the hos- pital sixty-five days; lost sixty-five poimds in weight, and was believed to have cancer of the stomach. From this time he had more or less gastric disturbance, consisting of pain after eating, usually delayed for several hours At intervals of a few weeks there would occur severe gastric crises, m which tlie pain would be agonizing in character shooting from the stomach, back, and sides ; he vomited sometimes large quantities and occasionally had attacks of diarrhoea. When in hospital, in 1883, he was taught to wash out the stomach with a tube, and he has done it ever since, at intervals, with great benefit. He remained under observation until March 26th, and the blood con- dition was carefully studied, with the following results : January 5th, r.b.c, 950,000 per c.mm.; 6th, 770,400- 7th, 1,053,000; 8th, 1,086,400; 9th, 1,175,000; loth' 1,179,000; i2th, 816,400 (bleeding the night before)- 13th, 1,034,400; 15th, 916,320; 19th, 1,300,000. H rom this time the rate of increase was rapid. When he left the hospital the blood-count was over 3,<;oo,ooo per c.mm. "^ On January 14th he had a large movement of the bowels containing blood, but there was no vomiting I^rom this time on the bleeding ceased. His apnetite be- came ravenous, and it was with the greatest difficulty that he could be confined to proper diet. Examination of the abdomen revealed slight distention; no tenderness- no trace of tumor. The abdominal walls were thick, and it was difficult to outline the stomach, the gastric tympany extending a hand's breath below the costal margin. The organ appeared to be slightly enlarged; liver dulness normal ; splenic dulness not increased. There were the usual cardiac and arterial phenomena of profound anaemia. Throughout the month of February the im- provement was very rapid. He gained in weight ; began to have a little color and had no gastric distress, even after a full meal. He had diarrhoea at times ; three or four stools in a day. Early in March he was .mxinus to "o to work, and was with difficulty kept in hospital. He had no vomiting,, and stated that he felt perfectly well with the exception of a slight weakness. He had a ravenous i ill : 3 21 ! 1 1 ! ^ ' 1 - J i ■I 1.1; ';1 'liEi i:iiii:-k'itll If I ir appetite, and I repeatedly had to warn him against eating too much. He returned to work March 26th, and through the spring and summer remained fairly well. On August 4th the hemorrhage from the stomach re- curred and continued four days. He lost much blood and grew rapidly weak. In the course of a week he re- turned to work, and on September 5 th called to see me at my office, having come directly from the workshop. He was profoundly anaemic, extremely short of breath, and could scarcely get up the stairs. I or nearly a week he had been passing blood from the bowels, without vomit- ing. He was admitted to the University Hospital Sep- tember 5th. He complained of slight L^astric distress, but had no bleeding until the 20th, when 1 vomited nearly a pint of blood, dark in color, mixed with food. The same evening he passed large quantities from the bowels. With the exception of weakness he insisted that he felt well, and was always asking for more to eat. There was no further vomiting during his stay in hospital, and his blood- count, which had been about 1,500,000 on October 8th, rose rapidly to nearly 3,000,000 per c.mm. He gained seven pounds in weight within a month. On the 8th the examination of the abdomen gave re- sults as follows : Somewhat dilated; uniformly tympanic; no tenderness ; no tumor to be felt ; obscure sense of in- creased resistance at a point midway between the navel and right costal margin ; liver dulne&s from the sixth rib to costal margin. He has periods of freedom from abdominal pain, but not of long dura ion. After a full meal he is at first com- fortable, but in three or four hours there are uneasy sen- sations in the stomach, often positive pains, which may become severe. When the stomach is empty and the pain becomes intense, taking food, even a biscuit or half a glass of milk, will give relief. As stated, there is no epigastric tenderness, and he always locates the pain along a line from the ensiform cartilage to the spine of the left ilium. Case H. — From 1869 dyspepsia and occasional attacks of gastralgia. In 1880 hcematemesis and mehena. In 1882 slight melcEna ivithout vomiting. Since then repeated attacks 'of gastralgia. — A. B , ag* d forty> good fam.ily history ; was delicate as a lad, but after the age of four- teen enjoyed the average health with the exception of dyspepsia, to which he was liable, and he would at times 5 nst eating !6th, and well. )mach re- jch blood eek he re- to see me workshop, ireath, and a week he out vomit- ;pital Sep- stress, but d nearly a The same :els. With ; felt well, ;re was no his blood- ;tober 8th, He gained n gave re- tympanic ; ense of in- the navel le sixth rib 1 pain, but t first com- ineasy sen- ivhich may nd the pain balf a glass 3 epigastric long a line left ilium. 'fia/ attacks \elccna. In \en repeated food family ige of four- tception of lid at times regurgitate food without discomfort or nausea. In 1 869 he had gastric distress sufficient to make him at times press hard against the stomach ; no nausea; no vomiting. With the exception of attacks of dyspepsia he remained well until September, 1876, when he had fever, and, dur- ing convalescence, violent attacks of gastralgia. These occurred sometimes with vomiting. He had more or less gastric distress until 1879, and he was believed at this time to have malarial gastralgia, and was ordered quinine and arsenic in large doses. In September, 1880, after a hard day's work, he returned home at 10 p.m., and had a great deal of gastric trouble, and before he went to bed regurgitated his food and, mixed with it, some black mate- rial. He slept well that night, and in the morning had a large bloody stool. That day he vomited a large quantity of blood and became very exsanguine. After this time the pain increased very much, but it was always relieved by a hearty meal. In November and December he was in the hospital on the strictest diet, and lost in this time about forty pounds in weight. He improved after this, and in July, 1881, went abroad and was away for two years, during which time he had much discomfort but no very severe attacks of pain. He consulted many of the leading physicians of Europe, and the diagnosis was uniformly gastric ulcer. \Vhile in Paris he had slight hemorrhage from the bowels without vomiting blood. He returned to this country in Decem- ber, 1882, and has been working off and on ever since, but never entirely free from gastric distress, occasionally hav- ing severe attacks of pain. In January, 1887, he had such an attack which lasted fourteen days, and lost twenty-eight pounds in weight. He has repeatedly had to take morphia in large doses to relieve the pain. The patient looks well ; weighs one hundred and sixty-five pounds ; tongue clean ; good ap- petite ; good digestion. Examination of the abdomen, negative ; no tenderness ; no tumor. Remarks. — These two cases have certain points in common. In the first place, the long duration ; the symptoms in one instance recurring over a period of eighteen years ; in the other at least twelve years. The peptic ulcer, gastric or duodenal, may be an exceedingly chronic malady, lasting ten, fifteen, twenty, or, according to Brinton, even thirty, years. Anatomical observations i.'U-,,. .J<-^ ■.! ■, !■ : it. ■ SP M i ^ im^ show that a large proportion of these ulcers heal, yet there are others which, from their general condition, can scarcely be repaired. The deep excavation, the size of a dollar-piece, with hard fibrous base^ thickened peritoneal coating, and indurated edges, which we find so often in fatal cases, is an unlikely ulcer for cicatrization. The time element in these two instances gives no clue whatever to the situation of the ulcer. The pain in gastric and in duodenal ulcers is very similar, with the exception of the time of onset, which, as a rule, in gastric ulcer more closely follows ingestion of food, while in the duodenal it is deferred two or three, or even four, hours. This is, however, an uncertain symptom. In Case IX. of my series, close questioning elicited the most positive statement that food had no special influ- ence, one way or the other, in inducing or in aggravating the pain, which was more likely to come on while the stomach was empty than subsequent to a meal. The late onset of pain in duodenal ulcers has usually been attributed to the action of acid chyme passing out of the pylorus toward the close of gastric digestion. It is to be remembered, however, that the chyme passes continuously from the stomach, commencing, probably, within a half-hour after taking food. The increased acidity of the gastric contents toward the close of di- gestion may have something to do with it. While perhaps too much stress has been laid upon this point in the differential diagnosis between gastric and duodenal ulcers, it does hold good in certain instances. A more important criterion, I think, is in the occurrence of gastric crises, agonizing attacks of colic, which seem to be more severe in the duodenal disease. A feature worthy of notice is the occurrence of severe gastralgic attacks at night. Absolute immunity from all gastric distress in the in- tervals between taking food is more common in duodenal than in gastric ulcer. It is to be noted, in the cases here reported, that gastric distress has been more or less con- stant. A feature common to both ulcers is the prolonged interval ot freedom. In Case VIII. of my series, a di- agnosis of malarial ga'-tralgia was made by an eminent cUnician, based lar-cly upon the fact that the patient had repeated periods of complete immunity from all symp- heal, yet ition, can ; size of a peritoneal 3 often in The time hatever to rs is very , which, as gestion of ) or three, uncertain licited the ;cial influ- ggravating while the las usually )assing out ;stion. It me passes probably, increased lose of di- 1 upon this ;astric and instances, occurrence vhich seem A feature : gastralgic ;s in the in- n duodenal cases here )r less con- ; prolonged series, a di- an eminent patient had 1 all symp- character ^""^"^^"^ ^^ ''"^'^''^ °^ ^^^ ^°^^ aggravating 'rhe point upon which the greatest stress has been laid in the diagnosis of duodenal ulcers is the occurrence of melcena without haematemesis. Bucquoy and Johnston Doth hold that it can be recognized by this symptom alone. If so, the diagnosis in the patients whose history IS given above is plain. The first case had repeatedly passed blood from the bowels without hemorrhage from the stomach, and the second on, at least, one occasion As already stated, it was this symptom which, in Case vni. of the series I have reported, led Dr. Palmer Howard to suggest the existence of duodenal ulcer In the above-reported cases I should hesitate to give a posi ti ve diagnosis on this symptom alone, with the co-existence of such marked gastric disorder. In Johnston's case and in several of Bucquoy's patients, I grant that the condi- tions for a correct diagnosis were fulfilled, and I accept the importance of melaena alone as a valuable localizing index ; but I submit that instances such as I have given illustrate the uncertainty, rather than the certainty, which still pertains to the diagnosis of duodenal ulcer ..i>^... ni ■OK "" ^^'^ '■^"^ '^H '^-»^ti J ,.'_■■ , . . 1 - i-,A J . ''"•"^~^'<- ■ ''■*'■ ^1 .£ K^- ^ ^■ .j- '•'- , ' *A.\\.^*%r^ A ..en.->-n. "turn and bladder, a\\\ : of the parts supiilin: and the hmibar nervi - nijortant and vahialik- f wliich nnich may lit J four cases of injury fi ith paralytic synipton-.s i incontinence of iiriiw in the distribnlion ul ;ral nerves. He i|uoti> gunshot wound in tl:.- ears after the accidnit a of the postero-intornai lis and of the penis ard Df injury, the result of height, whicii was lol- id incontinence of feces. ; legs, but there was ali- us, perineum, s( rotiini, ipper tsvo-thirds of the sand within a il'w weeks )Ossible, but ejaculation len flowed slowly post the scrotum was anss- chenschrift. No. 32, 18 V#»»»i fha Vi • <• U.M ./ u... LESIONS OF THE CONUS MEDULLARIS. 3 thetir. the testes were sensitive to pressure, and the . reuKLstenc reflex was present. These parts are sup- pl.ed froin the genito-crural nerve, a branch of the lun. Nar plexus, which is, as Thorburn points out, usually unaflected in these cases. A still more instructiveca.se is reported by Oppen- heun ,n the last n.imber of the y/,r/./,./ Psvc/ua/ne, lid. XX. Heft I. A workman fell from a height of nuieteen feet upon his sacrum. There were numb feelings in the legs, paralysis of the bladder and re.tuni,and complete anaesthesia of anus, perineum scrotiun, penis, and of the skin on the postero- internal a.spects of the thighs. No erections. The reflexes were retained. The movements of the legs r.re perfect and the numb feelings disappeared, llie other symptoms persisted and death took place about three and a half months after the injury The autopsy showed a fracture of the first lumbar verte- bra, and a traumatic myelitis and haematomyelitis of the conus medullaris, and a degeneration of the posterior roots of the third and fourth sacral nerves roming from the conus at the .seat of injury We liave here the very anatomical facts needed to com- plete the picture, and they moreover render it very probable that in these cases the terminal portion of t c cord-the conus-is itself the seat of the lesion, although It IS possible that involvement of the nerves alone would produce the symptoms. By no means the least interesting aspect of these cm IS the light they throw on the situation of the i;n.ves>cal centre in man. Kirchofl"' had already • Archiv f. Psychiatric, Bd. xv. e s e e 8 1 a 4'i 1 1 ■M !■ ill ill matenally enlarged during the pa.st twenty years, ha.s increased with each decade ; in 1873—83 a.s maiij' were admitted a.s in the previous twenty yeans. Taking the .stati.stics of four period.s we ^-^^i"i^^53. '54. '55 a death rate of 24.3 percent.; 1863, '64, '65, I Read l.y title l.cforc the Cnnada Medical Association, Septcinher, 18SS. f !: v-m ^ OSLER, concluded that it wos situated in the conus mcdiil. laris in the region of exit of the third and fnnrtl sacral nerves. In the case of a man who had lallm on the nates, and whose important symptom was l)aralysis of the bladder and rectum, the lesion wa, found in the conus three centimetres above \h filum tcrminale. Oppenheim's case is a still nmk accurate demonstration. The following case can be understood with tli: aid of the preceding remarks : Joe. C. H., ait. sixty-three, applied at tlie In- firmary for Nervous Diseases Mart h 7, 1888. I'amilv history good. Has always been healthy and wdl, though as a young man he had syphilis. Served in the army and on June 8, 1862, sustained a Iractiire of the spine. In the battle of Cross Keys, as he was crossing a bridge, a bullet struck him on the cartruli;e- belt, and the shock knocked him off the bridge, and he fell on the rocks in a sitting posture. He was senseless, and on coming to found himsell m tk ambulance wagon. Was in the military hospitals three and a half years at Winchester and Fort McHenry, for three years of which time he was on a water-bed. The skin of the back was not broken bv the fall. He was paralyzed in the legs and lost control of the bladder and rectum. After a time I he coidd move the legs, but he did not walk until December, 1865. Since that time he has been able to be about, but he has never regained control over the bladder and rectimi. Uses a catheter three or | four times a day. Never knows when he is going to have a stool. , Ffgsenf Cofufi/ion.—WeW-buWt, vigorous-lookin? man for his age; walks well, but favors the leftside A'*t... ,'../*,/ frmu //,<. \\,„ V^^u TU..U.„I T^,., PiOll I in the conus metliil. f the third and fourth a man who had fallen iportant symptom wis rectum, the lesion was centimetres above the ii's case is a still more )e understood witli th: ree, applied at the in- March 7, 1888. Familv been healthy and ucii, ad syphilis. Servid in 562, sustained a fracture i{ Cross Keys, as ho wis ick him on the cartridge- him off the bridge, and itting posture. He was to found himself in the 1 the military hdspitaii : Winchester and Fori f which time he was on ;he back was not broker, zed in the legs and lost I rectum. After a time it he did not walk until at time he has Ijeeii able er regained control over Uses a catheter three 0; lows when he is going to 1-built, vigorous-lookins 1, but favors the left side | LESIONS OF THE CONUS MEDULLARIS. 5 Distrilmtion of the ancxstliesia. Front view. Hear view. a little. When stripped, it is seen that the left leg is slightly smaller than the right. Measurements gave right calf fifteen inches, left thirteen and a quarter inches; left thigh also somewhat smaller. He says the leg has been thin ever since the accident, but he IS always able to get about quite well. The spine IS straight, the lower dorsal vertebrce a little promi- nent, lumbar normal ; no signs of abrasion or of any scars; no pain on pressure. There is complete anesthesia of the lower gluteal > e s '» e e i I i matenally enlarged dtiring the pa.st twenty years, has increased with each decade ; in 1873—83 as many were admitted as in the previous twenty years. Taking the .statistics of four periods we hav^m_i853^'54^'55 a death rate of 24.3 percent.; 1863, '64, '65, I Read by tiUe before the Caiindn Medical Associntion, September, 1888. 6 OSLER, regions, posterior aspects of the thighs, perineum, scrotum, and penis as far as its root. In all other re- gions sensation is perfect. He does not feel the luis- sage of a catheter. He is impotent. No informa- tion asked about seminal emissions. Gluteal reflex well marked. Cremasteric reflex present. K.-J. + +. No ankle clonus. ■ We have to deal here with a residual paralysis of the bladder and rectum and of the skin supplied by the small sciatic, inferior hemorrhoidal, pudendal nerws arising from the third and fourth sacral roots. Whether the injury involved originally the cord or only the branches of the cauda equina does not seem possible to determine. The fact that slight wasting of one leg remains would indicate a neural rather than a central lesion. These cases do not all result from injury. Rosen- thal ' reports the case of a woman, aged thirty, who, as the result of exposure to cold, had incontinence of urine and feces, associated with anaesthesia of aims. perineum, vulva, vagina, and lower gluteal regions. The legs were in all relations normal. From a con- sideration of these cases we may conclude : 1. That the ano-vesical centre in man is situated in the lowest segment of the spinal cord-— the coiii;s meduUaris— at the region of exit of the third and fourth sacral nerves. 2. The association of paralysis of the rectum and I U. jc Jkis centrum Ano-vesicale, Wiener med. Nos. J, .' , and 20, 1888. Pres>e, x^„l f the thighs, perineum, ts root. In all other ru- le does not feel the ])a.s- mpotent. No informa- issions. LESIONS OF THE CONUS MEDULLARIS. J bladder with anaesthesia in the distribution of the inferior hemorrhoidal and pudendal nerves points to a les.on of the lower sacral nerves or of the conus medullans^ It is not always possible to determine uhich IS affected. a residual paralysis of the the skin supplied by the rhoidal, pudendal nerves nd fourth sacral roots. i originally the cord or ida equina does not seem t fact that slight wasting indicate a neural rathur ;ult from injury. Rosen- ^oman, aged thirty, who, ;old, had incontinence of with anaesthesia of anus. id lower gluteal regions IS normal. From a con- may conclude : ;entre in man is situated le spinal cord — the conns of exit of the third and e s >> e e s iralysis of the rectum and jsicale, Wiener med. Prese matenally enlarged citinng tne past twenty years, has increased with each decade ; in 1873-83 as many were admitted as in the previous twenty years. Taking the statistics of four periods we hav^m^f853, '54, '55 a death rate of 24.3 percent.; 18^.3, '64, '65, I Read hy tiOe before the CanadnMcdicRl Associntion, Septemlier, i88,S. 1 i i 1 ; r i.^ .iiiiW iiii u la 11 filfeS Reprinted from the New York Medical Journal for Decemher 22, 1888. xaii d.- /'^ v^^ .M ^h ' K^ ■ 1 ON A FORM OF PURPURA ASSOCIATED WITH ARTICULAR, GASTRO-INTESTINAL, AND RENAL SYMPTOMS. By WILLIAM OSLER, M D PROKKSSOB OP CUBICAL MKmczNB IN THE UNIVBR8ITT O. PENK8TLVANU, The combination of purpnra rhcnmatica with diarrhoea IS frequently referred to by the older writer. The cases which I here report have additional features and, With others to be found in tlie literature, belong to a very remarkable group worthy of more careful study. The clKiractcrs are : T. Recurring outbreaks of purpura often associated with urticaria or local oedema. ir. Articular pain, sometimes with swelling III. Gastro-intestinal disturbance-colic, vomiting, diar- rlid'a, and occasionally hiPinorrhage. IV. HaMnaturia, albuminuria, and sometimes a fatal nephritis. Case L-A B., boy, aged six, seen January 23, 1888 with Dr lun. Norhe„,natie liistor, in family fso.Le memb^ g tj. An aunt's clakl on father's side, aged three weeks '-1 of purpura ha-morrhagica. The child has been excep-' ■onal,, well deve oped and strong. During the past summer le Im led somewhat in health. The present trouble begm on tour weeks ago with pain about the ankle, fo.loweX attach of colic, with diarrhoea, and a skin eruption, urticaria' d t- le ts le :e .>s h A 1- i- 1. n ! ill ^i'- .6 te materially enlarged during the past twenty years, has increased with each decade ; in 1873-8.3 as many were admitted as in the previous twenty years. Taking the statistics of four periods we -''il^^M- ;54. '55 a deatlM-ate of 24.3 percent.; 1863, '64, '65, I Read by title before the Cnnadn MclicaiAssociation, September, 188S. f:^ 11 i i I'l A FOUM OF PURPURA. like in cbaructor, which te.ulo.l to beco.uc purpuric. Large are-is were blaclv and hUio, jii>t like a bruise. About ten clay, after the beginning of the Ulnes. there w. bleedir from the bowels, but uut in large au,ount. Ihcr. :;::J:^tinall.orethanei..o.^^..st.s — :;::;:r';:::^:::u" :""e::ic^ .or ti:; pa. ... „J:'::.u.^, «,o,.-i, ...... '■-";■■»;■;■.'. 2:^,0 ■; fnr.ner i)luiup condition. Terai-crature, 98 , pulse ao tongue L tl^^n-od; abdon.en slightly protuberant uot pa.ntul on Z^. When asked where the pain is, he always place. > ' ; enlar.'ement of the spleen or ot tho !;::."|r.r^;^ro:';he skin over the elbows there is frVsl roi. of eddish-brown urticaria wheals rather nu,,. Lm a d^ss cden^atous-looldng than onlinary h.ves; there ,b a ntcl. also on the Hexor surface of the r>ght ar>u. Tho. loi a re all lu.nu.rrha,ic, and about the raised ones are nunu.,- ousnudl extravasations. There is no swelling of the elbows. Tbout the buttocks and .highs there are very n.any purpu,.. snots No swelling of tlie ankles. ...,., i ,i ' An attack of pain can.e on during the v.s.t. I ad . chani t^r of o-di..ary colic. The stools were brown,sh-bhuk n c but contained no blood. The urine was clear; s,k. . !ravy 1-018, containing distinct traces ot a bunun. Mun SopS exanlination showed a fe.v red blood-corpuscles .ukI '^7ZX ;::!r:;:tr other occasions between -lanuary ... nd February 7t'h. About the 25th of January oedema ot tlie :ir noticd. This increased, the scrotunj cc.,,e swol en, and within ten days there was general anasarca, lb u^^ewas highly alhun.inous, and contained tube-casts and „ ^7d^3-n,elH.y again, ln.t learned froni in. ..nt. that the renal symptoms persisted, and these assumed ti,c A FORM OF riTKPUR.A. lie purpuric. I-argo d.araotor of Bright's disonso, of which ulti.natelv he died in iibout six wecln. The present attack began on Saturday, October 20th, with pain in the arms and knees, and a rash came out on the elbows and legs. Throughout the week he had great pain in the .joints, and the knee-, ankles, and right elbow became swollen. On the 29th, the day after his admission, the following note was made: The patient is a moderately well-nourished man • looks pale ; the tongue is furred, swollen, and indented. Hotli dhows tender, not swcdlen ; complains of pain on flexing the rijrht arm. On both arms there are numerous purpuric spots from 1 to 3 mm. in diameter, most abundant on the tlexor sur- faces. Just below the bend of the right elbow there is a large extravasation the size of a quarter-dollar piece, which is a little raised at tlie center. There are eighteen or twenty spots on the extensor surfaces of the elbows; no extravasations on the skin of thorax or of abdomen. Ilij) joint not painful to touch or to niovement ; the right knee is a little swollen, and can not be tiexed; the right ankle is not swollen, but is tender. There are numerous fading ecchymoses on the extensor surfaces of the thighs and many on the skin of the popliteal spaces; there are none on the legs. During the examination he had several at- tacks of colic. The urine was turbid and deposited a floeculent sediment of mucus. On boiling, it cleared slightlv. On the addition of acid there was a distinct deposit. Microscopically \f- le IS h If- d I' i- i. Q ! f s\ 1 1 J ma enally enlarged during the pa.st twenty years, ha.s increased with each decade ; in 1873—83 as many were admitted as in the previous twenty years. Taking the statistics of four periods we havc^m_i853, •54, '55 a death rate of 24.3 percent.; 1863, '64, '65, I Rend by title before the Canada Medical Association, September, 188S. :■■ I i t ii : ■5: t 4 A FORM i)V PURPURA. there were leucocytes, isoluteil red l-leod cori-uscles, nnd a few blood-casts. He has had proli.so diarrham, but no blood in tla- stools. , , , • Octoher 30th.— Mvina not materially reduced in aniomit. Specific jjravity 1-016. Chemical and microscopical character> as before. Has had persistent vomiting to-duy. NoremUr ht.—V&^^^A a restless night; vomiting has been very distressing; complains a good deal of joint pain ; the lobes of the ears are very tender to the toiicli, congested and red; no distinct extravasation ; the right elbow is red and swollen; la^t night e fresh eruption of puri)uric si-ots appeared on the exte- rior surfaces of both elbows ; the spots are raised, and look like tho«e of purpura urticans. There are also two spots on the metacarpal joint of the left index finger. The ecchymoses on the flexor surfaces of arms have faded. The knees and ankU. are not swollen. Temperature, 100°; pulse, 88, small. Heart soun.lfi normal. Tongue still coated ; gums not spongy. jth —For tlie past three days the albumin in the urine Ims been much more distinct, and there are many tube-casts. Uric acid deposits if the urine is left standing. Tlie genenil condition has much improved ; the diarrhoea is checked, and he no lon„'er complains of abdominal pain ; vomiting is not so dis- trcssiniJ. .;;(/;. —Patient much better to-day; no joint pain; the ec- chymoses have a' .lOst faded, and the vomiting is checked. From this date the recovery was rapid, and at present (hito (November 30lh) convalescence is established. The urine is still albumin.ms. The treatment consisted in the administra- tion of naphthalin with Dover's powder for the diarrhani and colic, and increasing doses of Fowler's solution. Remarks.-k\k\n^on, in Pepper's "System," vol. ii, re- fers to this form of purpura as described by lleiiocli ("Berliner kliu. Woclienschrift," 1874), and by Coiity "Gazette hebd.inadaire," 1876). The latter author, i.i an exhaustive article, has collected a large number ot cases, and describes the disease as " «».e espke de purpura dWigine nerveuser Wagner (Archiv dcr lleilk.u.de. n'lmscles, nnd a few but no blood in tin.- educed in nniouiit. oseopical clmrneter> day. vomiting bas been oint pain ; tiie lol)e.~ ngested and red; w ed and swollen; la>t )peared on tlie ext* - raised, and look like io two spots on tlie The eccbymoses on he knees and ankK ^ se, 88, small. Heart IS not spongy, min in the urine bus iro many tube-casts, mding. Tiie geneiiil jeais checked, and lie oniiting is not so dis- joint pain ; the ei - ling is checked. 1, and at present duto lished. The urine is ed in the admiuisiiM- for the diarrh(jea and lution. ' System," vol. ii, vc- •scrlbcd by Houocli !74), and by Oouty 'he latter author, in irge number of cases, ( espece de pit rp urn nv der Ileilkuiulo," A FORM OK PCRPURA. g U(l. x) and Zimniennann (" Archiv der Ileilkunde," 187o) liavo also reported oases idontical with those above des(Mil)ed With the exception of a paper by 15iiiot on " Purpurd hewor- rhar/lque avec oedemes mohilea et crises inh-sfimiks'^ (" Revue iiuhI. de la Suisse Roin.," 188(i) I Hnd no very recent ac- counts in the journals, I think these jases come properly under the designation imrpura rheumatica, of which they constitute the most an-- gravated and serious form. The varieties of this condition may be pjrouped as follows: 1. Cases in which the purpura occurs with slight articular pain, or witii diarrluea alone, or in which the eruption comes without these symptoms in children who have had rlieumatic manifestations. 2. Acute arthritis involving many joints and associated witli exten- sive yj^^ry^wra urticans — the pe/iosis rhemiutUca of Schonlein. ;i. The variety here described in which, with articular ati'ec- tion and purpura, there are gastro-intestinal crises, luemor- rliages from certain of the mucous surfaces, albuminuria, iind in some cases a fatal nephritis. Are these cases truly rheumatic, or is not the articular atl'ection upon which so much stress is laid analogous to tliat which we see in luemophilia and scurvy ] It is diffi- cult to escape from Mie former view in the presence of characteristic cases of peliosis rheumatica with endocarditis and pericarditis; and yet the close relationship and even iiitorchangeability of certain of these cases of purpura with urticaria, with erythema nodosum, and with the angio-neu- rotic oedema, favor the suggestion that the entire* group may depend upon some poison — an alkaloid, possibly, the result of faulty chylopoietic metabolism — which, in Vary- inn' doses in ditiorent constitutions, excites in one urticaria, in a second poliosis rheumatica, and in the third a fatal form of purpura. d t- e ts n « li n 6 e materially enlarged during the past twenty years, has increased with each decade ; in 1873—83 as many were admitted as in the previous twenty years. Taking the statistics of four periods we havem i853,j54, '55 a death rate of 24.3 percent.; 1863, '64, '65, I Rea.l by title before the Canada MedicarAssocration, September, 1888. i'i^, lihf t f- 4 t I 1 I* f t materially enlarged during the past twenty years, has increased with each decade ; in 1873—83 as many were admitted as in the previous twenty years. Taking the statistics of four periods we -i^i"L^53' '54, '55 a death rate of 24.3 percent.; 1863, '64, '65, I Read by tille before the Canada Medical Association, September, iSSS. m l:H . 1 1 1 i ! 1 i Mil fh Jl m ,aS'- li iaaaa li X ^- II £ Rrprintrd FROM TllIC rNIVKRSITV Mkdicai, Maca/im;. THE MORTALITY OF PNEUMONIA.' By Wiluam Osr.KK, M. D., Professor of Clhiical Medicine, University of Pcnusvlvania.- Pl,y- siciati to tlie University and Philadelpliia Hospitals and the Infirmary for Nervous Diseases. Whether or not the inortaUty from pneumonia li-.s increased of late years, and, if so, to what cause or causes this is to l)e at- tributed aie questions of the utmost practical importance, What are the facts as to the increase in mortality ? The last United States Census Report gives a total of 63,053 deaths from this disease ; 8,330 in each 100,000 deaths from all causes against 8,128 in 1870 ; 6,874 i" i860 and 3,755 in 1850, with the mean age of death at 32. If correct, these figures would indicate an extraordinary' increase in the mortality, but Dr. Billings writes " that the conclusion cainiot be drawn that the mortality has in- creased, because in preceeding years the data were very much more imperfect and unreliable. ' ' The statistics of the large hospitals do not show any decided increase. I have taken the figures of three representative institu- tions ; the Montreal General Hospital, in the North ; the Penn- sylvania Hospital, and the New Orleans Charite, in' the South. At Montreal the statistics are available since 1853, and we find in the decade 1853—63 a mortality of 16.2 per cent.,- decade 1863— 73amortality of 20.3 per cent; a total of 1012 ca.ses with 206 deaths equal to 20.4 per cent. It is interesting to note that the total number of cases admitted to this hospital, which has not been materially enlarged during the past twenty years, has increased with each decade ; in 1873—83 as many were admitted as in the previous twenty years. Taking the statistics of four periods we h^vein 1853, '54, '55 a death rate of 24.3 percent.; 1863, '64, '65, 1 Read by title before tlie Canada Medical Association , September, 1888. !l ; \ i , iiassa.] , 2 per cent.; I S73. '74. '75. 29.1 F^r cent.; rSS^. 'S4, '85, 16.1 percent.; figures wliich.l.. not indicate a regularly progressive increase in the mortality. Hy the kindness of Dr. Matas I have heen enabled to get the statistics of the Charite Hospital of New ( )rleans since i S.v .. In decades the death rate has been as ft)llo\vs 1S30 — 39 - 2 9S cases - died 133 " 242 - " 37« " 429 1 840 — 40 1850—59 1 860 — 69 1870—79 - 685 - 1 172 - 747 - K)f)7 percentage 44. fi ' ' ^2.2 43-9 " 40. 3 Total. - - - 3969 'S'^^ 3«-"i Here too figures do not indicate that there has been a very marked increase. There was a slight reduction in the decades from 1840 to i860, bnt the ri.se in the sncceeding periods never reached the maximum attained in 1S30 to 1839. The well known great fatality of pneumonia in the South, particularly among the negroes, is born out by thes statistics. At the Penn.syh mia Hospital the following are the returns which were kindly furni.shed me by Dr. F. Packard, Resident Physician. Dr. Hartshorne, in his paper before the College oi Physicians of Philad Iphia, quoted the mortality in three years of the 4th, 6th and 8tli decade.s to show a progressive increa.se in the death riiti-, which might possil ly be attributed to changes in the methods of treatment. There is indeed an increase, as shown in Table I, but four other periods of three years in successive de- cades illustrate the beautiful elasticity of figures and show that the mortality has, if anything, been reduced. I. II. 1845-46-47 1855-56-57 1865-66-67 1875-76-77 1885-86-87 16 percent. 25-4 " " 24.1 " " .^9-2 " " 36.1 1848-49-50 1858-59-60 1868-69-70 1878-79-80 37.9 per cent. 21.2 " " 22.8 " " .^2.7 In a total of 704 cases .since 1845 the mortality has been 29. i per cent. . In the Boston City Hospiial the death rate for the past thir- teen years has been 29.1 per cent., a total of 1443 cases with 421 deaths. . • r ., I regret that I have not been able to get the .statistics of tlic Philadelphia Hospital, but I .shall allude in a few moments to the .1 has been 29. 1 very lii^li rale ol' iiiorlalily in tlial iiistitiitinii. It is very generally aekii.nvledKed llial the death rate prior to ..S40. in the days of active aiitiphloKislie measures, was very iiiueh liiKljer that! under the rational methods since eni])loyed. Cer- tainly, the figures ([uot,,,! l,y Wilson Im.x in Revnold's System of Medicine support this, and show particularly that the mortality was greater when bleeding was employed. Xot to enter into details which are .so acce.ssil)le, it will I.e sunicient to recall the remarka- ble records of the Ivdinburgh Innrniary. IJefore 1H4H the death rate in 567 cases was ,V'..l per cent.; from i,S4,s to 1X56 in 611 cases, 2r.2 percent,; and from 1X56 in 54,s ca.ses the mortality was only 12.7 per cent. In hicksoii's able K.s.say on Pneumo- nia' the .statistics of So, 437 were collected with a nio'rtalitv of 1^,915 giving the proportion of deaths I in 4.,s. This writer alludes to the remarkable ecpiality of the proijortional mortality— •' in p..ice and ail comfort, in hospitals of wealthy conununities, in the field of destructive war, and in the ho.spitals and barracks, the emphatic .seats of destitution jirlvation, exposure and neglect ' The retin n >f the Montreal Ho.spital, the Pennsylvania Hos- pital an c New Orleans Charite certainly do not bear out Dr. Hartshorn's .strong statement that the " mortality of pneumonia to-day is under similar circumstances, more than twice as great as it was forty years ago.^ The truth would .seem to be tliat in our large city ho.spitals the death rate in pneumonia always has been, and is likely tocontiuue tobe very high, usually over 25 per cent', often reaching 40 or 50 per cent. Tufortunately it is upon the statistics of these institutions that we depend for our information and we have not similar large return^ in private practice with which to compare them. The Collective Investigation Committee of the JJriti.sh A.ssociation recently jiublished a report of cases drawn largch- fn^n i)rivate pratlice, with a mortality of 18 per cent., a ratio considerably lower than thuL in hospital practice. As illustrating the difference between private and hospital practice in llie .same city, I may state that the death rate among 170 cases treated by Dr. Palmer Howard of Montreal in twenty years was only 6 per cent., a striking contrast to the rate of mortnlity at the General Ho.spital during the same period We nmst remember thai the paup-r population in the large cities of this country has developed enormously in the past twenty years, causing a very great relative increa.se in the number of individuals who live under I Stiuiics in I'atlioloxv and TherapcnUcs, iSfi; sioianscffl/'lhlplll!;-. ""••^^"'•'•"■^ 1' 'I"'- 'listnl.nto.! to th. .Vllowsoftlu. CoHckc ofrhy- 11 L I ; ■■' f ' '•it u conditions which render them more susceptible to and less able to withstand such an acute affection as pneumonia. To this, I think, we may reasonably attribute an)- slight increase in the death rate which may have occured at certain hospitals. In a self-limited fever like pneumonia it is highly improbable that any great increase in the death rate has followed a change in the methods of treatment. 77/<'>r /s )io acute discciM' 7, ■//// so Jcu • cases in 7vhich the /ssne of life and death lies in the adntinistmtion of druf^s. \\\ young, hcaltliy aduits ■A\i\xreva- lent. Jeff. K, ict. 25, bartender, brought by police patrol on the 21st Ila.l been .Irniking heavily lor three or four months. Attacked suddenlv on the 20th Violently delirious on the 21st anf 22<1 ; had to be constantU- watched an.l re- strained. Temperature 103-104^^; signs of pneumonia atri-ht base. On the 23d profoundly unconscious. IX'ath on the moniing of the 24th. I. M. I)., at. 4", painter. Had pneumonia twenty vears ago V hird dnnker, was on "spree- and sat up hi a bar-room on bVidav night tlie 2,vl Had pains m cliest and cough ne.xt day. On the 26th was admitted to the venereal ward avd there had a chill. When transferred H, the medii-al ward the emperatur, as .(,4^ pulse 120, respiration, 40. Signs of consolidation of right apex, u ch had rapidly extended and by the ist had involved the * entire lung. The tongue was dry and tremulous and iie had low delirium. The pulse feeble, 120-130. Resjiiration not very rapid, rarely aI)ove 40 per niinute. Death on the morning of the 3d. The autopsy showed pneumonia of right lung and marked interstitial nephritis. William N., tet. 25, rag picker, very hard drinker. On Saturday De- cember loth, drank very heayily ; was out all night and much ex]K.ses not high, 100—102° pulse 17 2— 1 2,S respiration 40 to 50, and the delirium was the m'o.st serious spinptom. From the 24tli to the 27th profuse diarrhrea. Gradual failure and death on the 3d. Thomas L., :et. 30, a heavy drinker, l.ell on Saturday 7th in a pit and cut his head, which was dressed at the I'ennsvlvauia Hospital. Was seen by Dr. Kdwards on Monday 9th, at 10 A. M., and then looked like a man in the early stage of delirium tremens. Was sent to the Hospital and admitted to the Avard for drunkards. In the evening was conscious. Temperature 104 ><°, pulse 120, respiration 34. Was very delirious through the night, and in the morning there were signs of pneumonia at the right liase and he was transferred to the medical ward. At . 1>. M., he wasactiyelv delirious, pulse 120, respiration 40 temperature 104.4-5°. Much tremor; lips a little cyan- otic. Soldification of right lower lobe. He gradually became (juieter. Tem- perature rose to 105.4 5°, respiration 70, pulse 120, and he died shortly after mid-night, al)out thirty-two hours after admission. The autopsy showed red hepatization of the lower and middle lobes of the right hnig. ' Ki.lneys These are fair ilht.statious of the fatal ca.se,s, which are .so com- mon at the Philadelphia Hospital and similar instittitions which admit the pauper .sick. f)ccasi<)nallv a loiigh-fihred drunkard will survive, hut as a rule tlie disea.se is fatal in tho.se who are at- tacked while under the infltience of alcohol. Often the patients are admitted moril>u;id or extremely cyanosed. Last winter I had three such cases bled with temporary relief to the engorged ven- (nis,>^/stein, but without retarding the downward course of the diseasv Could we exclude from our tables the subjects of chronic a choholism, I am sure lh:i., even at th ■ Philadelphi:i Hospital, llie death rate from pneumonia would not be more tlian S or 10 per cent. II i 'i;r The serious complications of pericarditis, myocarditis, endo- carditis, meningitis or colitis cause death in many healthy persons attacked with the disease, but a careful examination of post-mor- tem records will show that apart from these complications the fa- tal cases usually show signs of more or less extensive disease ni other organs, interstitial nephritis, fatty liver, fatty heart or chronic endarteritis. I was nuich impressed with this m review- ing the records of loo autopsies in this disease which I made in . Montreal.- Kxcluding the cases with almost necessarily iatal complications, and those with serious alterations in important viscera, but a small number remained in which a simple pneumo- nia however extensive, killed a healthy man. ' A good many complicated factors combine in an individual to cause death, but studying the fatal cases of pneumonia as so many lessons from which to learn wisdom for the future, we may, I think, divide them into three groups, ist. Tho.se in which the death has resulted from such complications as gangrene, men- ingitis ulcerative endocarditis, conditions at present l)eyoiid our art to remedy. 2d. Cases in which death has resulted from me- chanical causes, over-disteiuion and paralysis of the right heart. 3d The large group in which death has been due to failure of the geiieral powers under the influence of the high fever, or of the specific poison, or of both combined. We are likely to be deceived in our therapeutical conclusions unless we bear in mind the unquestionable fact that a very large proportion of all cases of simple acute pneumonia in healthy ad- ults recover without the u.se of drugs. Careful nursing, feeding, local applications, keep the bowels open and the skin active, meet the indications. Kven cases of great severity with extensive in- volvement of the lung we .see the crisis occur normally under most adver.se circumstances. Such a case occurred last session at the Philadelphia Fo.spital. The patient, ijdmitted on the seventh day of the disease, had been up and about at his lodging and drinking heavily, and had had neither medical nor domestic care. Although delirious on admission, the crisis occurred on the morn- ing of the eighth day and he entered upon a convalescence as sat isfnotory in every respect as if he had had the most approved an- tiphlogistic treatment. I have often puzzled over the cadavers of persons dead ol pneumonia and asked why should this man have died? Too ~"i Canada Mc.lkal and SnrRical Journal. .SS5. Trans, of Ha' n,ila,l.l,.l.ia I'allw.l «i cal Society, vol. xii. ti itulividual often the answer is the echo of the question. The cause is evi- dent in inan^- cases in the form of serious complications, such as endocarditis and meningitis. .Some years ago I was struck in the post-mortem room, with the cases of young vigorous men, who had died with distended right hearts and systemic veins and ex- tensive, though in some instances limited, areas of consolidation. It seemed as if the heart had failed in o\-er-distension — asystole — and I determined, when the opportunity arose, not to let such cases die without a copious venesection. Clinically, I think, we see this condition in two different periods of the affection. There is an early cardiac embarrassment during the first few days of the disease, leading to .slight cyanosis ; and in a later period, at the -th — loth day, we .see with increasing anxiety, the changing color, a dull suflFu.sion, a deepening hue, then the marked cyano.sis. Uleeding may be indicated at both these periods. In hospital practice we more commoidy .see the patients in the latter. For ten years past I have practiced free bleeding to the amount of from 20 to 25 ounces in adults, and yet I have to confess to disappoint- ment in my results I have seen but one case recover after bleed- ing, out of twelve or fifteen. The ca.ses of bleeding in the late stages have been uniformally fatal. I know they have often been performed with the patient in cxireinis, but it .seems imperative to attempt to relieve an over-distended circulatory system. I know it does relieve in the cyanosis of cardiac dilatation from other cau.ses, but in pneumonia there are doubtless conditions other than mechanical. In these cases the administration of oxygen or com- pressed air is often most .serviceable. Complications carry off many, and direct cardiac failure not a few, but both together do not num- l>er the ca.ses, which we .see gradually fail under the continued in- fluence of the fever, the disturbed cardiac-respiratory mechani.sm and the poison. Here we are are often baffled, btit in this group we .see repeatedly the beneficial effects of the timely use of cardiac and respiratory stimulants. i til 1 m W\\i\\\\\ I'MlliiiliKi 1 !.] ! 3 ! ; ■ i i J J, U lil m }\ in X<=-i V [ReprintiHl from Thk MkdicaL NliWs, April ij ,111, 1 389.J ON PHAGOCYTES. An Address before the Alumni Association of Bellevue Hospital, New York, delivered April j, 1S80. By WILLIAM OSLER, M.D., PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OP FFNNSYLVANIA . ^M^ There are in the body groups of tissues possessing cells, v:>ich either normally display amoeboid changes, or are capable, under certain conditions, of assuming them. By amoeboid properties we mean not only the capability of free movement, but the possession of a power which enables a cell to take foreign particles into its interior. Tissues containing such cells are derived from the mesoderm, the type of which, phylogenetically, is a free wandering cell. (Minot.) In the development of this layer epithelial and non-epithelial portions may be distinguished. For the former Minot has suggested the term mesothelium, and the latter His catls me- senchym. The distinction between the two is, however, largely artificial, as the epithelium maybe, and in places is, in development changed into connective tissue. And, thirdly, there are in the mesoderm, at all stages of its development, certain cells which are free and inde- pendent— mesamoeboids (Minot), and which persist sub- sequently as leucocytes. These mesodermic tells in the adult body, which are capable either of free amoeboid movements, or of taking up into their protoplasm solid particles of various sorts, are met with : \ : i- ! i tenderness on palpation. - ■i,-,i,. i rui .t!» , -r , ■ ., »>-, , n- i ,,, , i '- I saw the patient for the first time on March 5th, and was struck with his distressed appearance. He hiv propped up in bed, had slight dyspnoea, dry tongue, pulse 100, temperature 100^ He complained of ' Rood by title at tlie meeting uftlie Aesocitttluu f .mericiiu I'liysiciaus, Wiisbington, 1888. Il jt imi\- il&!"J m^ ari 2 OSLER, (0 As the colorless corpuscles of blood and mucus. (2) The connective-tissue cells, free and fixed, within the connective tissue proper, or forming the supporting framework of the solid organs. (3) Cells of the splee , bone, marrow, and lymph glands. (4) The vascular and lymphatic endothelium. (5) The alveolar epithelium of the lungs. All of these cells possess, in a greater or less degree, the power of taking solid particles into their interior, virtually, as we say, of eating them. On account of the possession of this property, Metsch- nikoff has suggested for these groups of cells the term plnv^ocytes, as expressiveof their most distinctive feature, and for the process in general the term phagocytosis. He regards this function as a property handed down from the primitive unicellular organism, and traces in an interesting manner the evolution of cells posse-;sing it throughout the animal kingdom ; attempting to show a genettc relation, physiologically at least, between the free living rhizopods and the cells of the middle germinal layer of the higher animals. Not a little of the attrac- tiveness of Metschnikoft"s views is derived from the glamor of evolution thrown over them by thus attributing the retention in certain cells of an atavic property in the highest degree useful to the organism. I shall consider first the action of these phagocytes as normal phvsiological factors in the work of the body ; and, secondly, take up the theory that these bodies pla\ an essential role in the protection of the organism from the invasion of specific germs. And, first, two illustrations from comparative phy- siology to indicate the important part assigned to phago- cytes in certain transformations which animals undergo. In the development of the frog, the removal of the tail of the tadpole, and of the gills, by gradual atrophy, is effected, according to Metschnikoff, by the activity of nd mucus, ixed, within ; supi)orting and lymph um. less degree, heir interior, ;rty, Metsch- clls the term ctive feature, gocytosis. landed down 1 tracf 5 in an possessing it ig to show a between the idle germinal )f the attrac- ,'ed from the lus attributing roperty in the phagocytes as of the body ; ic bodies plav rganism from parative phy- ned to phago- mals undergo, val of the tail lal atrophy, is the activity of ON PHAGOCYTES, o the amoeboid cells. At a time when the hind legs begin to bud, the leucocytes migrate into the tail, and by their phagocytic action remove the tissue, fragments of which as muscle, bits of nerve fibres, etc., may be seen in the mterior of their protoplasm. The gills are absorijed by an Identical process. In the transformadon of the larva into the fly, Kowalewsky' has shown that the large masses of muscle tissues, so abundant in the larva, and other parts unnecessary in the matured condition, are removed by the acuity of the phagocytes. It has long been known that foreign bodies, such as ligatures, portions of dead bone, and other substances may be completely removed by leucocytes. Interesting as IS this, and bearing directly upon the question, I pro- pose to hmit myself entirely to the consideration of the two aspects above referred to. Nowhere in the body do we have such a facility for studying the action of phagocytes as in the organs of respiration, in which, with the cilia of the bronchial mucosa, they share in the work of cleansing the air-pas- sages ; and of these two important agencies it is hard to say which plays the more important part in the expul- sion of those particles of foreign matter which, in cities at least, we constantly inhale. There are several groups of cells engaged in this work : The ordinary mucus cor- puscles ; the alveolar epithelium; the connective tissue elements of the pulmonary stroma, and the leucocytes of the lymph tissue in the bronchial, tracheal, mediastinal glands. The mucus corpuscles, which in health are derived largely from the muciparous glands, and in intlammatory states from the general bronchial mucosa, arc actively concerned in attacking the dust which reaches, in ordi- nary inspiration, as far at least as the medium-sized tubes. The examination of the morning sputa of ,i cigarette- ■ 'f 11'^'^ I Zeitschrlft fur vissensdwftliche Zoblogie, Bd, 45. tenderness on palpation. fm^sa^Bmr- _ I saw the patient for the first time on March 5th, and was struck with his distressed appearance. He lay prup[)e(l up in l)ed, had slight dyspnoea, dry tongue, pulse 100, temperature 100^ He complained of ' Read by title at the meeting uftlie Association of American Physicians, Washington, 1888. 4 OSLER, smoker, or of a person who has been exposed to a dusty atmosphere, shows very clearly that no small proportion of the carbon grains is incliuled within protoplasm. The free granules are abundant, '-ut almost every leuco- cyte has its little load which it has picked up on its road from the finer tubes to the trachea. I have always thought this represented a neat bit of economy of labor, as there can be no question that it is easier for the cilia to sweep half a dozen angular pardcles, when enclosed m a cell, than to work at the same when free. In all probability, the finer particles which fall upon the tracheal or the bronchial membranes are gotten rid of almost entirely by cells and cilia. There does not appear to be, to any great extent, penetration of pigment granules between the ciliated epithelium. It is unusual to see beneath the tracheal mucosa any collection of carbon grains. We do meet with it in the submucous bronchial tissue, but the active vibratile lining seems to afford a tolerably sure protection. The lymph vessels open on the surface in the pseudo-stomata, and in the experimental work of Arnold and others, leucocytes carrying black grains have been seen in the submucous lymph vessels ; yet the process does not seem to go on to any great degree. The particles which reach the air cells find no active current to sweep them from the spots on which they iall. It is possible to conceive, under certain conditions, of the air cells graduallv filling, were it not for the activity of phagocvtes, derived largely from the alveolar epithe- lium, which stands, as it were, at the gateway of the lymphatic circulation. The cells i.nin" the air cells, seen, for instance by scraping gently the cut surface t)f an cedematous lung, look as flattened, desiccated, and lifeless as do the scales of the scarf skin. But appearances are deceptive in this I Untersuchungcn iiber Stauljinlialatioii und Staubmetastase. Leipzig, 1885. ON PHAGOCYTES, 5 I I- Staubmetastase. case, and the protoplasm of these cells is not onlv active but probably vanes much in shape with the distention or contraction of the alveoli. When in contact with liquids and m pathological co.iditions, thev change so much in form that I hnd it often a difficult lesson to teach students familiar with normal histology only, to recognize in the large, swollen ovoid cells so common in sputa, alveolar epithelium. .Moreover, from the rapid way in which they may be desquamated, there must be ample pro- vision for their rapid restitution. How far in a normal state these cells take part in the work of cleansing the lungs, is not yet definitely settled. In the voung, thev do not often appear in the sputa, except when there are indications of catarrhal changes, but, in the adult, their presence is very common. It is rare to see one in the sputa of a hospital patient, which has not brought with it a load of carbon, all of which may not have been de- rived from the air cells, as these bodies can undergo amuiboid changcb, and, like the leucocytes, are probably not above picking up a grain or two in their course toward the larynx. In cases of bronchial catarrh, and in phthisis, these pigmented cells of the alveoli may be very abundant, producing the blackish streaks which may be seen with the naked eye. When these cells have undergone the myelin degeneration they seem no longer capable of performing scavenger work. In coal-miners, or even in stokers and coal-heavers, these pigment-laden cells may be extraordinarily abun- dant. It is not only when the patient comes direct from the mines, or from the coal-yards, but the old poitniiairei; which haunt in such numbers our city hospitals, expecto- rate for months, or even longer, sputa containing tiie pigment-laden alveolar cells, staining the entire expecto- ration. So persistent may this be that the process may be regarded, not simply as an extrusion of the daily dole of carbon, but as a definite excretion, if we may so use the term, of particles which have been stored up in pul- monary parenchyma. ■I- tenderness on piilpation. I saw the patient for the first time on March 5th, and was struck with Ins distressed appearance. He lay propped up in bed, had slight dyspnoea, dry tongue, pulse 100, temperature 100^ He complained of ' Read by title at the meeting uf tlie Assuciation of Amoricau Physicians, Wasliiogton, 1888. 6 OSLRR, A certain proportion of the inhaled dust particles escapes the mucus cells and the alveolar epithelium and penetrates the substance of the lung, entering at the kitt- substanz between the cells, or t'uough the pseudo-sto- mata existing in the alveolar wall. The particles of coal- dust iiave such sharp angles that we may suppose them capable of met iianically lacerating the delicate alveolar cells. In dweller-, in the country, as wdl as in wild animals, breathing an air comparatively pure, the cilia and the phagocytes in the air-passages appear cpiite able to pre- vent access of the carbon grains to the lung tissue; whereas in the dwellers in the cides, and in animals kept in confinement, the impurities in the air are so abundant that these agents arc insufficient, and sooner or later the grains ; penetrate the air cells, aided, no doubt by the movements of inspiration and expiration ; and we have the well-known marbled or car1)onized organs which we sec every day upon the post-mortem table. When the particles reach the lymph spaces, the fixed and free connective tissue cells of the stroma join actively in the work. On section we see :.. the alveolar septa large numbers of round protoplasmic bodies, two or three times the size of colorless blood-corpuscles, which are usually packed full of dark grains, A certain proportion is seen within the ordinary connective tissue corpuscles, and, in addition, there are, in variable numbers, ordinary leuco- cytes. But even these forces are insufficient to meet the constantly advancing stream of dust particles. The des- tiny of those which escape the phagocytes in the alveolar stroma has been accurately followed in the investigations of Arnold and others.' Entering the lymph stream they are carried first into the lymph nodules, which, in the lungs surround the bronchi and bloodvessels, and a large number becomes fixed in the cells of the follicular cords or are permanently embedded in the stroma. ' Vide recent work of Kleiner. X'irchow's Arcliiv, Ud. cxii. ON PHAr.OCYTKS. 7 As they pass alon^r the 1\ iiipli cliannel^ into the inter- lobular septa beneath the pleura, a still further nunibe lodKc and hecnnie permanently encldserl in the stroma cells, and, linally, the remnant pa!>s into the larger lymph channels and ultimately lodge in the bronchial and tracheal glands. Here the lymph and stroma cells of the follicular cords dispose of them permanently. That this is effected in great part by the phagocytes is, I thmk, unquestioned, A scraping from anv moderately pigmented lymph gland shows that the 'chief part of its carbon load is warehoused (so to speak) in proto- plasm, the granules lie for the most part imbedded free in a connective tissue matri.x. Here the struggle is piactically over, and though not a victorv, vet tlie compromise which has been made is the best' which could possibly be effected. The sharji irritating particles have been placeil in position in which they could do the least harm, and, though not expelled, have been safely imprisoned. OncL in the lymph glands of the bronchi, it is thought they never reach the general circulation, but it has l)een shown of late years, that under certain circumstances the carbon particles may pass the bronchial filters and spread far and wide throughout the system. Soyka's remark- able case in which undoubted coal particles were found in the tissue of the spleen and of the liver illustrates what really may occur. Weigert' in particular has called attention to the frequency with which in the spleen and in the liver carbonization of the connective tissue occurs. He states that it results whenever densely |)igmented bronchial glands form close adhesion to the pulmonary veins, through the walls of which the carbon particles pass and so reach the general circulation. I would not call the condition common, but I have seen at least three instances at the Philadelphia Hospital in which the ir- ' Kortschrittu der Me.licin, Ikl. i. :1 ;. ;■ 'i tenderne.'ss on palpation. I saw the patient, for the first time on March 5th, and Avas struck with his distressed appearance. He hiv pro[.pc-l up in l)ed, had slight dyspnoea, dry tongue, pulse 100, temperature 100^ He complained of ' Read by title at tho meeting oftlie Associatiou of Amorican Physicians, Waaliiugton, 1888. 8 OSLER, regularly distributed piHineiU in tiic spleen and in the liver (in the latter chiefly alonj; the portal canals) was iind<)iil)ti.'(!ly of extraneous, not of hicinic orijjin. Tho steps in this |)rocess described may be followed in the lunjfs of any town dweller, but to see in perfection the remarkable activity of the pulmonary phagocytes, one must study the early stages of anthracosis, particu- larly in those exceptional rases which we see occasion- ally when a miner has been killed by accident or dies of acute disease. It is not, I think, too much to say that the larj,'cr part of the pi^'mi ' contained in 1un^;s almost, if nut ipiitc, black, is enclosed in [.otoplasmic cells. Here too the invading particles are more forniidable and not so readily dealt with; yet one frequently linds long irregular bits completely encircled by a film of proto- plasm which the phagocyte has stretched to the utmost, just as we may see an amceba extend alon^ tlie whole length of one of the short rod-like diatoms. I know f)f nothing which illustrates better the remark- able anueboid properties of human protoi)lasm than a slide prepared from the scraping of such a lung, or of the black juice pressed therefrom. Scarcely a leuco- cyte can be seen which has not been at work, and many of the larger cells have the protoplasm stuffed to the full with carbon grains. Only in the work of the pond amoebae preying amongst desmids, diatoms, and algie can we see such better illustrations of active work. There is, of course, this difference, that the amoeba eats to live, and so far as I know never loads its protoplasm with useless ■^^'■ff. The body phagocytes take anything, never exer.. a selective powers. The particles which gain entra' .t j the lungs may be far too large for a sintrle phago ; ^e to attack successfully. I have sketches showing rod like particles, the ends of which appear enclosed in protoplasm of a dumb-bell shape ; while in one instance not only were the ends enclosed, but the ON PHAGOCVTES. central portion was completely enveloped l.v tin thud leucocyte. A physiological process in which pha<(ocytcs play a ieadinjr roli\ is the removal and diKinteKiatioii of the red blood-corpuscles which have lived their life and are no longer tit for work. The cells coiitainim; the red blood-corpuscles, which arc found in the hone niar.ow and in the splef i, ^ wever much opinion may differ as to their mod of oii;., •. cannot, I think, be rc<,Mrded in any other 1 ;hf 'han ;. phagocytic elements with this definite fun- Uo,i 'i'hcy ;.\ist normally in the red mar- row, and in i.S^: ipieen ind we may recojini/e (i ) cells which appear t ,-, x.um. their size and shape, elements of the pulp and ,;j) cells which belong to, or are derived from the endothelium of the capill.uies, and (3) the ( ulls of the stroma. The gradual production of the pigment in this way has been so often described, and is so well known that I need not now dwell upon it. In certain morbid conditions we see this process widely extended, and we find cells containing red blood-corpuscles in the liver, in the lymph-glands, even in the blood itself; and particularly is this the casein those states associated with rapid blood deterioration and destruction, as in acute fevers, when these bodies may be enormously increased. In certain forms of an.emia so abundant are they in the bone marrow and in the spleen that they have been re- garded as directly concerned in the widespread hicmo- phthisis. The observations of Quincke' and his pupils have shown that the liver is the chief seat of blood destruction in pernicious anicmia, but the totally different ippearance presented by this organ, even in long-standing cases, to that met with in malaria, shows a radical difference in the nature, possibly in the seat of the hicmolytic action. In the former case, the pigment is chiefly in the liver k(J ij < rHnit.-M'hcs Ardiiv f, kliii. Med., Bds. xxv., xxv XXXIL, XXXMI, tenderness on palpation. *«»,«,. :^. I saw the patient for the first time on March 5th, and was struck with Ills distres.sed appearanee. He hiy ])n)ppe(l up in bed, had sligat dyspnani, dry tongue, pulse 100, temperature 100^ He complained of 1 Read by title at tho meeting nftlie Association of American Pliyaicians, Washington, 1888. llNIWf!,.'!, .\>'. lO OSLER, cells ; in the latter, in the stroma and about the blood- vessels. We cannot from this regard pernicious anaemia as an hepatic disorder. The liver, probably, makes the best disposal it can of an abnormally large amount of coloring matter, which is, I should suppose, not brought to it in the same form as in malaria, but rather in a form similar to the raw material of the bile pigment, which would account for the active participation of the liver cells. The deep beefy-red color of the muscles in per- nicious anaMTiia also tells of an abnormally large quan- tity of coloring matter at the disposal of the tissues. In chronic emphysema, in mitral obstruction, and in all affections in which the circulation within the lungs is permanently embarrassed, the condition of brown indura- tion which ensues affords a very beautiful illustration of the same process. The blood corpuscles by diapedesis reach the stroma of the air cells, where they are seized upon, just as are coal particles, by the connecdve-tissue cells, and are gradually converted into a pigment which retains for a long time its brownish tint, but which may ultimately become black. Neumann, in a recent paper,' doubts whether the brown induration of the lungs is really the result of the ingestion of the red blood-corpuscles by the stroma cells. He holds that in many instances, at least, structures within the corpuscles, which resemble so closely the red blood-disks, are in reality only pigm.ent forms having the size and color of the red blood-cells. We certainly see structures within the cells which cannot possibly be mistaken for anything but red blood-corpuscles, and, I think, the expert eye can usually discriminate between such and the round aggregations of pigment, however d( -eptive may be their form and color. Phagocytosis has been studied in the process associ- ated with absorption of extravasated blood. Langhans Virchuvv's .Aixliiv, Bd. no. ON PHAGOCVTKS. II Lit the blood- ious anaemia 1, makes the e amount of not brought ler in a form ment, which of the Hver scles in per- ' large quan- tissues. tion, and in 1 the lungs is rown indura- Uustration of )y diapedesis ;y are seized lective-tissue ^ment which t which may whether the result of the stroma cells. 3t, structures osely the red Drms having vVe certainly t possibly be jscles, and, I late Ijetween ;nt, however ocess associ- . Langhans was the first to show that blood effused into the tissue did not simply disintegrate and disappear, but that the connecdve tissue elements were actively at work, and that no small proportion of the colored corpuscles was ulti- mately taken into the interior of their protoplasm. This has been amply confirmed, and I think th^re can be no question as to the fact ; but observers ar' by no means unanimous, however, whether the phagocytes are essen- tial in the process. Probably in large extravasations only the peripheral parts are dealt with in this way The fi.\ed connective-tissue cells with migrated leuco- cytes all share, I believe, in the process. It must not be forgotten, as Neumann has pointed out, that pigment granules in the interior of the cells may resemble blood corpuscles very closely. However this may be there can be no doubt that the cells are concerned 'in the transformation of the haemoglobin, whether they take it up with the corpuscles or after it is diffused from them Remarkable differences e.xist in the final transforma- tion of the haemoglobin, resulting in the formation of two pigments, ha:matoidin, which develops chiefly in the central parts of the extravasation, and an albuminate of iron, hajmosiderin (Neumann), which is formed at the Iioundaries of the clot and wherever the coloring matter comes in contact with the tissues. That this difference is related in some way to the influence of the cells, is in the highest degree probable, though Neumann is not in- clined, from his observations, to attribute an important action in this respect to either the fixed or wanderino connective tissue elements. The question is one to which a few years ago I gave some studv in connection with development of cells containing red blood-corpus- cles, and I was much impressed with the truth of Lang- hans' statement as to the frequency and numbers of these structures in the vicinity of extravasations of all kinds. In the intestinal canal the leucocytes assist, to s.nne i ■ ) \i tenderne.ss on piilpation. 1 saw the patient for the first time on March 5th, and was struck with Ins ( ilistressed appcanince. He hiy jtroppcd up in bed, had slight dys])nani, dry tongue, piiL^e 100, temperature 100 \ He complained of Read by title ut th« meeting .jftlie Assuciatiuu of A moricaii Pliy«icinUB, Wiisliingtoii, 1888. 12 OSLER, extent M least, in the absorption of fat. Schaefer's ob- servations upon this point' show very clearly that during digestion the amoeboid cells of the mucous coat become filled with fat globules. How these are obtained we do not as yet know clearly. Whether the fat penetrates between the epithelial cells, or whether the leucocytes pass up between the cells reaching to the surface and here secure the fat, has not been definitely determined; though from the presence of an occasional cell, or even a nest of cells between the cylinders, the latter view is probably the correct one. The leucocytes pass to the central lymph vessels, where they disintegrate, and dis- charge their load of fat granules which has, meanwhile, in the protoplasm of the cell, been broken up into finer particles, which form the so-called molecular base of the chyle. Possibly, too, the leucocytes may take up other ingredients. It is interesting to note that in many of the lower animals the amoeboid cells of the endoderm possess an active digestive function. The observations of Parker and Lankester appear to confirm fully the researches of Metschnikoff on the phenomena of intercellular diges- tion in invertebrates. So far, we have been dealing exclusively with the action of phagocytes under normal conditions. And it is clear that these mesodermic cells have important func- tions throughout the life-history of the organism. Not only in the early steps in the development of the blasto- derm do we see them actively at work, but in various stager, of development, particularly in that of the bone, their action is of the first importance. In the mature body we have seen that in the lungs, in the intestines, and in the blood-making organs, the phagocytes have most essential functions ; but the question of chief interest to day relates, not so much to this normal process about 1 Monthly International Journal of Anatomy and Physiology, 1885. lefer's ob- liat during at become ned we do penetrates leucocytes urface and :;termined ; ill, or even tter view is lass to the ;e, and dis- Tieanwhile, p into finer base of the :e up other iiany of the ;rm possess IS of I'arker :searches of iular diges- [y with the ns. And it ortant func- .nism. Not f the bhisto- ; in various if the bone, the mature e intestines, ocytes have :hief interest rocess about d Physiology, ON PHAGOCyTES. 13 which there has never been much doubt, as to the sup- posed part which these cells take in protecting the body against the invasion of parasites. The theory 'elaborated by MetschnikotT had be^n hinted at i)y many previous observers, but to him is undoubtedly due the credit of bringing it into promi- nence, and of doing in connection with it a very large amount of interesting work. It must be allowed that he came to his task ueil prepared. Many of us can look back with pleasure to his brilliant investigations upon the intracellular digestion m the Planari;e"ind in Sponges, carried on largely at the Naples Marine SMtion • investigations the truth of which, so far as I know, has not been controverted. Following these studies, directly in the same line, was his interesting research into the methou of the absorption of the tail of the tadpole, al- ready referred to, in which he appears to have denion- strated that the atrophy of this organ results in reality from the active removal of the fragments of the tissue by leucocytes. So f;ir the work was biological, and had no direct bearing u])on the phenomena of disease further than that, in the latter illustration, it bore out the well-known fact of the absorption by leucocytes of foreign bodies placed within the tissues. In 1884, in the 96th vol. of Vir- chow's Archiv, he published a paper' which arrested the immediate attention of students in parasitology. It is now too old a story to narrate at length ; it will be sufficient to remark that in the daphnia, the common water-flea of the aquarium, he had studied the reladon of the leuco- cytes to a fungus with which these insects are prone to be infected. 1 he phagocytes attack the fungi which enter the body cavity from the intestines, and pracdcally eat them, enclosing them in protoplasm. Where one cell is insufficient, several combine to enclose the spores in ' Ueber cini! Sposspilzkraiikheit der D, ipliinon. I tenderness on pulpiUion. I saw the patient for the first time on Marcli 5th, and was struck with Ills Read hi title iit th« meetiiitj; ol'llie Association of Americiin Pliysiciaus, Wiisliiiigton, 1888. 14 OSLER, large plasmodia-like aggregations— giant-cells. If tlie invasion was in such large numbers, and the activity of the fungus so great that conidia were formed, the resisting forces were insufficient, victory remained with the enemy, which meant the death of the daphnia. Of lOO insects studied, 73 became infected, of which 59 -ecovered and 14 died. Following this line, Metschnikoff proceeded to study the relation of leucocytes to anthrax bacilli, to the micro- organisms of erysipelas, and to various other affections. He likened specific inflammation to a warfare in which the invading army is represented by microorganisms, and the resisting forces by the leucocytes. Even in details the analogy was maintained. Notice of the arrival of the invaders was telegraphed, so to speak, by the vaso- motor nerves ; the line of communication, the avenues of mobilization, were represented by the bloodvessels. The aim of the invader is to secure the territory, to multiply rapidly, to live at the expense ^f his host, and to manu- facture and circulate substances injurious to him. The aim of the resisting forces is to encircle the enemy, inclose him, digest him, and render in inert in battle. Many phagocytes die in the process .vi, if in large numbers, the heaps of the slain represen ^us ; an abscess is a bat- tleground densely packed wim dead bodies. If victory remains with the invaders the organisms pervade the affected part, multiply, and induce conditions incompat- ible with the life of the part, or perhaps with the life of the entire organism. If the battle is with the host, the parasites are destroyed, perhaps not without loss, but the normal state is gradually restored. Practically, on this theory each organism is regarded as possessing a stand- ing ai-my composed of mesoblastic cells, capable of rapid reprouiiction and rapid concentration, 6ne important function of which is to protect the organism against de- structive agencies invaJing it from without. Certainly a most attractive theory, fully deserving the attention ( ! ON I'HAGOCYTES. 15 which It has aroused. On the one hand widely accepted on the other bitterly assailed, the question is as yet far from settled, and to the position in which it stands I pro- pose briefly to refer, and then to offer some results of my own observations upon a disease in which special facih- t;es exist for the study of the problem. Metschnikoff has studied a number of diseases, ery- sipelas, anthrax, relapsing fever, and tuberculosis, with'a view of finding facts in support of this thcorv, and his communications within the past four years have been numerous and elaborate.' Thev have been so widely abstracted and so often referred to that ] shall not occupy your time by entering into details, but will briefly indi'- cate the chief points upon which he lays special stress in these difierent affections, and note certain of the observa- tions which have been made by other workcs. In erysipelas the cocci are attacked first by the leuco- cytes filling the lymph spaces, which rapidly proliferate and actively eat the microorganisms. Not alone do the colorless corpuscles act as phagocytes, but the fixed connective tissue cells assist in an important manner. In cases of recovery he found that behind the advancing cocci the leucocytes were crowded with parasites which showed evidences of digestion and destruction. The connective-tissue do not appear to attack the cocci, but are chiefty concerned with the absorption of the inflammatory exudate, even taking up the leuco- cytes whicli have died. In fatal cases there was enormous development of micrococci, the majority of which lay free in the tissues not enclosed in the phagocytes. Inoc- ulations with erysipelas cocci in white rats confirm tiiese observations made in man. The leucocytes attack the parasites, whicli undergo rapid degeneration in the proto- plasm. The larger connective tissue cells, macrophages did not attack the cocci. Metschnikoff recommends'ex- ' Publislied cliinly in Virchow's Aichiv. ilm^ !: tenderness on piilpation. I saw tlio patient for the first time on March 5th, and was struck with Ins distressed apiiearance. He lav prop|)cTle between tVie cells and bacteria. In uUhrax Mrt- ■ snikoff has studied the relation of the phagocytes to bacilii introduced into fogs, which, as is well known, posses, immunity at the ordina.)- U:nii>era- ture, bu. succumb -vhen the a>niperature is raised. A graft of a piece of anthraN tis-ie under ine skrn of a Irog is within from fifteen to tw,- vy hou-s sunounded by leucocytes, which take up many baciil.. According to K(.ch th' ,' inav grow inside the cells and even burst them,' but Metschnikoff holds that the anthrax filaments do not develop within the cell, but are gradualy de- stroyed by them, and that th>. Is the reason why the frog at an ordinary temperature recovers. In the heated frog the bacilli rapidly develop aiul the efforts of the leuco- cytes proving insufficient, tht .animal dies; not, it is asserted, from any inactivity on the part of the leucocytes but because the bacilli secrete a liquid which protects them from attack. In Haumgarten's criticism' he rc'ates some experiments ^vith the anthrax bacilli which directly antagonize these observations. Pigeons do not die when inoculated with anthrax and he found that the bacilli injected degene- rate in precisely the same way in these creatures as ^vhen in distilled water ; only here and there did the leucocytes contain the rods. He found that in frogs, though the bacilli are eaten by the leucocytes inversely to the degree of heat to which the animal is exposed, there is never total destruction of the bacilli by the phagocytes. . , , ,. ,, Hess'^ has performed experiments which bear directly upon these points. Anthrax cultures in Zeigler's glass chamber, inserted beneath the skin in a nimals not v ery 1 Zeitschrift f. klin. Medicin, Bd. xv. Hft. I u. 2. 2 Virchow, Archiv, Bd. 109. ON PHAGOCYTKS. 17 susceptible to the disease, as cio^'s and birds, showed active migration of the leiu ■ - ytes into the chanilier which appear to attack the bacilli and to destroy them. These very striking experiments certainly indicate what, of course, is well known, a high degree of activity on the part of the leucocytes, finding their way, as they do, into the chamber closed at all points except one nar- row orifice. But, as Hess says, it is a question whether the disintegration in the cells necessarily means destruc- tion by the cells. In relapsinj^ fever Metschnikofif states that the spirilli are not attacked by the leucocytes in the blood but are destroyed only in the spleen. In the artificially produced disease in monkeys, he finds abundant inclusion of the spirilli in the phagocytes of the spleen during the period of the rise in temperature before the crisis. This, how- ever, may simply mean that the spirilli, most of which gradually disappear from the blood at the crisis, have lived their life and are about to die, and in this state arc taken up by the normal splenic phagocytes, just as are the effete red blood-cOrpuscles. He explains the recur- rence of the second, or even of the third, attack of the fever by supposing that certain spirilli remain alive after the crisis and start afresh a new generation, which is not retarded in its growth, as the phagocytes are too busy in digesdng the spirilli which they had eaten during the former attack. An interesting study of phagocycosis has been made by Laehr, a pujjil of Ribbert,' who has studied the effect of injection into the lungs of rabbits, through the trachea, of staphylococcus pyogenes aureus. Within a few hours the cocci are almost all to be seen within the alveolar epithelium, and in the leucocytes, which latter, in the course of a few days, disappear from the alveoli and pass into the bronchi. Meanwhile, the alveolar epithelium ■!■ '.f ' Alistracted by Bitter; Zeitschrift f. Hygiene, Bd. 4. tenderness on palpation. I saw tlie patient for tlie first time on March r)th, and was struck with liis distressed appearance. He lay i)r()ppe(l up in bed, had slight •lyspnoea, dry tongue, pulse 100, temperature 100^ He complained of ' Ueiul by title at the meeting ultlie Association of Amorimn Pliysicians, Wiisliington, 1888. :i ll i . ■ • ■ VM I ll ■ S i^^l 1 ' , i ■ . - 1 i * 1 i8 OSLER, proliferates, causing i catarrhal intlammation. Within the first week the cells contain many cocci, which gradu- ally become less numerous, and in the second week en- tirely disappear. He looks upon this as a confirmation of Metschnikoff's views. In a second investigation, Hess' has studied, in rab- bits and in cats, the relation of the leucocytes to the staphylococcus aureus inoculated in the cornea. At first there is marked increase, which leads to an acute inflam- matory process in the neighborhood of the cocci. The leucocytes increase rapidly, and within two.or three days almost all of the cocci are within cells. In cases which recover, by the sixth day no cocci are found. When the process does not result in healing, the phagocytosis is slight. 1 • 1 t Baumgarten states'^ that experiments made in his lab- oratory do not confirm these results of Hess. Ribbert, iii his study on the destruction of pathogenic bacteria in the body, supports Metschnikoff's' views. He found, after injection of the spores of Aspergillus and Mucor, that they collected in the organs of the exper'- mental animals, particularly in the liver and lungs, and that within a few hours after injection they were sur- rounded by leucocytes, which cither completely pre- vented or restricted the growth of the germs. Injections in very large quantities might not be sufficient to hinder the growth of the parasites, and the animal died. In the lungs and in the liver the phagocytes are much more active than in the kidneys. Precisely similar occurrences were found where the spores were injected into the ante- rior chamber, and it is worthy of note that he found on the anterior surface of the iris, in the neighborhood of the pupil, the phagocytes much more active and the dis- 1 Virchow's Archiv, I5d. no » Jahresbericht, Bd. 3. •i Abstracted by Bitter Zeitschril't fiir Hygiene, Bd. 4. ON PHAf'.OCYTES. 19 jff's^ views. integration of tlic spores imirli more m;irked than in tlie posterior part of the iris in contact with the lens. Rib- bert holds that the destructive influence of the leucocytes is exercised chiefly by their preventing access of nourish- ment to the spores (particularly of oxygen), and in favor- ing, also, an accumulation about them (if destructive metabolic products. He regards the fi.\ed connective- tisHie cells of the liver, and the giant cells which develop in the liver and in the lungs, as the most important agents in the final destruction of the spores. As we might suppose, the \ lews of .Metschnikoff have met with sharp criticism in many quarters, and from no one more ably and at greater length than from Baum- garten.' While not denying that the leucocytes eat the bacteria, he claims that the process is by no means uni- versal, and is carried on so unequally, that we can scarcely speak of an active warfare waged against the parasites. As a specially weak point, he alludes to the powerless- ness of the phagocytes in the Daphnia disease so soon as the conidia are formed from the sjiores. In relapsing fever, the freedom from attack which the spirilli enjoy in the blood is urged strongly against the phagocytic theory. The fact that spirilli are found in a number of cells of the spleen toward the crisis simply means that the phagocytes of this organ behave to them as to other foreign bodies. Probably, too, the spirilli be- gin at this time to lose their vitality, as is shown by their less active movements, and are then readily taken up by the splenic leucocytes in a manner precisely similar to effete blood corpuscles. In erysipelas, Baumgarten criticises the position in which Metschnikoff finds the parasites, namely, in the second zone, behind the advancing cocci, as conclusively showing that they are not fighters of the battle — not, as * Loc. cit. tenderness on palpation. I saw the patient for the first time on March 5th, and was struck with liis distressed appearance. He hiy prop[)e(l up in \m\, liad slight dyspnoea, dry tongue, pulse IC '. temperature 100''. He complained of ' Road by titia at the meetlug of tlie Associ ^un uf A.rr ric au Physicians, Washington, 1888. if^ 11 y/.' Ih I Ml ' '1 i . if V ' 1 0, «f 1 ■ 1 a I 2o O S L E R , he expresses it, "the heroes of the day, but the hyenas "''?heS;vntion.'>f-'^ristmas-Derkinck-Hoh..feUl>are also dire, . , opposed to che th. ory of Ph.'^gojy;"^';- "^ finds in anthrax experiments that very few of the bac.lh :; taken up by the' leucocytes. In rats they degenera e within two or three days after inoculation, and for the most part outside of the cells. He holds d.at pus orma- tion is a conservative reaction against the Penetration of the bacterial germs, but that the neutralization o he action of microorganisms depends much ...e . n the chemico-biological relations of the tissues than on .uy propertv of the cells to destroy them by 'f >^>f "• "'^ lievv in fact, approaches thai of Ribbert already lefer red to Tn ascribing the limitation of bacterial growth to nutn- \we change: particularly to the restriction of oxygen, rather than .. any phagocytic action of the ceU^. In Klugge-s laboratory, observation. 1; • '^^^^^^' .™^°; byBitterand bv N .ttall,-^ of San Francisco, which d. rectly contradict those of Metschnikoff. ^utud s eUbora e experiments appear to show conclusively that the destruc- tion of the bacilli in the living body is not effected b> the nhatrocvtic action alone. , ' Aml.lastly . in tuberculosis, the question of the relation of the cells to the bacilli is being carefully siudicd. In his recent p^per on th. subject,' Metschnikotf claims that tl^' degenTtion of the baciUi, which has long been Inown to ..curwithip the giant cells, results directly from their phagorvtic action, and is not a natura decay Balga en. on the other hand, regards the relation of the giant cells to the bacilh as one of the strongest evi- dences agaih^t the theory ..t phagocytosis^ ^ 1 Fortschritte H. ' Medicin, 1887. .Arc V fUr l.v^em-. Bd. iv. I would p.ruculudy recommend the Vu .ry of (■.fner's to those wishing furth.. details, and for a striki" ie-- • experiments, the pap-r of Nuttall's. 3 \ ,,\v biv, Bd. 113- ON PHAGOCYTES. 21 With tlie relations of phagocytes to harU.ria, I have had so little practical experience that I hesitate to express any positive conviction on the (jiicstion, but I have, for nearly three years, been working at a problem identical in all its relations, but in which the parasitic bodies belong to a higher class of organisms. I refer to malaria, and to the h.imiatozoa which occur in the blood u{ this disease. A sceptical attitude in these days of hastv ob- servation and of still hastier conclusions is peculiarly appropriate. I complain of no one who, without ampli opportunities for | ,onal study, claims the right to ques- tion the full significance of Laveran's important dis- coveries. Perhaps better than any cme else, I am in a poMtion to extend sympathy to the sceptic, as, until ample material came to hand m 1886, I was among those who looked upon tiu' work of Laveran with extreme incredulity. The corroboration in almost every detail which his studies have received during the past three years is in all respects remark ible. W-irking as he did, alone in Algiers, under circumstance , the reverse ot favorable, without proper laboratory equipment, without the stimulus to be found in the asso( : ition of men in large cities, it is not only in the highest degree credita'ile, but most encouraging, that an army surgeon, actively engaged in the duties pertaining to his battalion, could accomplish so thorough a piece of work, requiring but little subsecpicnt conection, and receiving at all hands ample confirmation, Richard, in France; Marchiafava and Celli, Golgi and his pujjils, in Italy; Sternberg, Councilman, James, Shattuck, and myself, in this country; and \'a:)<;iyke Carter, in India, working far apart, have all jnacticallv confirmed, with minor modifications and amplifi' tio;,- Laveran's observations. While the invariable assoiiation ut these parasites with malaria would appear to be settled, their precise mor- phological relations are still a matter of discussion. I tenderness on piilpation. I saw the patient for the first time on IVrarch nth, and was struck with Ills distressed appearance. He lay propped up in l)e(l, liad slight dyspnoea, dry tongue, pul. St -ovth corpuscles, converting the h.cmoglob.n ,n o bhck niu-nent. Under certain cucumstanccs, mo.c ;^j:;^.iunn, the paro.ysn.s, these j;-^- '--- in size, and undergo segmentat.on, break.n^^ p .^ umb.^r of s mall free spherical bodies. In ^"^^> '^' """ ; Trs in the blood, but more constantly ^-^^;^^ the remarkable flagellate organisms. Last v, in more chronic cases there are the still more extraordinary cies- ^'r^ms: Practically, the unanimity which exiss in the statements of the observers above nanvd regarding l;::^t,dies, places the M-^tio,. of th- e- -ce m malaria (and 1 may say, based upon the number ot l^gadve observations, in malaria only) beyond any reasonable doubt. . ^, ,■ That thev truly constitute the actual germ of the h.- ease is however, a point upon which opinions may d. Her The constancy of their presence, their absence in othe individuals in malarial regions, their abunckmce in the ' er forms of disease, the destructive influence he extrt upon the blood-corpuscles, are urged by Lavaran in evidence of their pathogenic nature However this may be, the question which here con ce ns us relates to the relation between the phagoc^es and these bodies. Surely one might suppose that here, •f anywhere, the theory of phagocytosis might receive conSrmation or rebuttal. What but phagocytes are he amceboid forms of these parasites which exist in the led blood-corpuscles, gradually destroying the stroma and I i ON PHAGOCYTES. 23 the hiEmofflobin until notliing but a sliull remains :■■ Here, indeed, are foernen worthy of the steel, or, rather, of the plasma, of the leucocytes. What, then, are the facts.' Mow farr m we say that in the hloodin malaria, the seat most assuredly of the chief pathological changes, in acute cases, that there are evidences of a struggle be- tween the phagocytes and the hicmatozoa. It has long been known that the leucocytes in this disease (i)articu- larly in chronic cases) contain pigment granules. There is no other affection in which melaniumia is so constant a feature, th- leucocvtes containing irregular pigment, and occasionally free amoeboid forms of the parasites. The cells containing red blood-corpuscles were very alnindant, but here, as in the spleen, it was particularly noted that the red corpuscles not containing the parasites were as freiiuentlv, or even more fre^- quently, encl.)sed in the cells. In the liver the pigment existed in three elements. le- s- '-e IS y )f 1. is 3S d g ic il le V- d id n le temiernepH on jKiiiKiLiun. I saw the patient for tlio first time on March 5tli, and was strut' liis (listrcs.sed appoaranee. lie lay propjied up in bed, liad - l-'^^^^Sjof^.^ be exuectedfrom the presence, in such numbe s, ot to.s so deEuctne to the red corpuscles. In the spleen, bone marrot Ld liver, the organs in which the c- -dying blood-disks are normally cremated, to "^^ / f ' ^ <^^ nression we have, as might be expected, an actuity : ti;nire to th; increased amount of -tenaUo b •consumed, but scarcely such '^^ff^^'^^^^'^ action as would indicate, on the part of the leucocytes, ^^in:t;:mSng theory that to the action of phago eves is due the immunity against certain diseas so. against a second attack. I cannot now ente . In tlu, present unsettled state of our knowledge it would be p.e- "To'conciude : While phagocytosis is ;-if esjKead and nnportant phvsiological process throughout the animal k "lorn ind while it undoubtedly plays a most impoi- ur'n in many pathological conditions the quest.o ;,- an active destructive warfare waged by t^ejoo d ell against the microorganisms of disease must still be considered an open one. nifts e s f 3 3 tenderness on palpution. I saw the patient for tlie first time on March r)th, and was struck with Ills distressed appearance. lie hiy l)r()ppe(l uj) in bed, had slight tlys])noea, dry tongue, pulse 100, tenii)eraturc 100'. lie comi)lained of ' Rsad by title iit Uio ineetint; ciftln) Asancliitum uf AiiKrirun Plivsiciaus, WiiBliiugtuii, 1888. A ■ i's { «i f<: ..'1 I .!» y \ xcv Extracted from the American Journal of the Medical Sciences for January, 1889. PULSATING PLEUKISY.' By William Osler, M.D.. PKOFIPSOU (.F CLINICAI, HEIIICINE IN THE VMVEKSITV OK I'ENNSYIA'ANIA, PuLSATixr, pleurisy i.s sucli a nire condition that the folh is worth phicin^ upon record: Strain in liftinr/ : pain in left .'v„si,. ll,e,l..r,l ns .1 "'"^''l'""-, i'", J IVenmus -- •;;;:;;!;;^;:^,,,^^: ^,^S<;" ule bev.na the right „,ar^n r'^'Tnf hph^Vor he c V pnoea wa/ relieved, the appetite improved, ''";^,rTirV,n:iin^n';,f" !:r!5::- Co„okB^^^^^^^ au,li«ci.ni.>.keseeu.nt.e IZi' "'\*lvr::;:^;;;:,tS'': ibo' re,': !;;;:rcsr ei:^c"i;riSt itri^p;;: ,„.. ei,.,. .„ >i,e r,;.! rib, ,1.,11 below. ,l,i. "■',,; f.;;5'ttV|:'-E';,,,,,.,„vie,,lar a,.d A i!u/iiiltMti(ni • Iiisuiratioti is loi.ti •uui uicla^ m ni*- .- ?;r^rrvin'r,,C ;",„!' .'.alVle .L^. »„ eougbi„.. N„ beU r;;i;"T„:i«lrrt.l'Ti.*'u - „l«erved that the pe,-ca«ioa movable, ihis wa* \ti} luaiK ..viUa became hyuer-resouant .hich position t^^ P---""it^. :^'^\ ^"i^lion at'outer angle :?Sl alnlla --- ' -le .a^ distinctl^^mpanitic. To-day. ?or theS ime, ihl Ml s.H.nd Nvas obtained nith the co.ns V/A S nee the 20th he has had irre-i.lar tever reaching 10- in U c 2MI,. >^'"''« [»« -;; ^.1 j,,^,^.|^ ,,^tter. The physical signs persist; OSLER, PULSATING PLEUKISY 11 sxamination detcrniined. jmra-stornal iiuUlon onset eiilision had :pansinn was tinguinhable. >ace. Tactile the left side rij^lit niarfj;in puncture the full pleura nied by Dr. ni removed. By the Dth visible to the ' the clavicle, turbid serum The tcm])era- ite improved, ' comfortable. )e seen in the tient has im- a seems quite pain ; left side Ise seen in the m. The left it the extreme c'lcar to the clavicular and y murnuir has ■ith the breath Is in the lower tiing. No bell the percuirsiou ipanitic. Dul- 1 was distinctly rijrht side, in hyper-resonant 1 at outer angle initic. To-day, )ins. iiig 102' in the 111 signs persist; [ic lower border ,-mpanitic, from rns on his right loric breathing ■e the percussion note IS dull. There was noticed to-day in the fourth, fifth and K'leof theHcapuluand diminishell fremitus i,n i >H Ti"-'' t''« ^■•^P-"':^;^'e "."•^■^■nient of the left side became more impu.ed. The second and third intercostal spaces in front became promi- nent, presenting perceptible pulsation synchronous with systole of the heart About five days after the onset of the illness he had a severe fit of cu-diin"" less. Ihe cough continued tor a few days, witli expeitoration of ims The percussion note on the left side became dearer and the pulsating "tumor entirely disappeare.!. The temperature fell to norma! and the man's stren-th returned, ien weeks from the onset the man left th.' hospital strong and well. Dr. F. P. Henry, of Philadelphia,'-' reports a case from the Episcopal Hospital : Woman, aged thirty years, admitted in the spring of 1880. On the left side ot the thorax there were three strongly \mU:ituvX tumors-one about the size ot half a large orange, m the left mamm.u-y region, direetlv over the eentral portion o the heart; a second, much smaller and acuminated-;.,, with apex much smaller than the base-was situated on the left antero-inferior portion ol the thorax ; and ii third, the largest of the three, on the left postero- inferior portion, its long diameter, al)out four inches, eorrespondin- with that it tlie vertebral column. All these tumors possessed a strou" expansile svs- he pulsation. The day after admission pus was withdrawn hvpoderini- ally itom the smaller tumor. The , i-uor over the heart contained air, which I Archives Genf rales, 1883. * Doiitsches Arcliiv I'iir kliti. Modicin, 1. 1 xl. 1887. « Cliiiicil Uepoit on Cliruiiic IMouritis, p. 47 ; aud Ou the Roepiratory Orgaus, p. .181 18.56 •• Now Ydi-k ModicKl Ucconl, 1884. ' ' Canadii iled. and Snr}:. Journ., May, 1885. • Proceedluga of tlwi I'hila. Co. Mod. Sui-i.ity, vol. iii. p. 8.i. O toll c i ■ I \m tt 'i: M i G OSLER, I'ULSATING PLEURISY. was vcrv evident on iniinipiil ition. AH|.iriiti..n was p.T ,rmcHl, and. some time aftor. a .IraiiiMuv tub- wa. inserted l.y Dr. AsI.Ii.hni. The woman wan removed l)y lier IViemU, but was alive a year ultcr tlie ..[.eration. Dr. Jancwuy, of Now York, wrltos that he liaa met witli ouo case of empyeniii of tlie iolt side, in which the tiunor was situated in the left second interspaco, which pulsate e>. IMAGE EVALUATION TEST TARGET (MT-3) V. /£/. k /j^'^^. :/. f/, v, ^ 1.0 I.I la 1^ ||||I2.2 " 1^ 12.0 L25 i u — 6" 1.6 rfl 1 !__•_ riiuujgLdpiuu Sciences Corporation d ^^ 4^ "^ V \ \ ^^ w^ 6^ 2S WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 tA ^ t ^ b OSLER, PULSATING PLEURISY. that a certain degree of pressure is a necessary condition. Comby thinks that ..he pulsation only occurs when the lung is compressed and adhe- rent to the pericardium, so tliat the heart nKJvements are communicated through it to the ])leural f'l ;i(l, and «o to the che ♦^ wall. l'\'reol makes a somewhat similar suggestion, holding that in every instance the condi- tion IS one of pneumothorax, in which air forms an elastic cushion between the pericardium and the fluid through which the pulsations of the heart are directly transmitted to the cho.-Jt wall. The cashes have been mistaken for aneurism, and the situatio.i iu which the pulsating empyema necessitatis usually develops renders the error very jiardonable. The doubt can readily be solved with a tine hypoileiniic needle. The prognosis in pulsating pleurisy is not very favorable. Of the thirty-eight cases in Kepler's series, seventeen died. But we must remember that most of these cases occurred before the days of safe and frequent operations upon tiie ch"st wall. Complete evacuation of the fluid with free and permanent drainage meets the indications for treatment. <^ 1 < c^ ic -'/r.' -t -j», '/ *» ^.* CV/- f.*-:. _>!<=• vT '/*" A .;^ -^ / .^ \lui»ii:t fro'H -'//vr;,- ■"'^''"'■'■"/■///.■.I/,v//,„/„w,y,,, Miiryli Vliiin /'■ /-v I 'I'y.iKi/ luuiilly Kj /Vnnual Address. 'I'HE i.K'EXSE To I>RACTISE. HV Wll.MAM Osi.lK. M J) ori\ anent drainage f'"- ".akin,, ,„e ■■r.ici f Vvlu ;."' .T" "",--■■■ •■•">■ ;'i-'"K- '">■ ■■-' pn.rcsHi,,,,..,, ,„, ,,l i, . "" '";■ '■'^■" ""* ■ •"•■'t i. is a H„l,ioo. .I,.„u.l,t ' ■ ;"" ""■'■ ■•'"'"" 'lis>"ssi"n. a„„n v1, ., r "','"1"" "i-niisinK licalcl I.C'W, S.ill " 1,0 ,. , """"!■■"■■■■■■'">■ "Pl-itc. view. arc. .iu'sc »I,„ h„ ; ,,■'■"" ,"""•■■"•«'">■ -'-'"'"'■ "n.! .nicer,.-,,-,, l„„os ,^^1. , ,, ,' ",""'' '•'"""'' ^''^'■^ '"" "' "" i..R the fooii,.,s ,f ,,r,,e , ho,' ;;T;,r -^ '■^^■-■'•■""- l".IJc-,oJ. tl,c,-of„ro, t„ s,,oak ' I, '.•■•">,'l'^-"."roo,„ .■"ll>|.r"-iMo its in,|,oit.-„,oo, ivsls with the State, n.., t k.,,'" f'. ^'^\P'^'^^t=^^ "< .ucdicinc ri.ijlit and f< lines witliin tliat 'elic'\c It is ack priitc'ction to tlie lif ;viK'raI now ledn-cd that th IS tins f and hnil )s o| power IS \eiy \ar lonsly exereised in di police power wliieh extend,'- li^- citix.ens. At ])resent. 'erent States. 1 'i !-■ n WII.I.IA.M nsLKR, .M. 1). many, no rc"ni lati (»ns w hat cwv exist. A nv mc who wishes, irrL'spccti\L' <»! c|ualifio(ilions, vim vnicUsv. In a majority however, tliere are restiictions whieli (knuiiul evidence on the l)art of tile ])raetitioner tliat he has stiuhecl. for a lons^er or a shorter period, at an incorporated school. Practically, the rule l^revails that witli a diploma from a charlered seliool lie can bes^in at once, without an_\- hindrance other than that relatin;^' to re.^istration. The educational duties of the State do not here e.xtenci hcvonc th e svsten-. of common and schools, thou'di, in a few hisjher unu ersi ty wo rk is also norma under taken. Special edtication does not receive support from the public re\enn.^s. Schools of law. medicine, ens^ineerinii-. the olo.uy. all the special branches of study, are private enterprises, chartered by ihe State and maintained by fees from pujjils. or by tlie munificence of private friends. Certain jiriv ilej^es arc .^ranted to these Institutions by the State, the most important of which, in the medical school, is the reeo^nition of the di])loma as a qualification for practise. So unsatisfactorv. however, has this system proved, that there i s ( )n th e part the ])ublic, and of the profession, a j^-rowins.;- sen.sc of the neces- sity for radical chanj^^es, as shown by the number of ■, in which bills have either been already passed, or have ..i .u he fore the lej>islatnres dealinj.^- with the ])roblem. It is universally conceded that the basis of let^islation is the necessity of proteetini;- the people aj^ainst the depredations ol i,L;norant ^^raduates and of quacks. The aim is to provide a m inimum standard of qualification to be exa(.ted of all per sons who desire to follow the calling- of physician and sun fcon. Whilst we find Lc.iifislatures everywhere will ino- to support en actments necessary for the safety of the public, they will iioi (and it is rij^ht that they should not) sui)port clasK Ici^-islation: and herein lies one of the chief difiiculties. rf v\e 1. th around upon tnose en.ga.^cd m the practice medicine, -we find that an overwhelmins^- proportion bclonjis li the regular. or so-called, old school. A second small division professes to follow the preeci)ts of Hahnemann: while a ihin .still smaller, neither one th in"' n(^r the other, but a liltl both, professes a judicious eclecticism. These three bodic; have schools, medical journals, and in each State a more oi less complete orj^ani/.ation. In the eves of the la W ( W llli' •nVlitly disreoards medical theories) ,1M,,, , , ^ ^'-'^''i'v division uf theI„Hiv medic- \ ,""'■ '' '"^ ''"- H.^hcst mo„.ent. The ..'utcouK- > t h''/' 7^ '"' ''^^• ^'•^- hostile camps atid bitter war """ ''^'" ''^^•'•^' "- "-essitv of a dl c "" " •""' ' ^''"'- ^■""-"- '" .-at branches of „. J^^/^ ''^;- ^•'"•'•'-'-n <>f study in the '^i->io,3^ end.ryo,o,, ;;;:;., r::-;;j;:^'';''r-''^""^^'->-^ ^•oloM-y, and medical jurisprtKlence ^ "^'■'^^'^'"•^•^- .^y"-'^'- diffcrences onlv bcon e , " "" " ^''''''■" The 'n-rapeutics, a s^: „^^'i:;f ^^'^^" ^ ^^'^ the subject of tl- so-called scho^t : i;:r"T.r"''- ''^^^^^'-'^ "P'"-" -ist. So strong how^; '" '; "i"^' ^''*^— ^ <,f -'thical one), that the div'e .,' e Z" ' '^'^'""■^- "''^'•.^^■'v an separates absolutelv th-hJfe-e^-h ""''•''" ^'"■^ "'"' '^'•^"-''^ -eh other: and I do not s^; f V'^:"'''""''^ ^'•"•" ^^"ticp:ated do^^as arc nn 1 .^'^" '^'-'"^l ""t be so. while and a free science. ' "' '" "PI>-'-n to a rational ^- ^'- protection oM ^ H^t- T"^' ■'' ^ ^^'^ '^^-'ation .uether. not sin-dv I kno r; "'" '""^ ^" ^'^■'^- ^■•>'- ^^ to --y-at the i;;t ern ss t1^ ^"^ '^ ^:'" ^^"'^ — -1 - t'on which has to be n c ij^ f"'"'' ""'^ '"^ '^ '^ ^^ '1'- of the nine or ten i W s w/-? "l""'''^'' ^^''^-' ^^ ^'^'^'^ surely, in the inte^-^ t o^^ J 'll /; 1^^ '^^^-' '" — - - n,ay -H^^eronthe.p,est,on::;^£;:;-;:;;:r'"-''-^'^'--^^^'^^^^^^ In e■ i""-p',a' ':;;;::,,;''\^''''^/'"'' ■-«■■*-"■ " tiK' State or bv I). rti,.< . 1 , "■ '■' »l>IJ"n.tmoiit bv wltiC, »„„„. i , ; "^, "' '^;;""'«' "f " '>--!oill;]< ,,..„.„.•... ,. ... Ill or the license. each State int tives to a central pa i-elatin.u- lo medical tiipMonias. e.xami le nrt^anizati( n of the enti ne all candidate.' o an electorate, which shall send '■lianicnt. na\ iiii.- fill re profession veprcsenta- ediicatioii. cxaii eontrolofall(piest ions j ■■ , 4 H:! I I i inalion and rc^.-jst ration. wiiJ.iwi ()si,i;u, M. I). These \arious places are at ])resent in operation in different ixirtfi of the (.'ontinent: let us see how tliev woi'k. And Hrst of the eollei^es, whieh ha\e praetieallv had a monopoly for years, as tjie diploma has carried with it the jiriv ilei;e of re,L;'isiration. To all intents and ])urposes the medieal schools of the conn try are ])rivate origan i/.ations, manas^cd in the interest of the ]irofessors, who, with seareclv an exee])t]on. have direct l)eciiniary interests in the size of the classes. The .greater the number of students and t^raduates, the lart^er the fees, and the hit^her the income of the teachers. The runnins^- exi)enses and the interest on the moneys expended for the teachint^-plant are the first call, after which the balance is divided. 'I'h<.\se chartered corporations are wholly irresponsible, without super- vision by the State, the profession or the public. It would not be difficult, without fear of just rebuke, to brinj^' a railinj^^ ac- cusation aj^ainst theni . persistently actin.n' in their own, and not in the interests of the public. But the time has passed for this. Yet, it is surprisini^' to think that so many men, distin- j^uished in every wav in their profession, cultured and liberal, stdl elins;" to, and even advocate, the advanta,n'es of an irrespon sibility, which has made the American sxsicni of medieal educa- tion a by-word amons^st the nations. Let me not be misunderstood. These very men are, in many instances, th.ose whom we delij^ht to honor, with names which will last as lonj.;- as American medicine. Vet, to an unbiased mind, there can be no hesitation in attirminj^' that the system which has been permitted to develop in our midst has done, nay, is doinj^-, irreparable wroni;-. But, it may be uri;ed, on the part of the schools, that they are ,vhat the profession wishes. The stream does not rise hij^her than. its source. I do not think that this holds .n'ood at present. It docs not rc<|uire a \ery wide professional ac([uaintancc to .i>ather, that there is now de\elo])inj4-, throuj^hout the leni>th and breadth of the land, an earnest desire to support a hij^her medical education, ami this is borne out 1^- the success wl:ich ,ias attended the tenta tive efforts in th direction of the larj^er schools, which ha\L made a three years' college course ccmipulsory. Mere, let me remind those doctors whf) talk loudlv of medi eal reform, of the selfishness of schoolmen, of the diffieultv in )n in (lifVercnt )iullv of mcdi "f »>""."'-■ of s.,«>e„.:r : ,, 7 ;';, 7"; "- -i-.i,.., i„ -'"r "• nn, .K.SC. ,„,■«,. c,,.,,, :,,,:, '''7;"''''' ''^' '''''■•- "I'Hl.mc.nt. .Maiiifcsllv. it „„„l,i ,',."'"'' I"'^'*"' f"" -'- "f -n,,si.fc „i„, ;, „ ;"'-;hl-.«i.lH.,„,l,.,,„a,. ^"^ 'h>- mini,,,,,,,, i„ „,., '"■-'>'•""';' l"i.ryi,„-s',,,.„.,:^. '"'»«i->.'' ..f tiK. sc, 7„; , 7 7 7" ',""■"" " '— Wc »■"■- t„ cl„-,ct thc.i,- ,s,„de, ,7s' :, "'7''"">'' ''■ "«■■* "'-> l"-""I-" >™.,ld h. a, „„,7s77"; "'"" ""' ""•"'■-•"'■ '-> the "-■ -"'".•..•■ '""k e..n»ideruti,mH tl«.. ad,a,7 7 i . "''" "■'"" "'^' '»»e»l '"e van. t„ ».. „,„, tl, ,7 d 7 77"",'^ '"""'' ""« be.,, i„ •he .""». p,-..s,,.,,,,,. ,, ,7'.7 7^7f-''"-7eina!li„stanccs ".e-m-c i„ „.„,,„ ,„ f ;, 7„ ,7 7''"""-'- """"■"-"■ "- 'leal ,cacl,i„j,. and tl,o d.vd, p , 7 '7'."'-';-™->'». '"'e prac '-y, »itl„.„t fcar„f„,„„.7 7 ,7^77;7^'"' "7"'--'-- and 'v.th an a„,pk. and a jus, ,v„-,M > , ' ""''""'" '""'-■ '"et ->.e.,i.s „,,,.,, dan,.„:'i:;d7:77l:f,.:'""..':",- "■'■»'■ "■■'-' "-■ -y an-4cr()iis it is t en>and()ii th '"'• the aver o arouse the si Jier advanee, sh L- couvietion that a t uniburinj.^- eonse |'<-'e]i (lone, i i«e Anicriean stud wo session course ■owm^ how it-'uee, and to Uurin- [hv past i n spite of th (-'nt. Hut ii IS sufificient t-'ii years, the L' agitation which has 1 «pite of all that has sac! truth ii 5een so active lust be told, that a (. ii IJ \fvm '1 Wll I I \M OSI.KK. M. I). hirs^c pcivcnUij^c of (locLors arc i^raduaUcl annually aflcr onlv two sessions of study. On paper, the two session schools almost universally demand three years; one of which, it is stated, may be with a physician. Now, it is notorious in these schools that a larj^e majority of the men reccisc the dei^rce at the end of the second collciic year, and it is just as notorious that not 5 percent, of the cases in which a preliminary year of study has been ])asscd with a phj'sician is a hona-fuic period of medical instruction. It jirac- tieally amounts to this, that a man enters without any fair ])re- liminary test as to elementary education, say on the first of October of the present year; and eij^htecn months from date, or rather seventeen months, sometime in March, 1H91, he will be let loose upon the commonwealth. ICitihtcen months in which to master one of the hij^hest, as it certainly is one of the most difficult of the professions which man is called upon to practice ! That, gentlemen, these are facts, sad facts, each one of you knows. Yet so blind do men seem in this matter, s(j wedded to this pernicious system, that I have known physi- cians in larg'e practice, able, cultivated men, contributors to medical literature, standini;' hii^'h in the esteem of their brethren, permit their sons to follow out this curriculum. Picture, if you can, the mental condition of such a , graduate: an incoherent jumble of theories, a chaotic assortment of what he would call practical tips. But this question has its trat;ic side. which completely overshadows everythinj;- else. It makes one's blood boil to think that there are sent out year by year scores of men. called doctors, who have never attended a case of labor, and who arc utterly is^norant of the ordinary e\eiv day diseases which they may be called upon to treat, men ulin may never have seen the inside of a hospital ward, and who would not know .Scarpa's space from the sole of the foot. Yet, j;entlemen, this is tlie di.sj>raceful condition which some .schcjol men have the audacity to ask you to perpetuate; to 'jon tiniie to intrust interests so sacred to hands so unworthy. Is it to be wondered, considerin^i;' this shocking' laxity, that there is a wide-spread distrust in the public of professional educa- tion, and that quacks, charlatans and impostors ])ossess the land } lallv after only ^^•>>'i-\i. \i)|,Ki;ss. ''"t thr hamWrain^ is ,.„ the u-Jl ,i 'H'en read, and the pn.phcev in eo • ' '"^^•'•i'-xiati,.,, y^^^ ^' -'-is not the vis .n . ■^ , , ' " '" """■"' '"" ^■'"'"'nKnt. ten years in searcel.- a Stat H k r:'' '' ^^^Ir'"^'- ^'-^ -^i^n ;''^i^.- ^■<'nl,,cliti„n h.uveen the eoik.pv^. i?''"'" ''''''" ""'•^'^Ineted '-sionai and State ,vst a ;':;"" ''"/"^^" '^''— "f I>n.- p>--Mn the h^;: . ';::^^^^^^^^^ -• ''V the State soeieti " s,^ " '""T"' '^' ^''^' •--—•• ^i^^KMvn in Xorth Carolina. Vir-ini,', J/ ;■ '"'"^''^" ""■■'^'"- "<> ^''ffienlt3-, and u eonstitutes a^ i" ''""^^"^^'- >^--"ts measure uiil be widelvad.rpted ',. ^^ '^''■". ''^ '-^ years tin's ^^ simple meehanism. and ,, elen- i V'?'" ^^''^^"^^^^^'^^ i" 1— are too Hnmed. an U ^ r " i " ''""^' ^'"^ ^1- preliniinarv and special su ns ' "" "'""■"' '"" ^dueation. of the profession In each S^uf " ^'■"'^" ^^ '^'''" ^'^ l--r >-^"^::;n::";:t::;:r:':s^ istr--- - .^...hiehn.avhedo;.. Oft:— ^^^^ -- pel vent., were n. eeted in,., ^■^^""'"<-d, 54, „r creased eonsidera]>lv i p ^ti ■ '"' "''"" '"'^'^t l.ein- -^ the praetieal branehes --^"^'"afons were instituted ^H<'^uu:"^'iJ;-rb.^;r::i!;^^^ -^ta,e of ^i.in. he 1;: ',;""' '^'^--"^ the .reat ad- ''^. the praet.ioners.\;::^:;; ^ '::;;.--'" ^"- the hands •ninonty rule of the college. - ""' '"^'' ^^'^ Theoretically, there e'ln h, -<'-ni/.anee of all matt perhaps, thouo-h of this I licalth within the State. ers relatiui- t ;^"""'^'''eiit. which should t; medical edueat; am not .so sure, of quest ike on. and I'ltonal di\i ■"^lons which nii^i^ht as.senibly di.slrict be made. ions of public s. or other ter- 1 I 1 \\ould send 1 1 m 1 1 one, or Wll I I \M OSI KK, M. 1). perhaps two. rtpivscntati\L's Id llic Ixiafd ( ilcpcmliiij; iipnn ilif pi-()fc'ssi()ual po[)iilati()n in (.'acli districl). Tlic electors would be eonslitiited by all practitioners irrespective of sehools, which had rej^istered at a certain date. A man who had i)raetieed, even w ithoiit a diploma, for a certain time would, under these eireumstanees, ha\e to be recoj^ni/.ed and permitted to re,i;isler. The (lovernor of tlie Stale would issue the first warrant for the eleeti(ni, which would subsetpiently be the preroj4ati\e of the executive of the board. Ft mij^ht be necessarv, at first, to luue, from each district, members returned from at least three of the divisions which at present constitute practitioners. 'I'hc rei)resentation sliould be per capita, tlie number of constituents in each electorate to Ijc previously arranj^ed. The term of the board should be, at least, four or five years, and mcmbcis should be elij^ible for re-election. Conducted by ballot, there should not be the slij^htest difTiculty in carryinj^- out such an election. There would be, of course', active cansassini;'. and perhaps, many nominated from one district. Thou,i;h there would be opi)ortunities for jjolitical trickery and i^errymandcr- inj;-, I think, on the whole, it would be found that an election could be conducted with tolerable ])urity. The universities and schools would have full representation on the board. To such an organization, I believe, mij^ht be intrusted the control o*' all matters relatini;- to medical education in the State. It would correspond to the law societies, and to the svnods and confer ences of the various relij^ious denominations. The powers of such a board would be accurately defined by lej;islation. and should relate first to preliminary education; secondly, to tlu examination and rej^i.stration (;f candidates f(jr the license to practice; and thirdly, the control of all matters relatins^- to dis cipline with the profession. The neces.sary expense would be met — first, 1)y the fees paid by the candidates for examination; secondly, by a small annual tax levied upon all res^istered prae titioners. Such a body could look forward hojK-fuUy to a per manent establishment in each State, with buildin.ns suitabh- equipped for examination, and with every possible provision for conductinj4, in an orderly and .systematic manner, the bu.^i nes^ of the ])rofession. The first important function of the board would be the re^ti lation of the minimum standard of education reiiuireil on ^NM'AI. .\!(|i|c so with us^ A .,r Vn L ' ''"''^ "''>■ ^'"""^' '' ""t ^"'"''"^'■'- "t I'ui'onn tv would il>,,. 1 wl>'^-l. cannot I,c expected in the sehools T •'"'" t'H' prelinnnary test should he inde, e ent ^"^^""'"^''--^ ^^ t-sional n,en. and the exanunatH::^ d i^^";:: ""^ '''•'■ 'IXlcrent parts o( the State. The period \ \ "'^■''' '" ^-" the passing of this prelin.!: 7 ,•:;>;:""[;' '1^'^^' measure would etrectuailv prevent the entr '''' '' ^clucationwassuehthatu!eyeo.dd',^" ^:l;;-^ with the subjeets of professional studv "'"'"^'> •^''^^I'l'le The examination and re.i^istration of emdidnt. statute the nH,st important function of tr;;!:;!;^ ^^'''''' ^"'"^ 1 «■'!<- sLRcuon ot examiners 'n,,, S.UU. B,„„.ds .,„ u,e ,„„■..„■ »d„„„ „;,■;. .'J . ',! '""f'"" '" "11 tl.c il.niht uhk-li tlicv l,,v,. -iv , ,1 , • '•"«'-'ly l«'wcl .■.,.",.,.«, nK.„ f.„. ,„M .^ -T, ■ : :;-"'■;"■ "—«■■.■)• H..C1, ,. IVdinK exists ,„„, «,„„„„;„", ""■,"'■"''■-"•" >hc' board as c...„n,„cr „„ hi. .„ 4 ' *'', rT'''""" ' " «"!' •»■" cxa.Mi,,,,, „, „,„. ;,"';,;" -""'""t-i.s. and <';.»•, d,c„,ist,,v, pi,ysi„i„,., „„,, pa.i„„ ; ■ : ■„ J" !'"•••'; students fr„„, th. lah,„.at„rie.s .,V ,„„• fir 'chs sc " ''"'''T' of conduclinj^- tii know personally, in would entrust with tl ii'-y students in the tl ly in each State to h e necessary test wor f.nind men fully ca'pabli I hi many States of the L' tve the h Kiior to "inn, men to whom I le utmost eonddenee the examinati.m of * leory and practice of uied ii 1 1 icine, and 1 lO wii.i.iAM oM.r.k, \i. I). dntil.t not that in surj^cry. niidwitVrv. ^■viutc(.I„j.v. atul in the P^'lvKlot sni)jcct of thurapcntics nan L(|nallv ul)lc in these dcpartnients uoukl l)c' forthcoming. ThL-rc need not he any ditlicnlty in the existing dilferenees between the \an(nis schools of practice. All students would he examined in the i-rcat primary divisions, anatomy, physi- olo^y and chemistry, and so also in ])atholo;4v and morbid anatomy, ohstetrics. and in operative KyniceoloKv and in medi- cal jnrisjjmdence. The examinations in these branches woidd be imib.rni. In therapeutics only would there hv separate tests for rej-idars, hom.eopathists and eclectics. On api)Iicati()n. the student would ha\e to indicate for winch of the three he wished to apply, and. if successful, would he placed ir one of the three divisions of the State Register. I am free to confess that this scheme may. to some, seem L'topian, but I am firmly convinced that the majority of those that hear me to-day will live to see Stale Hoards ori^anized on tliis, or upon a moililicd plan. With the third funeti(m (.f the Hoard, vi/.. that relating f. discipline. I need not detain you further than to say that in any etlective act there should be penal clauses .nivin^ authority to pro.secute irregular and unlicensed practitioners; to remove for cause a name from the rc-isler; anil to exercise such addi- tional powers as ini.iihl. in the opinion of the framers of the bill, be thouj^ht justifiable. Now the entire feasibility of such a scheme is illustrated by the professional history of the Province of Ontario. Up in 1.SO5-6 there was a Licensing Board appointed by the State, which deidt, however, in examinations only in the ease of can didates without diplomas, but to all intents'and purposes it was simply a Board of Rei^-istration to which holders of dci-rees presented themselves, i)aid a small fee and obtained'' the license. The schools practically eontrolled it. In the .session of 1.S65-6 the profession of the Province sought incorporation, and the Act was framed which, with certain iin portant modifications, at present remains in force. It practi cally hands over to the profession, throuj^h th.c elected rciivr sentatives, the manai^cment of their own affairs so far as thc\ relate to preliminary and professional cxaminatiims and cer lain disciplinary enactments. In spite of the strenuous oppo ■\N'M'.\I MHiKKhs, t I Mil..,, nn tlicparu.f nianvwh., fdt tint it u-. •"K thiuK tiM.s t.. I.,p tlu.'i,m,o,-t.n , """' ''"«'•"' sutisfac-tion. s„ch as a,v al.nost i„e ^.i ' ^ '^ "" "" '-'• '-'^^y- -^tu- ., yeat-s of .xistcuv h ns . T "'"''• t'-- e"ti,v pn.t.ssi,.,, ,„• „,, iVn, ,;,,•"''''''''"''''■'' ''■''-i''-'t.asopp.sit,.,, ,, : '^,:^7'•^''••^'•>•p- ;''''-'i<-'-i.nwasavisitwitlMnv- .J" J' ;r''"^^ tec nx.iii of the Iloiisi' in uh; i ' "^.^I*^"' t" t'le n.minit- "-S tlK. healed ,l,,s,„„c with rcfcren . : „. , : " ""''■ IK-ar „,u„ the umk;„ ll,f,„ , 'Ulc-l,lc-,„u,tevc.„ l„e.,„lu ';.'!-;::;- c:^\:;:;:.;r::;;;;';^xr'' '■-'-" 'he inevitable „i.„ a ,.e,.fee,K. ,„„. , ee ,' ','"" T'" s-sses a n.aK'nilieent ee„„al l^l.ildi,,,. h .iel, , '"'""' 1","" examinaUcins. with „|K ,,„ r ,. '" "I'rUi t.i e..iHhiel the iv"vi„eia, ,.i,„-a; ' "!^:: ,: •:::«■;» ™- -»' .•<.— i...- a small annual cv'levi,..! ^■«im,„ali„ns ami a ul'x I w.;:^'"'" ^^'' --'^«-^-- -i- in the oth.. To those who look upon such a schcnc as I spe-tk of ■. ■ I t<.p>an. and ur^c difficulties on acc. .... . P''^^tKallj the same ,n '11 the P^rilish I'n ii^Ii jK-rhaps .i^rcatei- in d CK'"'-c. !'iat which th ei-e so sueecssfullv c •State of the V iiion. •ninces i)nor to ,S66. What has 1 c eciually well accomplished existed 111 b 'cen done in e\erv •:i li ' vi 12 WII.MAM OSI.KK, M. I). rhc -rcuL -am is the pulilic o-iuirantcc tlial when a man has received the lieense to practise, he hai, at any rate, thr elements ct a solid education; that he knows the structure and I unctions of the human body; and that he is capable of mect- ini4- the ordinary enieri^encies of professional life. Such a pl-in removes the irresponsibility of the schools, establishes a uni- form curriculum of studies in each, and exacts a minimum time fca- theoretical and practical work. The difference is simply this, that under our present system independent and irresponsib! : schools have the upper' hand and dictate terms to the profession and to the public, and d(. whatever they please. With an organized profession, thn-u^h Its representatives m session, the schools take the sec(md place —they exist for the profession and the public. 'Hiere can be no (piestion as to the ^rcat superioritv of this method It is essentially democratic, and should commend itself in everv particular to the profession of this country. It is infinitely superior to he .second method carried on at present in many of Uie Slates, althouj-'h the Examining- Boards nominated by the Governor or the societies are better than unrestricted registra- tion. W hile the interests of corporations are fully represented in this system, they have not the oxershadowin'u- power such as uas -ranted m (ireat Britain ])y the recent Act in which it seems almost ridicuh.us to think that only six representatives from the profession at larRe found a place in a Board, and this number Knul-iuMly granted as a privilege, not as a riMht It does not do. however, to underestimate tlie difficulties which liave to be encountered in any attempt toori-anize these Boards. It may l)e premature in many States. 'The pn.fes sion, I have iTcciueiitly heard it stated', is not ready for it This, from my own (jb.servation, I should doubt I bJlievethe g-eneral body of the i^rofcssion, when it fulb- understands tlie question, cannot but aurec that the method is in reality a safe one. I am sure that the public, through the press, will heartiK concur in any plan which will guarantee that the praetitioner's to whom they entrust life and limb shall l,e educated men ( )p[)()siti(m will be strongest on tlie one hand from tht which 1( their askance it any measure likely to interfe llools, re with h prerogatives, and on the other hand, the members ..f tl (unieopaiJnc and eclectic fralernit\ 11 ■ not uniiaturailv di'eat Kil wlicn ;i iiuiii at any rate, the lie structure and -•apable of nicct- fe. Sucli a plan stablishes a uni- i niininium time present system he upper hand -• puhlie, and do L'ssion, tlirouj^h he second jjlace 'J' he re can lie method. It is itself in e\ery It is infinitely resent in many minated In- the ricted rei;ist ra- lly represented ino- i)o\\er such iVct in wliich it representatives l'5oard, and this is a rij^ht. the difficulties ort^ani/.e these The profes- ready for it. I believe the ulerstands the 1 reality a safe ;s. will heai'tib - practitioneis ated men. m the schools, interfere with embers of the turalK- dreail ANNTAI, ADDRISS lest in any such arraiio-cmcnt -> fnii ,„ . ""t be meted them. "''"''" "^ J"'^^'^"^^ ^^-"l^' -The antat^onism of the schools is not I b,.i; ' " 1- eifectual they would have to be Ue 7' T""'" that many of the F-.enDi.v , "'^^^'' '^ '^ notorious ••; l.i..l.c.,- s,a,„,a„, „f ..a,„i„.,.i„„ ':,',„ ;,;;;"" '" '""^ '•■"• >li'.-.I fairly will, th,m i„ a muttcT „ , , /■ • """""' '" -i<"..»i«fee plainly t,,.!,- H„„„, „■.*;':,::;;::::■■;:; ;;-' same as our own. aie the I i 'I 1 1^"' 1 : f 1 1 ^ i ^ M-' ■' 3 ii ' s III il^v/l ^QUANIMITAS: VALEDICTORY REMARKS TO THE GRADUATES IN MEDICINE OF THE UNIVERSITY OF PENNSYLVANIA, MAY ,sT, ,S8,. BY WILLIAM OSLER, M. D., PKOPKSSOR OF MEDICINE, JOHNS HOPK INS UNIVERSITY, BALTIMORE. PHILADELPHIA: PRESS OF WM. F. FELL & CO., Nos. 1220-24 Sansom Street. 1889. I if i - : ■ \ ^ a ■ ■ i ^ 1^ • ;■ I I i 1 1 II m :-| m ■ ^^^..Ji ^ /EQUANIMITAS. an.flcmnu-Cnstom, wl.icli lies upon us with a u-elL^ht heavy as frost, has nuulo even stale to .nany those tZ£t annual ceren.omes. To you at least of thase .veseTu^ houl.l have the solen.nity of an ordinanie-ca Ld as you are tins day to a hi.d. dignity and to so weig y an office and charge. You have chosen your Genfu ^anS have passed beneath the Throne of Necessity, ami w 1. the voices of the fatal sisters still ringing in your " will soon enter the plain of Forgetfuh.ess and d nk of the waters of its river ; but ere you are driven all ni Lr of ways, hke the souls in the tale of Er the PaniphyZ ^ It IS my duty to say a few w^ords of encourageme it and to jouri^:;:' "^ '" """^ ^^ '^ '''''^''' ^^^^'^--^ -' "'u: I could have the heart to spare you, poor careworr survivors of a hard struggle, so "lean and p a" d eaden-eyed with study;" and my tender mercy, whic has been ever towards you, even now extends so f^^r as to wS will T'^"" ''''' '''-' '' '''' ^^-'^ «^ ^^--"t: which Mil make or mar your lives, two which may contribute to your success, or, more important to many help you in the days of failure. ^ ' In the first place, of all q mlities in the phvsician or surgeon no one takes rank with imperturbability, and I purpose for a ew minutes to direct your attention to thi most essential l,od,ly virtuo. ilaply those of you in whom It has not developed during the critical scenes of the past month may catch a hint or two of its importance perhaps- a prescription for its preparation. It means cool- ness and presence oi mind under all circumstances, calm- ness amid the storm, clearness of judgment in moments of grave peril, immobility, impassiveness or, to use an old i^nglis h and^ nost expressive word, phlegm. It is the *The Republic Book X. u II \\i i u :, ''■'"' 'i ul «,l m f 1 1 >U'^^- m :| I •' w / ■'^1 u t •juahty of all others which is appreciated bv the laity thoujjh often misunderstocl by them ; aund,spensal,le factor. One of the first e s™^ 1, i oou„„g a good-n„tnre.I e,,„ani„dty is not o e" cc ,00 n .ch of the peo,,le amongst whom yon dwell i "1° . e, go ^bnt wisdom lingers," anj the average dfcl trT'iri;::^"!^'? ■»«•-' »- -hit m^or:::: in the old Romans, wlioiu L credulity which made tliem fall juacks of the time- sucl ucian ^"oiir^j.a for easy ;tinis to the whose exploits male as the notorious Alexande f t :f e one wish that his advent had been' . t delayed some eighteen eeiituries. Deal <,^eiitly then with this delieiuusly eredulou.s old hiiinau niiture in wliieh we work, and restrain your indignation, when you tind your jH't jmrson has triturates of the lOOOth potentiality in his waistcoat pocket, or you discover aeeidentally a case of Warner's Safe Cure in the bedroom eupboard of vour best patient. It must needs be that otfenoes of this kind come ; expect them, and do not be vexed. They are curious, odd compounds these fellow crea- tures, at whose mercy you will be; full of fuds and eccentricities, of whims and of fancies. I do not mind telling you, (Jentlemen of the graduating class, a secret which I would not for my cap and gown mention in public. It is this: the more closely we study their little foibles of one sort and another in the inner life which we see, the more deeply is the conviction borne in upon us of the similarity of their weaknesses to our own, until we weary of a uniformity which would be intolerable did not a Imppy egotism render us oblivious. Hence the need of an infinite patience and of an ever tender charity toward them; have they not to exercise the same to us? A distressing feature in the life which you are about to enter, a feature which will press hardly upon the iiner spirits among ' you and rufHe the equanimity, is the uncertainty which pertains not alone to our science and art, but to the very hopes and fears which make us men. We aim at the unattainable in seeking absolute truth and must be content with broken portions. You remember in the story how the Egyptian Typhon with his conspirators dealt with good Osiris; how they took the virgin Truth, hewed her lovely form into a thousand pieces, and scattered them to the four winds; and as Milton says "from that time ever since, the sad friends of truth, such as dost appear, imitating the careful search that Isis made for the mangled body of Osiris, went up and down gathering up limb by limb as they could find them. We have not yet found them all," but each one of us may pick up a fragment, perhaps two, and in moments when mortality weighs less heavily upon the spirit, we can, as in a vision, Ill a vision. see the form divin,. i.Kf „^ .. 'Vn-.n,w.(. ^"'' "'""^^'''^''^t'"'*' I'oni a lo,.,sil '( lias bc'cii said Hmf ;., . , <^l.iHly ex..vis.d iMc.na.l'';:T'''r '""■"•'• '"'">- ;l-turbs our nu.ntal pladdi^. I ; ,.^;7i;''''''V'''^'- cures, gettin^r ,uh| spcMdinfr vn„ ''"'" '" I"'"'"^'«'-i«>naI Hwuy, tl.a tlu.e is no , : i . '''^ ^V^'' J-arts ^iv.,. /tissadtotinnkthatiori;;;7X ;;"'•''• ''^■'"^• clisapiKHHtniont, porhaps failure V ^'"'^■^' ''^ "' «tore course, 10 escape from the ca i,,. •'':'"" '"'l'^' «f professional life. Stand un ' """^""^ ^^'^''^'^'''t ^o Your veiy hopes nu y hZ " 1 '''" '^^''"^' ^^'" ^^--^t- all that was iiL and d^M^^pT -"V'" ^^^''^' '^^ ''^ ford, and, hke him, you m . , \Tt \ '' ^'"' '''''''' niglit alone. WeH fm- vo ?f ' '''"^^«'^' "^ the -teney lies the viet^ - I/Ui:;,:'''-^^^' • '"' ^^^ '" ^- the wished for blessino I ' ./ i ''"''"''«" "^"^^ ^'^'"^' «trug^-le with defeat and t ?'''' ^"^^ ^^'^''^ ^^ a bear/ Well for youhu't'r'fr^^^ aeheorfiil.pi,,,,^;'^ ;i 3^;-ballh^ "iVon, ourdesolation on y do ^ul/rr f '^^""^'^""^^« oven with .lisaster aluM and . ^'' ^^'^■'"•" ^'^'^ ■sn.ile and with the he u T\ W '""""'''"*, faee it with a tl- blow. AncH . i;^ ::^,"^'-' ^''-' ->-l. beneath even when failures em et^,^^^^^^^^ iH'fore, cling to your Zl ' -1 ^ ''''''>' '"^^'^^ ^^'i'^xl tlu. 1) rk T<> 2 !"K'^:,^"V'^^C''''<^^l^oland before ehall t^^nge, and cahnl ■er, set the slug-horn to vour I It has h y a\\-ait the result. IpS, l)l(>w tlu souls, >cen said that "In nafi and what is this but you to bear troubles and to jxificncc ye shall win your an equammity which enab] rise as superior to the trials of •M ; k lifo. S«mu, % us ynii slmll do besido all \V(it(>rM, T can but wi.sh tbiit yoij may iviip the promi.sod blessing of (|uietn<.'.s,s and of assuninco forovcr, until "Within this liCf, TliotiKh lilttd o'er itH strife," you may in the j^i-owing winters glean a little of that wisdom wliieli is pure, peaceable, gentle, full of mercy and good fruits, witiiout partitdity and without hypocrisy. (Scnilcmcn — The past is always with us, never to b(* escaped; italone isentbn'ing : but amidst the changes and chances which succeed one another so rapidly in this life we are apt to live too much for the present and too much in the future. On such an occasion, when the AhiKt Mater is in festal array, when we joy in her growing prosperity, it is good to hark back to tluf olden days and gratefully to recall the men whose labors in the past made the present possible. The great possession of any University is its great names. It is not the " pride, pomp and circumstance " of an institution, not its wealth, nor t!ie number of its schools, not the students who throng its halls, but the mat who have trodden in its service the thorny road through toil, even throu.h hate, to the serene abode of Fame, climbing "like stars to their ajipointed height." These bring glory ; such bring honor: and it should thrill the heart of ever}- alumnus of this school, of every teacher in its faculty, as it does mine this day, reverently and tliankfully to recall such names amongst its founders as Morgan, Shippon and JIusli, and such men amongst their successors as Wistar, Physick, ''uton and Wood. Gentlein.. "f tJie Faculty, — Nohlem' oblige. And th'^ -u> 'iU.'ity ,,i the past touches us to-day in the freshness oi «o. ow at the lo--^' of friends and colleagues, " hid in deivths u twle.ss nighw' We miss from our midst one of your l.>est-known instructors, by whose h^ssons yoii have profited, and whose example has stimulated many. An earnest teacher, a faithful worker, a loyal son of this University, a good and kindly friend, Edward Bruen has 9 >V() ri.c.rn fo-duy, ul.s,, win.' f'onor an ).„n,.n.,| „an„. ,.,. ' '! '""" "''"' '"'H' U'itli ^"■'•«x nm ill I,, ,,^,,,, V;, '^"••'' ""•".■..sSa,n,„.MV. J^e.1 his career. ^^ "" ' ""^"'^^0' wJ.ich d.aracttT- lV.r.su,mlly I mourn fho l„ss „f .. «« 't ' " "° ^•^•"^'^^^">.tioM 'T. ''^"^'^-^ -^'I truest ontoT .:'''" '^•^^^-••' -'^ i" edition :— ''^ tlie phra.se, a liberal e,!,,. ''Whatever way „,v,,av,s,p,n„, el a,ul „.,.,, t,,„- ,„,, '™*o ,1,0 ,„o„„„i.4„..; ,2 „"'{.,"";" "'*■• ' '""«- "■«''» liavo thought eliit n ,1 '''■'■ '"'*•'' ■'■"• Ono '^ lover of hi., ,.rofeii„„ . ; , »'«"■'»•">»« -io dear l„' I -y, .hat ,I,e Herc,,lorp Cof ! "'«'',' ''"" ""•"«''! l>ore boon ro,icl,od. H„t it 1, „ f f """'■" ""'Wti.m i,„d to-day I .ever ,„y oon-looH^t ,, „ r,'.^" "*"'«'• "^ ' m.i o„co, sentlomon, in „ if , ' "'««ty. Afore •'-".g of friend. I ,;„: L;\ ;'■''"• "- ,.rioeK, "'"ci, no „.ord« oould oxnro,. M ft '" '*'"'""» "' -').- H i, „.,•„, ,n„ now T,, 'V-^^'r °f "'.vl,oart, gratitude ivoll up from n,> inn ''""" """'"'"its of il , <1 10 at every step during the past five j^ears. A stranger, I cannot say an alien tanong you, I have heen made to feel at home — more you could not have done. Could I say more? Whatever the future may liave in store of suc- cesses or of trials, nothing can blot the memory of the liai)py days I have spent in this city, and nothing can (jueneh the pride I shall always feel at having been asso- ciated, even for a time, with a Faculty so notable in the ])ast, so distinguished in the present, as that from which I now part. (Icnilcmrn, — Farewell, and take with you into the struggle the watchword of the gootl old Roman — jEqua- nimitas. X stranjTcr, I mado to feel Could I say store of siic- miory of the notliiiig can g been asso- table in the ; from wliich DU into the nan — ^Equa- il -i iM Ml I I! » Il ; H 1 , III II I 1 i vi ■-: IS 1 •d bl ■ Xo I , . , Extracted from tlie Amencan^ournal of ti.e Medical Scie ^..^^^^^^leai^enees for September, 1889. >*(LV hr_r ' ' « '""'"!!i'r;'-""-' «,..™,,,,,,„„„„,^^_ 889.] XAH ATROPflv iPULO- •TIMORE. '»"gue to the heart Ind " '^'' ^^'^ °^ ^'^^ th-se points the so -ca Ld 7'^'""' 'ying between fo"nd, or even in rareln'tn "' u"'""^^ '"^^ I^^ Th)roidaI growths a!o' ' '""^'" ^'^'^ ^^^^•l^^^- ."ost -mnfoniy sub sternar-' ""''"" "" ^^--' ;--f directly ;i",'hl™d" 'oTt^^"' ^"' ^«"- I'ave been described CVirchmv ,. l^'"''' ^ ""'"ber More rarely tumors develop frointrl^^^^^^^^^^^ ""'■ ^^■ or aberrant bits of a late af W '\^ ^'^^P^'" portions chest, forming large n ra h '"^ '"''^"^ '"^« ^'^- A most remarS ^'ie r; '^ ^'T''- {Pn^ger„,e^. ^^..wT^ m'^""*^^ by Dettrich -nan, aged sixty, X^' .^^..^^.^f 7). In a '^"h cough and hiemoDtvsi.H °' ''''"^ ^'"^<^ •Oe greater part of t^e'^g raT f°""'' ^'"'"^ '--ve,itwai::rs;:,n:H:-,:s lished by Dr. B. Sachs. >ow y ort: Men ,,11 ficultie.s have been ing upon the situa- ave been described ■u wo have scarcely .^ing all the forms gressiva— of which srtrophic muscular which atrophy and Jrs in one grouj) and •recedes for months not surprising that Gowers, however, ly occur in families, hie disca.se. hy that the greatest ig forms have been le, and of Landouzy 00th. plan in (li.M(l just beside it. There was no sjjecial connection w iih any thoracic organ, though filling completely liic top of the left thorax. There was a large brondir- cele, the left lobe of which was in contact with ilk tumor and could not be isolated from it. On .section, it consisted of \ series of imperfo tlv separated cysts containing a yellow-brown ihiid in which were plates of cholesterin. The upper jiari of the tumor was firm and hard ; some of the sepia had calcified, others had a fibro-cartilaginous ((in- sistence. Mi The relations of tliis mass, its anatomical < harai ter, and the nature of the contents of the cysts, ideiui( a! with that which is found in so many ca.ses u\ did \s deferred. Death ocrntLH .^ ^^^"^'■' ''^^ operation i'tun>or was founS ISrifl'S'"'-^ i ^^"^^-"orten" '"''e of the thyroid and fo ned a ,rl''''"'!,^'"'>' '^^ '^^ "I'hes m circumference hv^^'"""^ mass eitrht ;>'the thyro-hyoiciVig^u enf S: bH '"^^^' ^° ^''^ '-^1 l'e.side the trachea to the b f, .! ' • T '^ P^^^^d down ■"ass had an elongated Lueww""' ,^1°'" '^^''i"''- the end rested upon the Teft b on h' ' ^1 ''"''^• '^'^ '°^^'- i -neasured one and three uu^rf.?- u'""^' "'"s surface I "■ "PPe.- right angle of th'e ma ' !"'?'' '" '^"^''h. At "ii'i remnant of the left Inh^ T • " f™"' "^s a sniall ?"es of the two blend ni not f""^ ''^f '"'""r- 'he tis- ■nKMightlobeofthethJfoidwafoT;''"^ ^'?' ■"" ''^^''^^'■ -s a rase'stm :'to Kret 11 '"• ""T. """ ^"^^^ '' f^'ioMtroma"t^:^S^^;::'- ^'-growth don n the trachea. " extensions 'TIUORE. ficultic? have been i'lg upon the situa- ave been described n we have scarcely liug all tlie forms gressiva— of whicli ?rtrop]iie muscular which atrophy and irs in one group and recede.s f'cr months not surprising that Gowers, however, ly occur in families, lie disease. ly that the greatest g forms have been e, and of Landouzy ■oth. plan in * I i ?_ ^ 2 ' 1 ^£i^ ll Xd-lx Extract3d from tlio Amej-icar^JcHu^n^^ f,^^ September, 1880. ON A CASE 0I< HUMKRAL MUSCLES. By \Vii.liam (Jslkk M I) HRorE8Hou or „k,„c,nk, .un,s. „o..k,ns v.n,>.,n\, n.tT,.,„„K, .J..H ,• '^''''''^•■■'\""";* '"'""^"T "'vopatlne., the difficultios have been gieatl noreased by the .lesenption of tunas depending upon the situa- tion of the atrophy. Varieties of tl>e .une disease ha^; iLn d^c^d Z::X^ nuUad.s, and iron, the inevitable contusion .e have scarry Erb has sin.plified matters ve,y nu.ch by gnn,,)ing all the forms under _o.e des.gnation-dystrophia muscuIari;pr4rc:siva-of wS two eluet types are recognized: parah-r^'' ^"'"'''■' ^''''''''''"^'^'> ' '^'' P-udo-hypertrophic n.uscular (2) With primary atrophv. As cases of pseud^-hypert.-ophic paralysis occur in which atrophv and hypertrophy exist in the same nu.scle, or wasting occurs in one group and enhiyement m another, or atro,l,y in one group precedes for mont^' .e development of hypertrophy in another, it is'not surprising th i th se two forms are regarded by .nany as identical. Gowers, however calls attention to the fact that, w!,en cases of atrophv occur in families they never present the features of pseudo-hvpertrophic disease It IS m the cases with primary muscular atroi>hy that the greatest confusion exists m classification, and the f. .wing forms have been recognized and described : "s na^e oeen (1) Ei'b's juvenile form. ^l^,^!"^ facio-scapulo-humeral form of Duchenne, and of Landouzy ana Uejerine. (o) The hereditary fe-m of Levden. (4) The peroneal type of Charcot, .Marie, and Tooth Gou-ers ht,« it seems to me, followed the sensible plan in .lisregarding all of these subdivisions, and describing the cases under the designation simple idiopathic muscular atrophy.'" GASE.-Sebastian ]5., aged fifteen, sent to the University Hospital iisnea by Di. B. Sachs, >ew York Me.;.. Journal, Dec. 15. 1888. 11 i' I i- K M 2 OSLER, IDIOPATHIC MUSCULAR ATROPHY. November, 1888. Good family history, both parents living; mother lame, cause unknown. Has one brother, aged twenty, and a second aged thirteen. J las three sisters, aged seventeen, eight, and three respectively, all well. Two brothers are dead, cause unknown. rermwd /ustori/.—Ha has had measles, smallpox, and |)ossibly scarlet fever. For several years he has iiad attacks of aljclominal pain. He has also had (■arache. Until five years ago lie was well and strong, and j)layed about like other boys. From this time he had gradually been getting weak in the arms, and for between three and four years lie lias not beenable to whistle. All of this time he has been in fair health, but has had increasing dilficulty in dressing himself, and in getting froni the recumbent to the erect posture. J'rcicnt condifion. — Station erect, back not curved, gait normal. Face smooth, immobile, and expressionless— the so-called facics myo- pathi(iue; naso-labial fold absent; lips project, but the prominence is in Fio. I. Appeiii-aiiro "( Ihco. part owing to the teeth. The eyes are large, no exophthalmos; move- ment of the eyeballs normal. On attempting to close the eyes the pal- pebral slitremains open about two mm. in breadth. ]\Iost forcible con- traction of the orbicular muscles fails completely to cover the eyes. (See Fig. 1.) He is unable to frown or to pucker his eyebrows. The'for'ehead can be wrinkled. He has fair power of movement of lips, and he can pucker them in the movements to whistle, but cannot make the sound. AVhen he laughs he o|)ens the lips vertically, but the angles of the mouth are not drawn out. The zygomatics do not appear to act. The dilators of the nose move slightly on deep inspiration. Neck. Thyroid is a little enlarged. The clavic;.lar portiim of the sterno-cleido muscle is w!i.^tei,.o,,s. triceps, an.l hra.hiulis anti Vo Im 8U es are nuu.h wasted. In n.ukin.^ strong (lexion of the arm the. is a 8 igh hcliyon thehieeps. At the outer niargin of thenm.e ,m t f t e right burps there is an oval, firm portion. I'n.portio a y nJ ^n Icie rrZ';"-''V"''^^.- '^''-. ^■-•-'■"' ■"--..•es'at the ,,dddl fi " d a .pnirter inches. The supinators imve lost their pro lence Ti flexors reman, .n conside,-able bulk. The.-e is a fai,'volun e f n.us. le in the extensor surface. Pro..atio.. and supinatio.. a.v perfec " e 1. u are hui; ,.o spec.al wasting of the thenar or hypo.tlH...are,nineso the interosseus spaces. He cannot .nake a hit satisfactorily with eith . hand. Moven.ents of the H,.ge,-s a,-e slow but perfect. Tli," a. ^et' X^uZ' '""'^' "'"■'^' "" ^'''" P^.lma.^urfi,ccs ami "ni- [i'l Fig. 2 gives a fair representation of the .listribution of the at.-ophv Lowrre.vlrc,n,t,es. The glutei do not appear wasted. The th l 1 s at the nnddlc measure eleven and a half inchc's. The regio.. of tele nal vast, seem .so,,.ewhat wasted. The calves ,neasu,-e"nine a< la a f inches No wasting of the leg muscles. Moves the feet and toes jleil jeiltlrS; f^S"^ '""""• '^""^'^•" ^^^'•^"••'^'•^ I-'-^^-^- ^-'- onie^a^;^^ ;;S' '"^' '"" ""^ "" "'"•^'"" ^^'^^^^eneration in any The patient can still dress himself, but with difHcultv. When reci-m- bent, he cannot raise himself upright. He gets out of bed bv rol ii . the feet and legs out first, then turning on his fhce and .sli.ling ,;ut. " _ Duchenne first described a foi-.n ot muscular atn.phv beginniiur i„ infancy an.l attacking the muscles of the face. Landouzv ami Dg- jerme (lievue de MHecine, 1885) have studied this form with great care and regard it as diHerent from the other forms of juvenile hei-editarv myopathies. In their first communication they described two families and reported a post-mortem which showed the spinal cord to be normal' In a second communication {Revue de MHecine, December, 1886) they described six cases, and again ex])ressed doubts as to the identity - ^ this w.th Erb's juvenile form, and also denied that it has any connectio.. with pseudo-hyperti-ophic muscular paralysis. Marie and (Uiinon {Revue de Medecine, 1885) describe four cases in two families, in one instance beginning at the age of thirty. They Imld that this fo,-m i- not essentially diffe.'cnt from the other varieties of the i)riinarv nivo- pathies. Kemak {Xenrologlsches Centmlblalf, 1884) describes the case of a man, age.l thirty-two, in whom the affection began in childhoo■', also, reirards thi>' tlu-m (I{rrup dr .]fnf,:rin>\ I.S.SS , ,,||,| i"n. Spillinaii and il iiiisli!iiter IM.Si) also report case ^|)erliiig . Xnirnloi/!.->r/ir.i (',-iit,ni/,/„ft Altoirether. thei ■e ;ire ii If musculiii' ati'd idiopathi has heiriiii inehildhond iH'^'an at the forlietl atfeeted the face. two years, and tl '■""''■'' '>'>(iut lwentv-li\ f (his I'l'.v- 111 theorcat majority of case, "••"I youth. Oiu'caseof Landou/vand I) I vcar III tl should variety of he disease 'cjerine This, uitii the caseofSJiiLier's, wl le case of M; er and arm ; fmr years ,'ater it lii'h heuiiii at lliirtv- years, shows that the onset of tl iM(( and (iiiiuoii, which | life. The alfect lo cases a I sec pathie iniisciilar iitrojihy, and J this variety as '" to conform to the charact )ei^aii at thirty 1" may he delayed until a.iult eristics of simple idio- Tl II 'Cpai'ate disorder. see no rea.son why we should cl ISSI 'y be le eases of this kind, and of KrI. nearly so frecpient in th venile form, do not appear t( which is not at all •^ ••ouiitry as the pseudo-hypertrophic variet the case of James Stewart no ciises of Erh's juvenile for'iii I ill! uncommon disease. With tl le exception of report (Oniadn Linrvt, September, I.S84) as I I. lave luH'u Icnow. of ilu. so-called Landou/.y.Dejerine type reported, and none, so far y t)eginning in oiizy and D^- itli great care, lile hereditary 1 two families, to be normal, er, 188G) they lentity ' " this iiy connection and (niinoii iniilies, in one t this form is )rimary myo- ibes the case in childhood ; ie, too, seems ive muscular ts the case of other niem- ■Mude, Bd. 8 ; , aged thirty- ! I M H i p ;■ ift * 1 J 'i f 1' r im^t^t^^Bigmi t9^H^^H|^^^Hm E („, . jrjiill 1 IliM fllilHP^ 1 '. i .J| 1 ^ "' '-'■;■[, 1 . L. r 1 ^ ' '1' ' ■ ■ ll[l^^^_ml/ J' -Pr.„.. .0. x„. ,o„„.., .., ,_,„ ,,.. ,,_,_ ,,,^^^^^^ ^^^^^^^_ ^^^^_ CASK OF SYPHILOMA OF TFfK CORD OF TFfE CAUDA EguiNA-DIOATH FROM DIFFL/SL: CENTRAL MYKLrriS. Bv WILLIAM OSLER. M 1) ■•rof.s,or of Medicine, John. Hopkin, U„iv«r,l,y. Bal.imor.. THK following case which was under the care of Dr S Wc.r ntchell. at the Infirmary for Nervous Dseascs' anato.^- ar;::^i^s. ''-'-'''' "^''">' ^°'-^ ^^ ^'^"'-' ^-i ^V^/Vv./ 5;.,/.;;M;:,^~.Chronic alcholism. history of syph- l.s. For n.ne months pains in the legs, particularly in the Changes. I ains ,n the arms, especialh- the right • no w-ist ing and on admission arms of equal Strength. About two months before death loss of control of bladder a ul r t ^ W. hm the last month o, life loss of power in the right r^' Wjth pa.ns ; partial loss of power in the left arm with maX' ed mco-ord.nat.on. complete paralysis of the left leg nl ual loss of power in the right. Development of becl' sCcs Ar thnt.s m knees and ankles. Towards the close of life high fever with delirium. *^' ylna^o,u^h^/S.,.;,,rrJ.--Gumma in antero-lateral columns of erv.cal cord opposite the right fourth anterior nerve root. Gummata mvolving the third, fourth and fifth ante- rior sacral nerve roots, and the second and third posterior Ztr'\ '" ""' 'f ^"" ^'^^^^"^-^^ degeneration of he left posterior median column. Central myelitis. Par- tial atrophy of the sciatic nerves. A. B.. -.vt. 42, lawyer, admitted February 5. ,888. Fam- ily history good. Had been a hard drinker for years and h.o .moked ariu chewed to excess. He had gonorrhoea four times and a soft chancre but no history of second- aries could be obtained. ; I M i :4! i*fi^ H f 2 n'lLLlAM OSLER. In 1876 he had delirium tremens. About April, 1887, he began to have sharp, shootin" pains in the arms and legs. They came on suddenly, were stab-hke in character, lasting only a moment and then passing ofif. No definite regions in the arms and legs were mvolved. He also had dull pains in the back of the head and neck. These troubled him more or less throughout the , summer, but he could get about fairly well. Towards the second week in October the pains began to be more severe in the left leg ; they were thought to be rheumatic in char- acter. About the twenty-fourth of October, his suffering was so great that he was confined to bed. By November 5th he could scarcely walk. The pain began in the right arm and shoulder, the right leg also was painful and weak There was no redness or swelling of the knees, but the left foot and ankle would get red and swollen, almost purple The left leg wasted rapidly and for a time he lost sensation m the legs completely. The left arm remained unaffected. About a month before his admission he lost control of his bowels and had a constant desire to urinate. He had to use the catheter for several weeks. The following notes of his condition were taken on ad- mission by Dr. Burr, Resident Physician. " Pie can stand a little with the aid of a chair and he can flex and extend the right knee and hip. He cannot move the left leg, the knee of which is swollen. He has very little pain, none in the right leg. The wasting of the left leg is marked. The knee-jerk is present on the right side but on the left side it is obtained with difficulty. On the right side cremasteric reflex is present, absent on the left. Abdo-- mal reflex present on both sic:es. No tender spots over p i , ■ bed sores on the coccyx and on the left buttock ; has . ain in the shin bones and in the groin at night. The arms show almo,st equal strength. The dynamometer registers 115 for the right hand and 120 for the left. For two weeks he seemed to be in much the same state though in rather less pain. Towards the end of the month the ankles and knees became more swollen ; the bed sores had healed. larp, shooting uddcnly, were cut and then md legs were k of the head iroughout the Towards the ; more severe natic in char- his suffering 3y November in the right ful and weak. 3, but the left most purple, ost sensation d unaffected. 3ntrol of his ie had to use aken on ad- ■ and he can annot move le has very S of the left ightside but ")n the right ?ft. Abdot--- > over ? 1; I ; : ; has , am The arms er registers same state the month e bed sores MARCH C^IS/-: OP SYPl/i/_oMA. On March i6th Hi,. „^^ • ^ ..nableto move t "' ,- , , T" " "' '"°"°"'» ^ ""•■-» l--" "- -veil,,,, ,.,. t^^z hie'";"" r''"^' >-^^'-''^>' ■' swollen ; the finge,-, oft he Ir 1 T^''' ""■' ^""^''•' '''■'"•■""s yesterday ; p„i„\„„„7J '■■■""' —e been numb since tl.e pohus o/ the elbo V ^^l, "'fr ■""" -">■' -d at '•ays; ,-,ght ha,., is powefC fi ' ' rf helT '" 1" =^^="' pressure " '' """'"' vertebne, worse on aiiy':rehi,;Tr;':„':r..r.':is"rtT''r""'^- -- ^-""- "Inar distribution of bo'l, l,:'!'''^'^ "= '"'' '--"- '" «- ealk','ati™°n';r:v''"' "''" '° --'y ™-ed, when ho will lH,ll,xo' thl" . '^ 'on","'; ""^ '°^''"^ g-K-nous ing to 10,° in.l r ., , 1 f ' ''""I'"-'"""-' --"se this ,norn- i. reached i^,^^ t "^1,'' '"^" .•^" '"^^ '"-""«■ At 2 ,.. „. '" ■02» by eVeninij '''°"°'"" ""'' """"*"'" ''"''""^ " Ml J ! I 4 n'll.IJAM OSLER. 22d.— The delirium persists and bed sores have again appeared ^on the sacrum ; the scrotum is oedematous ; he has difficulty in swallowing- ; the breathing is diaplirag- matic ; does not complain o f pain ; temperature, to-day remained below 104". 23d. — General condition unchanged ; is unconscious and is roused with difficulty ; morning temperature was 102" rising gradually during the afternoon till it reached 105.6^ at 7 P. M. ; at lo 1'. M., it was 106.8" 24th. — Low, delirious fever continues, reaching at 12 M. 107'' and continued elevated during the afternoon. At 10 P. M., the rectal temperature was 108'^' ; at 12:30 A. M., 108.4^ ; at 2 A. M., 108. S'' ; at 3 A. M., 109.4", See chart. Death occurred at 4 A. .\[. , Post-mortem, five hours after death. Body emaciated, left leg smaller than the right ; scrotum oedematous ; superficial gangrenous bull.e on each heel ; recent bed sores on sacrum. The skull cap was removed with difficulty, as there were strong adhesions to dura. Logitudinal sinus contains blood. Parts at the base of skull normal ; cortical arachnoid, opaque. Pachiionian granulations abundant and large ; pia mater turbid, strips off readily from hemisphere, but is somewhat oedematous. Convolutions look healthy, and the gray matter is of a rosy pink color ; white substance moist, with very few bleeding points ; lateral ventricles look dry ; third and fourth ven- tricles present no changes ; in the latter, the vessels just above the acoustic stria; are a little congested. Section of the ganglia at the base show no foci of dis- ease; pons and medulla symmetrical; no descending lesions. Cerebellum normal. Spinal Cord. — Dura mater natural looking, nowhere adherent except at the anterior part of cervical enlarge- ment ; no sub-dural exudation; arachnoid thin and clear. On the right half of the cervical enlargement the dura is attached to the arachnoid and to the pia over an area the size of a split pea. There is here a firm solid mass in the cord, not producing any special deformity, but appearing extern- ;here were .CASE OF SYPIHLOMA. ally as a grayish region, situated between the anterior roots of the third, fourth, and fifth cervical nerves The fourth IS involved in the adhesion of the dura The ante- rior roots are not involved, nor does the adhesion of the dura extend laterally beneath tiie dentated ligament The grayish translucent appearance of the mass extends for about a line beyond the posterior median fissure Ver- tically it is about one-third of an inch in length Fresh sections were made at the following points ■ Second 6.7-r7V.?/.-Interior soft, but outlines of ..ray matter distinct. The left column ofGoll has a grayish- white translucency. S,xth Ca-vical.~Qr.xy matter has lost its firm appear- ance, and is very soft and reddish in color. Seventh 6'r/-77W?/.-Central softening still apparent. Cor- nua not distinguishable. Second Dorsal.— Qx^y matter more natural looking Eleventh Dorsal.-OvxWm^ of gray matter quite distinct Ihere is a marked degeneration of the left postero-median fasciculus. The Cauda equina presents the following alterations • The three last anterior nerve roots leaving the conus meduUans are involved in a gummous growth the size of a bean, into which pass also the posterior roots of the second and third sacral nerves of the left side. They are involved about two inches from the cord. Lower in the canal there are two or three small fibres, which present slight tuberous enlargements. The tumor of the cord varies in transverse diameter from three-eighths to one-quarter of an inch in diameter; it is completely within the cord, the symmetry of which is not materially altered (Fig. i). In shape, above and below, It IS rounded ; in the middle, more ovoid. The ver- tical extent is not quite half an inch. At a limited region the dura is adherent to the pia, which membrane, at this point, is distinctly thickened. With a low power it is seen that the growth occupies the right antero-lateral destroying and pushing aside the anterio „..,^ the antero-median fissure and pushing back the posterio^ region, r cornu, displacing t i . * 1 1 ; i i i • i i .J ■ 5 . Ui :1 I f I i 6 WILLIAM OSLER. cornu. In the upper part of the growth, the outlines of the gray matter of the left side and of the right posterior horn are well seen. In the middle portion they are much less distinct ; and here the growth reaches so far over that it is only one-eighth of an inch from the left lateral margin of the cord. The growth is firm, not encapsulated, and sec- tions in ca. mine stain of a deep red color. The greater portion of the mass is made up of a dense fibro-caseous tissue, devoid of cell-elements, and through which passes a ''"'S- I- — Gumma of cervical cord opjiosite fourth nerve root. number of blood-vessels, some of which are obliterated some free. At the periphery, there is marked cell prolifer- ation, particularly towards the gray matter. This is also very distinct in the anterior median fissure. The anterior spinal artery is involved at the edge of the growth, and the adventitia encircled in three-fourths of its extent. The intima id greatly thickened, and the cell elements look much swollen. In the adherent dura, which is not thick- ened, there are amyloid bodies. The gray matter looks swollen ; at the upper portion of the tumor area, the large cells are distinct, but the nuclei do not stain well in car- mine. In the middle and lower portions of the affected lines of the terior horn much less r that it is margin of , and sec- lie greater ro-caseous h passes a Dot. )literated, 1 prolifer- is is also ; anterior 1, and the nt. The :nts look ot thick- ter looks the large ill in car- ; affected CAS/-: OF sypiifi.oMA. neighborhood of ,,rves *,"''■ P"""''"'*' '■■ "- in t'he't™;; ;: t;';:";; "" ""= ^'•'■""^'■^ "^^^-'^-^ ='•••- veryi„di:.™r;„t;;',ef' ""'™^"'''' '"<"" -™"-. and ha. The cervical cord nhnv,. fU^ carmine and by Wi g ,t ,e od^" tT*'' ■''"" "'" " '^^'^ tinct, and the nerve r.I 7 , ^'''^' '^''""'' '"^ ^''■^- nuclei stain well °°' '^'^'^^'^''^^ ^^^'^"-^ = ^hcir Fig. ..-Lumba, cord, .l,„wi„, .■,,.„e„,i„„ ., ,i. ,,„ p„,^^,___. ^__,^^^ The tumor of tlie Cauda has rr>-itto,i n :r ':7 irdV="T".' -■ "--^^"""- *,■;:;:: ,r;: aieasot indifferent tissue stained red snrrr.„n^ i u of actively poliferating connective it utretn^^ n^ T^ stain deeply in the hematoxylin, i: Ih Ven J c! t' seerL^r/'^ outlines of the nerve bundles 0";; seen, and, n places, numerous irregular areas, lighter in color, closely set together, which represent the degcne ating nerve fibre with their medullary sheaths nalo Tn i many of the axis cylinders stained ^ ' ''"^ esting. In the lumbar cord ,t involves a wide area, chiefly m the root zone, not reaching the median surface or the posterior, except close to the nerve root (Fig 2) In the dorsal cord rFiV. 7^ fl,o .^ot 7nn^ ;c „ . ■ , , -lot zone IS not involved, and the affected except a narrow wedge. w 8 fl ' r. I mm '1 I IVn.l.lAM OSI.ER. In the region of the tumor the degeneration does not reach so close to the posterior margin (Fig. i). A'- therelnonote.;! ?en -r::::.;^ '^^\ ^j^-^ ---• ^^ ^he bladder «-in, the View tS'r::;;^::Lr;:t:^ Fig. s—Portion of cross section of riyht fciatic nerve. sacral, not in the lumbar segments of the cord. The dis-* urbance in the reflex arc was here chiefly in the efferent branches mvolved in the third, fourth and fifth cords It will be remembered that of the afferent branches only the second and third sacral roots were involved A third point of interest is the ascending degeneration :n the left column of Goll due to ^he lesion ^in the ^^o k edit " P;^^--'- ---1 -ots, and, in part also, undoubt- edly, to extensive disease of the left sciatic nerve As is shown in the figures, the distribution of the sclerosis pre- sented the well-known variations in passing from the lumbar to the cervical cord. Lastly, the case offe rs chief symptoms of acute cental myeliti an excellent illustration of the high temperature, the arthritic disturb trophic changes, as shown i myelitis, particularly in the inces and the marked sores. n the rapid development of bed li: [From rnt Jehu, Mopkin, Uo^pim JJulleUn. No. 1, December, 1889.] ON THE VALUE OF LAVERAN'S ORGANISMS IN THE DIAGNOSIS OF MALARIA. By PROFES.SOR William Os^lkr, M. D. C-l The attitude of the profession on the ,,ueHtion of nucro-orKanisn.« of malam ih o,,e of judicions nkeptici.sn,. Between the badZ nXii of Klebs and Toma.ssi-Crudelli, and the protozoa described by l! e^n the average doctor cannot be expected to decide; but even a.nong workers and teachers, there is by no .nean.s unanimity. So far as I Zw there has been no conHrniation of the observations of the first nanuni ." U.'or ,! a speeifie bacillus in the disease. It is far otherwise with t e o ' ^s^ described by Laveran, whose work has now been confirn.ed In 2 ete" observers in Italy America and India. I do not know of a sinl d c hn or pathologist, living in a suitable region, who has really 2ke he «ubjec , who has not been convinced of the truth of Laveran'. tlmems Ooubtle^ many have had ,ny experience. In 1886, at the .„ee g" the sut ;:.T' T; ''"""•'" l^Hy-'ians,- whe„ Dr. Councilman prelte " summa. of Laveran's views, I (speaking out of the fulne.ss of mv ignorance) was extremely skeptical. When I ha.i the opportunity of g vin- to the 'nd r,:; th^ r;';-' 'z-^^-^-^'^^^-^^^^^h i wLso^ic:;;^^^ .md I h ad the satisfaction of confirniing, in almost everv particular the observations which Laveran had made, and discussed the whole uW t'in a paper, published in the British Medkal Jo^^rnal, March 12, 1887 For the past two years, at the Philadelphia and University Hospitals, I have id abundant opportunities of studying cases of malaria, witli !n ever-deenening conviction that the organisms of Laveran are peculiar to tlie disease.' ' L^^l% ^'''' ""' "^ '^l '"'^' distinguished pathologists in India, repeUed by the apparently extraordinary statements of Laveran, and had the J T/Ti Tf^ '" ''"' '"''J'''*' ""*" ''"^ appearance of my paper in ,?!k . "''''''• ^'' ''''^"™*« contribution to the subject, one illir TT.'^^'l '''"'''' '"'' ^''" '""'^^' ^°"fi"-'»« i" ''•"'^^t every detail the statements of the French observer. To the impartial student, this remark- able unanimity in observations made by Laveran in Algiers, by Marchia- faya and Celli and Golgi in Italy, by Councilman, James and myself in this country, and by Vandyke Carter in India, should, to say the least carry conviction as to the importance and con.stanev «f these bodies in uiaiana. While it may be a little early to ask acceptance of the view that M : b i| i lllfl i i > MM '1H 1 - .1 ^H i ^^H ; ■ . ^-'^^1 . these orsiininmn constitute the speiiCic germ of the diseMNe, the work iilreiidy (lone warrants positively the statement that they are peruliar to ami diag- nostic of the presence of the malarial poison. It i^ not surpriwing that certain ohservcrs, who have perhaps seen hut few case.-., have Ix-cn inclined to regard the > hanircs in the red corpuscles its dei,enenttivi" rather than as the manifestations of an intracellular parasit" ; hut the study of the reniar'.c- ahle serial development of the sci^mcnting fonm descrilied hy (iolgi cannot possibly he explained hy any other view, than 'hat we i. The value of the hlood examination lies particularly in the ciironii' cases and in anomalous forms. Here oui^ has to he constantly on guard and it may he impossihle for days to determine definitely the nature of the aftection. We have since the opening of the hospital, ad- mitted twenty-four cases of malaria to the ward.s, of which, i.. seven instances, the diagnosis was definitely determined hy hlood examina- tion, and I'ould have hecn determined in no other manner. So important do we consider it, that '..e now, as a matter of routine, examine the hlood of all cases of fever, and indeed all cases of low temperature, which seem so peculiar in certain forms of chronic malarial poison. We had a salutary lesson in the early part of the s'- Miier, in the case of an old man, aged 81, admitted July 2oth, with a temperature of 104°. He had on the 9th, a heat stroke, while picking berries, was better the next day and kept about until his admission. There were signs of bronchitis at the bases of the lungs, and in the right inter-scajmlar region, the note was higher pitched and the breathing tubular. The temperature rose to 10')°, and throughout the 2Gt!i, 27th and 28th, kept between 101° and 103°; on the 28111, between the hours of tj and 12 a. m , the temperature was subnormal, hut he hiid no chills. He was extremely feeble, not cachectic or sallow ; the pulse was very irregular. Neither I nor Dr. Atkinson, who saw the case for me dur- ing an absence of three ^.ays, had any other idea than that the case was one of low pneumonia in an elderly man. The patient died on the Sth day of his ailmission, and to my surprise and chagrin the post-mortem examina- tion of the blood and spleen showed the case to have been one of malarial fever. Had a thorough blood examination been made and full doses of quinine administered, the man's life might have been .saved. In five or six cases of irregular fever, the presence of the organisms in the blood has determined the nature of the disease. le work Jilready iiir to iiivl liiag- Hiir()ri»in>; that Ix't'ii incliiit'd riilhi'i- than as ' of the reinarlt- ly Ool^i camiol e (lealiii^ licre art' so ]i('ciiliar, ill tlu' hh)od ill • to convert th« 'senci' ill a few of these orijan- rclnt:i)n to tlie 111 my foriiior nw. Since that invincetl of the ions. In onli- vcr any (]ues- uiniiie readily jarticiilarly in 1 i)e constantly definitely the f hosnital, ad- licli, 1.. seven lood exaaiiiiM- Ho important lie the blood of which seem so had a salutary man, aged 81, on the 9tli, a iiid kept about e bases of the iiigher pitched nd throughout ■ 28tli, between but he had no the pulse was ise for me dur- e case was one the Sth day of rtein examina- ne of malarial \ full doses of id. In five or the blood has The routine exu.iunution is really not tedious, and we have adopte.l it now n the dispensary, as well as in the wards. Unfortunately for the general .ratu.oner,tlie determination of the intra-celhilar forms re.,uireH a tolerabl. high power with gcKxl illumination. We use the one-twelfth immersion, but wuh care a goo.l eighth is sullicient, an,l in the chroni.' cases, with the crescents u, the blood, a sixth su.Hccs. 1, is important to have the finger Up, from which the blood is drawn, thoroughly cleansed, and it is best to take |. very small drop of bUn..!, so as to have the laver uniformlv and thinly spremi out with the corpuscles isolated not in rouleaux Hr.efly to sum.i.ari/c for the information of those who may not have access to monographs on the subjc,,, the following are the im,,;.rtant facts relating to these organisms: First; In the acute forms of malaria there exists, within certain of the red corpusc es, amoeboid bo.lics, usually pigmeiite.l, which iin.lergo « definite evolution, increasing h, si.e, gradually filling the entire corpuscles aud which prior to and .luring the chill, undergo a remarkable segmeii- tatioii. I here are also, in some cases, free i.igmented bo.lies. To the form within the corpuM'les, which undergoes ciianges, the term plammdium has beenai.p ie,l Occasionally in acute forms, flagellate bodies arc seen free in the bloo.l, presenting from three to eight long, actively moving cilia. According to Councilman, these are much more common in blood with- drawn from the spleen. Second; In more chronic cases, particularly in the forms of remittent fever, which .are .so apt to be taken for typhoid, the corpuscles .lo not so often j.resent the intercellular forms, but there .-..-e remarkableovoid, rounded and crescentic bodies deeply i,igmeiited. These are, in all probability, related to and developed from intercellular forms. From certain of tbe.se, particu- larly the ovoid and rounded forms, the flagellate bodies mav be seen to develop. Dr. (Jhriskey has recently been studying the evolution of these forjis in the Clinical Laboratory, and has been able to demonstrate on many occasions the development of the flagellate bodies from ovoid-rounded forms. I hope, in an early number of the forthcoming Hosjiital J^eports to review fully the present status of the malaria .[iiestion and to report our exiierience, i)articularly in the anomalous forms of fever in which the blood examination is .so important. It is i)articularly t„ be desired that those who have ample opportunities for the study, "shall approach the problem with unbiassed minds. It rciuiivs a little patience in or.ler to be- come thoroughly familiar with the various phases of - '™»i"''l normal, when co,„ti„ed » t u,n e tn I f''*"''"' " "''*"" "'' '""" Mate betw.,, tiu» .■S^ ^a ^jf Z:^'^''' '° """■'•'- liver. I have „„,,. „„.. «„ „ ,„ ™ ^ i i ; t; ' r'«'-»' o'' «>» risors, i„ a ca«o „f oa,,.,,. „f the liver ™, 1, '"'''' ^^'^ «oo„dary «.„e.,'thero were ne^^U ^U .tl :[ " T'"'"" pression of larirer gall -inets hv Ihe tm„ , ' , ^ """ «.-.or,„„fi„.e.™i..e„tp,4i:ti;;:i:.i— ^^^^^^^^^^^^ 1 1(f •i 1 i t' :) 1 I 1 growing cancer of tliis organ, such as Hampeln' has described in cases of cancer of the stomach and such as are met with oc-casionally m rai)idly growing lympliatic growths, as noted by Pel of Amsterdam. Since writing tliis paragraph, tlicre has been in tlic Hospital a ease of primary cancer of tlie left lobe of the liver in a young man, who gave a history of several rigors of so pronounced a nature, that among other pt)ssibilities that of abscess was discussed. C7/r/(o.s/.s.— It is not usually recogui/ed that in cirrhosis there may be fever. The systematic authors on atfcctions of the liver, sucli as Fre- richs :md :Mur(;liison, speak of sliglit pyrexia in the early stages, par- ticulailv when the organ is enlarged. Carrington '' has made an inter- esting studv of this question, and states that of forty-four cases in which temperature observations were made, in thirteen fever was a more or less marked svmi)tom. In (pertain cases, sucii for example as the one which he described in full, serious diilicultics in diagnosis might readilv arise and it would be cpiite pardonable to suspect, from the irrcgu'laritv of the temperature curve and the existence of slight jaundice, that suppuration was going on. .My experience with fever in cirrhosis is small and I have n..t my clinical records at hand to examine into the pcjint. 1 have a ilistin(^t recollection in one or two instances, particularly in the hypertrophic form, of marked increase in the temperature, but, I should say that in the majority of instances of cirrhosis, fever was not a special symptom. Ohstradioii of the Duct bij GalMonc^.—Sim'e the bile passages have been brought within the s])hei-e of surgery, a renewed interest has been taken in all symi)t(.ms which give us more accurate knowledge of the character and situation of lesions in these parts ; and I wish particularly in this paper to deal with a form of fever met with ehielly in chronit; obstruction of the common duct by gallstones, as it possesses features of the greatest importance' for diagnostic purposes. The fever I si)eak of is intermittent in character and the cases pre- sent the following group of symptoms :— First : Jaundicie of varying intensity, deepening after each paroxysm, and whicli may persist for months or even for years. Second : Ague-like paroxysms characterized by chill, fever and sweating, after which, the jaundice usually becomes more intense. iZeitschvift f. kliii. Moiiicin, Bil. XIV. 2 Guy's Hospital Keports, 1884. »ed in cases iionally in jtei'dam. Hospital a oung man, ature, that uM'o may be icli as Fre- jtagca, par- ie an intor- es in which ,as a more nj)lc as the losis might t, from the [> of slight with fever at hand to one or two ed increase of instances ssages have interest has knowledge and I wish L' met with stones, as it c purposes. i cases pre- 1 paroxysm, , fever and intense. Third : At the ti me of the paroxysms, pains in tl le region of the / liver, with gastric disturbance. In a majority of cases tliis combination of svmptoms is, I believe characteristic of the exist.-nce of gallstones in ihc common duct. ' We meet with rigors, fever and sweats in three conditi.ms of the biJe passages : — _ As an acute and transit...-y proces. > ordinarv hepatic colic asso- ciated with the passage of a stone through the d'nct. In chronic ..l)stniction of the duct, us.ially by st<.ne, without lesions of the bile passages otlu^r thai, dilatation and catarrhal cholauoitis In suppurative cholangitis produced by gallstones or other'i-auses. W ith the first of these, 1 an. not speciallv concerned, ex<-ept so far as It may help to explain the occurrence of the j.aroxvsms in the second group. The d.stin.-tiun Ix^tween the <.ases of suppurative cholangitis and those of the second cafgory shall be ..onsidered subscjuentlv, and 1 sliall lu.w proceed to speak of intermittent hepatic fever with its associated symptoms as characteristic of ehronic obstruction of the duct by gallstones and without suppuration. The literature of the subject, though interesting, need not, for the purposes of this paper, be disc-ussed at length. Of the numerous writers on gallstones during the last centiirv, Soemmering' appears to be the only one to mention ^he symptom, using the phrase, in siicakincr of the fever associated with gallstones, "et ipsa febris intermittens." \\ e owe to French physicians our knowledo-e of this valuable symptom. .Monncret^ is usually credited with it.- recognition, but the thesis of INIagnin^^ and the \\<,rk of Charcot ' present us with the first satisfiictory studies, from which indeed has been derived mo^t of the information on the subject which we find scattered through the text- books and monographs. Among (German writers the work of Frerichs contains many cases illustrating this symptom of chronic obstruction, but he does not appear to lay special stress u])on its importance in diairuosis. In von Schueppers article upon gallstones, in Ziemssen's Cvcloptedia,' the remarks are leased on the work of the French writers.' Warner" has reported interesting cases. References to these svmptoms ''occur in *Du Concrenientis billariifs, 1795. 'Paris, 1809. ' Vol. IX. ^ i'atliologie Interne, Tome i. ♦Lemons siir les Maladies du Foje, 1877. 'Deutsches Arcliiv. f. klin. Med., Ijd. xxxiv. fV ^ 'i r ' i' J; ■1 s 1 . i 1 .. ?■ i r «i « iliii illi the various German text-books, but the question does not appear to have received the full consideration which its importance demands, and the majority of the writers, as Striuiipell, for example, speak of the fievre intennittcnte hcpatique as if it were always associated with supi)uration. Among English writers, Murchison, in his work upt)n the liver (third edition), notes the occurrence of rigors in chronic obstruction, and in his paper upon conditions causing an intermittent fever,^ he deals more fully with the general features of the affection. Harley, in his work on the liver, does not mention it. Ord refers to it in his paper on some of the rarer symptoms produced by gallstone.^ In the English text-books on medicine, it is not often sjioken of; even Fagge, whose work is such a store-house of clinical facts, has no reference to the subject. In this country, the question has been discussed by Bartholow, who gives, in Pepper's System of Medicine, a full summary of the French observations. In Sajous' Arauial for 1888, Dr. W. H. Thompson, of New York, rtlers to intermittent hepatic fever as oceuji'ing fre- quently in this country and as well recognized by authors; but in a private communication he informs me that he had been under a mis- apprehension, and so far as he knows the subject had not been discussed by any American writer. Musser,^ of Philadelphia, has reported several interesting cases. The following cases have been under my observation : — Case I. — Jaundice of three years duration. Repeated attach of c hills and fever; chohemia, death. Gallstone.^ in common dmt. J. H. R., aet, 68, admitted to the Johns Hopkins Hospital, May 25th, 1889, complaining of jaundice, chills and fever, which had lasted on and off for three years, ^yith the exception of attacks of eczema, he had been a healthy man until three years ago, when his present trouble began with dyspepsia and pain in the pit of the stomach. In the first attack there was sharp pain in the epigastrium, followed by a chill and vomiting. These recurred very frecpiently, and with them he invariably became deeply jaundiced and the stools 'Lancet, 1879. '^British Medical .Journal, 18S7, I. •' On i'aroxysmal Fever, nut Malarial. Proceedingts of the Tliila. Co. Med. Society, 1884. )t appear tt) ce demands, pie, .speak of oeiati'd with )n the liver obstruction, it fever,^ he n. Harlcy, s to it in his Istone,^ In en of; even lets, has no tholow, who ' the French Thompson, :'uri'ing fre- s ; but in a iider a mis- en discussed las reported icks of chills hid. spltal, May Avhich had f attacks of ), when his pit of the 'pigastrium, frecjucntly, d the stools , 18S7, I. , Meil. Society, were putty colored. He had been subject to catarrh of tl,c stomach and had always been constipated. The attacks of chills and fever had, at times, been very severe, and he would sweat heavilv after hem 0„ the occasion of his first visit to Hospital a Violent attack came on whde he was in the waitin<,-room ; he shook as in an ague paroxysm. His ^^•ife state.l tluit he had rarelv passed throe weeks witliout a chill of great severitv. Present concUtlnn.-Uuch emaciation ; skin drv and harsh and of an nitenscly bronze color. It presented manv snlall scabs, the rcstdt of scratching-^ The muscles were very flabby. The conjunctivae and mucous^membrane of ti,e mouth were stained, as were also the nails of the fingers and ^.r^. The expression of flu. face was dull and the speech slow. A: , :d(m was impaired from dryness of the mouth Jl^xamiuation of ... uioracic organs negative. Pulse 68, small and regular Abdomen w.s a little distended, somewhat tympanitic everywhere painless. ' The edge of the liver could not be felt. Dullness in mammarv line began at the (5th rib and extended 2.\ inches (C+ cm.) verticallv ' The most careful palpation could not discover the gall bladder The splen.cdullness was slightly iucreascrl, b„t the edge was not palpable. The urine was of a deep brownish-red color, acid in reaction, specific gravity 1008. It contained a small amount of albumen and a few tube casts. Temperature on admission was 98°. His chief complaints were of intense itching of skin and of occasional pains in the abdomen On the morning of the 20th he had a chill, in wlu,.], the tempera- tun> rose to 101° .nd he became delirious, would not answer questions and wantal constantly to get out of bed. The temperature sank to about^96° and remained at that point until eleven o'<-iock when it rose to 97°. (Gradually coma supervened ; the pulse rate increased to 160 and the respiration bcame very irregular, :',0 per minute. He was given an active purge luid sAvcated. The coma gradualh- deepened ; the temperature rose, icuchiug towards evening 101 °. Ho died earlv on the morning of the 27th. ' From his history and the repeated attacks of hepatic intermittent lever extending over a period of three years (a period of sufficient length to exclude suppurative cholangitis, abscess, or cancer), I made a diagnosis of obstruction of the common duct bv gallstones and suggested to him the propriety of an operation. To this he had I lii 6 given his consent, and entered the Hospital with a view of remaining a week to gain strength l)etor(> submitting to it. P()Kt-}[ni'tcin, by Dr. Welch. Peritoneum contained 30 cc. of yel- low serum. In thorax the pleural membranes were normal. The j)ericardium contained an excess of fluid. Tlie heart was a little cnlarjred, weighing in oz. (;>2()+gms.) The segments of tlie aortic valve were indura- ted along free and attached margins. On the aortic aspect of one segment was a iresli, reddish-grey, partially d(;tached, vegetation. The remaining two segments had coalest^ed in consecpience of ulcer- ation and nearly total disappearance of the septum, in the situation of whicli was an irregularly indurated, idcerated, slightly elevated ridge, j)artially covered with red-grey frcsli vegetations. On the ventricular aspect of this fused segment was a vegetation loxH) mni. Tli.e mitral and other vaKes were normal. The heart muscle was flabby and brownish in color; ou microscopical examination not fatty. The lungs were normal. The spleen was 15 cm. long and 10 cm. in breadth. Its contents were soft and dark red in color. The combinixi weight of the kidneys was about 12 oz. (.'340+ gms.) Cortex of average thickness. The striju (;l)scured ; organs not lii'm. Bile duct. Th(> oi'ificc of the common duct was dilated and con- tiiined a ])lug of thin, |>ale yellowish mucus, easily dis])!aced. Upon passing a probe i.-to the duct it entered a sac 1 J cm. from the orifice, which correspcmded to the dilated ductus communis choledochus. A round ulceratin.! opening 3 mm. in diameter communicated between the lumen of the duodciumi and the common duct in its course in the intestinal wall. A sac resulting from the dilatation of the common duct measuring '2% cm. in diameter was completely fill(>d with gall- stones of varying sizes, the largest being 2 cm. long bv J ,', thick • he smallest not larger than a ])ca. All were provided with facets. The walls of the dilated common iXw.t were thickened and the sur- rounding connective tissue very dense arid intimately adherent to the adjacent [)arts. The gall bladder \\as shriuik(>n to a small sac 2 cm. in length by 2 cm. in breadth. The walls were thickened and it cimtained a number of gallstones ansund which it had contracted. The cystic and hepatic ducts were greatly dilated and contained gall- ^ ,'h )f remaining 10 CO. of yel- poriciU'diiim }d, wij^liiiig vorc iiuliirii- [)ec( of one vegetation, ice of ulcer- lic situation tly elevated IS. On the 15x10 nun, nmsele Avas inatioM not [ts contents .•340+ gm.s.) IS not linn. (1 and con- ed. Upon the orifice, Jocluis. A ed between )ni'se in tlie le common with gall- 1! thiclc; aith facets. id the sur- M'ent to the 1 sac 2 cm. ned and it contracted, tained gall- stones ; a]tog(>t]icr not less than twenty conld i)c felt in the dnct. Externally they were deep hlack in color. The liver weiglied S ll,s. 11' ,.z. (I68(5.S gms.) ; the surface was smooth, mottled greenish and ])ale yellow in coh.r. Outlines of the lobules were indistinct. On section the bile ducts appeared moderately dilated. The walls were thickened and tlie .-outcnts yellowish, vis("i(l, and not purulent. Tile aorta presented several small atlicromatous ulcers. Case U.—Jlistnn/ ,>f prrnmis alffid:^ of ;/,ulxti,ne ro/ir. For ru/ht monfJi.^ m:an-inf j,ni,i with a;/ur-/;ir pm'o.ri/.-^,ii.s and iiilcmfmttion offhrjaniidirr. J\,.'^.,a;/r nftlH-r/a/Moiie. Rrmrcn/. X. K., act. ;',0, a dark, slightly built woman, was admitted to the Montreal General Hos])iiaI November 17, 1,S79. She had been hcalthv with the exception of o.'casioual attacks of indigestion. Fom- vears be- fore she had several attacks .-.f cramps in tlic alidomen. In th'c middle of September, 1,S70, they recurivd after a welting. At this time she l.ad vomiting, and the attacks were of such severity that morphia was given hypodermically. Two days after the onset she became deeply jaundiced, the attacks of pain recurred, and the vomiting became very troublesome, but in about two weeks she was al)le to go to her home, where she remained until November ]7di. ^Mleu admitted she was deeply jaundiced, the tongue was furred, she liad nausea and looked fcei)le. She remained in hospital during th(> winter, and I found her in Wanl 2.3 when T went on duty. During a residence of five and one-half months in liospitid her chief symptoms had 'oeen : first, jaundice, varying greatly in iiiieusity, sometimes almost disappearing, but recurring again in a few days; second, ague-like paroxysms- chills, fever and sweating — accompanied by severe abdominai pains, coining on at intervals of from three to ten days; third, great impair- ment of a])petite, dyspepsia, frcfpient vomiting, especially about the time of the paroxysms; fourth, great tenderness in the epigastrium, most marked over the right c(;stal border. After an interval of a week or ten days — during which the jaundice would diminisli, tlie bile almost entirely disappear from the urine, theficces become slightly l)ile-tingcd, the appetite improve, and the patient would sit up— the paroxysm would come on, either with a slight chill, not more perhaps than a transitory feeling of cold; at i !i i i f 8 otliers it would ho a severe rij^or, i„ which she would sludge as if in an ague-ht. This cold shxgo lasted from fifteen minutes to three or fmu- liours and was followed by great heat of the skin and hnrniuu- fever wJueh after eontiuuing for an hour or two would be followed hv " profuse perspiration. The tem,,e.-at,n-e, whi,.], was usuallv normaf or even sub-uornial, would rise in the attaeks, readiino' 1()2°-104° sub- SKl.us (puekly after the paroxysm, and sometimes sinking to' 1»7° The fever mrely persisted for an entire day. Among the eoneomi - tant symptoms of these attneks, vomiting with severe gastric nain were the n.ost <.ommon. The pniu whi,.h usually gave indication of the onset resembled that of hepatic coli,., being e,,igastric, and radi- ating to a p.,u.t beneath the right shoulder blade. It was scarcely ever as agonizing as the pain of ordinary biliarv c<.]ie, but was often severe enough to require morphia. Before and after tlu" attacks the eiMgastrium was very tend,.-, so much so that she would even com- plain of the weight of tlie bed c-lothcs. Vomiting was a marked teature, and usually aceomimuied the paroxvsm. The bowels were moved every day, sometimes t^vo or three motions. The color of the fa^ees depended on the intensity of the jaundice-light color ^^•hen the skui was deeply tinted; broAvnish when the color of the skin was less intense. For a long time the motions were filtered in the hopes of finding gallstone^. Invariably after an attack the jaundice deepened, and we could g,.nerally tell by her ap,>eanuuv alone ^vhether she' had had one. fhe urine also at this time became deeply bile-tinged. In the mterv^ls the pain subsided, and the nausea and vomiting beca.ne ess troublesome, but for days she ,.ould not take anvthino. b„ta little biscuit and milk. She usually remained in bed, but during a long interval she Mc.dd get up and go about the xvard. Itching of the skin was occasionally a distressing symptom. In A])ril I made the following notes : " Moderate jaundice ; nothing-special to be seen on inspoct^.u of the abdomen ,• on palpati.,n decided tenderness in the epigastric region most marked towards the right costal border ; no ftdlncss or increased resistance; Innit of dullness extends in nipple line from u,,per border of 6th nb to w.thin half inch (l.;j cm.) of the margin of tJ rib • splenic didlness 2^ inches (6.3 em.) ; heart and lungs normal ; nrinj bile-tnigcd, specific gravity 1020, no albumen; enormous dark n ke as if in an three or f J mi- ll rniu};' fcvor, )1 lowed by •: ly normal, or °-104°, sub- bing to 97°. lie eoneomi- jrastric jiaiii udication of <', and radi- vas scarcely it was often attacks the even com- ■i a marked )OAveIs were color of the >r when the :in ^vas less of finding pencd, and ?r she had iiiged. In ng became but a little inji' a long iiig of the t'onof the •ic region, ' increased aer border ' tl rib; al ; nrinc )Ms dark, grannlar, bilc-staiiicd casts, some containing epithelial cells; fieees day-colored, soft and a little offeiisive ; no lever." Towards the en.l of April she left the hospital and Mcnt to her home at St. Johns, where she was attended bv Dr. Robert Howard, who treated her for gallstones, giving large doses of bi-carbonate of potash. She had several j.aroxysms of pain with ii>ver, an,/>/, mV, unfU Amjmt, J882, jmnxlhr of vary- mg intemltij, "'ith recurring/ attack, of pain and intermittent fever. Recovery. November 9, 1 880, 1 M-as asked tosee Mrs. S., act. 5o, a well-nourished woman, wife of a florist. She had alwavs been hcalthv and had borne five children. Had been acc-ustomed to work in the garden and m the greenhouses. Her illness began July, 1879, and her phvsician, Dr. Sunpson, gave me the following particulars of the onset and development of the disease. "In July, 1879, Mrs. S. consulted me at her house for a mild attack of Jaundice, which she ascribed to having seen a disgusting object which emitted a most otiensive odor, causing her to feel sick at her stomach. When a young girl sli(> had an attac^k of jaundice following a fright. On August 4th, I saw her again ; the jaundice had deepened and she comijlaiued of a dull pain in tii.> irgion of the liver and general dis- tress. She remained in this state until the morning of the 6th, when she was seized with a severe chill and int(>nse ]iaiu below the ribs on the right side, extending into the epigastrium and to the right shoulder. It was iiUTeased by pressure and motion, the breatliing' was hurried and the anxiety of the patient most distressing. A chill of about two hours was followed by high fever, then copious sweating, which stained the sheets a deep yclh.w color. The liver was distinctly en- larged. The pain gradually abated l)ut the tenderness ])ersiste"d for several days. All the essential phenomena of jaundice were present. She remained under my earc until January, and during this time she had a paroxysm every two or three weeks, varying somewhat in in- 10 tensity and d.u-ati„„. The pain ^mdmUy boca.no loss and loss. The chdl fovor and sweating wore invariably present aftor each attaek, and thejaund.oe deepened. Itehino- ..f the siar the atta.-ks oontinnod, but durin.. the summer, under homreopathio treatment, the jaundiee abnost dis- appeared, and tor many weeks sh<. had not a paroxvsu,. Wh<.n first 1 saw her si.e was intensely ja.mdieed and suffere.! with the most ^err.ble .tclung of the skin whieh I have ever witnessek.some, and the pads at the bases of th<, hngers were mu<-h sw,.llen and ton.ler. Bv the loth she was v.1,^ much better. The Jaundice had begun to disappear, but at noon on the l(,th slie had a very severe paroxysm, the chill lasting noarlv two hours and there was no vomiting with this attack and no spc^iJl abdominal pain ; no chaug<. noticed in the hepatic region Ironithis time until Christmas day she had seven severe attacks, varying ,n intensity, five of which followed eac-h other on Frhh.vs The rigors were most intense in violence, shaking the bed and causin.. the room to vibrate. Temperature reached fnmi 103° to 104° The jaundice intensified after each attack. 11 104°. The After Chi-istinas she improved very much ; jaundice almost entirely disappeared and she was able to get up and go ah' ut tlie house. On two oeeasiouH she had scnere headache and great depression, tolh.wed by (H.pious sweating. Tlie palms <.f the hand continued verv tender. A ti-oul)lesome sympttmi was tlie pn.l'use sweating ahout the waist, sufficient to saturate the under-linen and render it neeessarv to wear cloths ai)out her. The urine became <-lear, the freces contailied bil(>; the liver showed no special aheration. The tenderness on the i-i-ht side of the epigastrium persisted. During the spring of 1881 the daily amount of the ure;i was estimated during a period of three weeks, but there was no special diminution during (lie paroxysms. I lost siglu of :\Ir.s. S. after the spring of 1881, when she was still considerably jaundiced and had paroxysms at prolonged intervals. On the 7th of .July, 18S2, she came to see me and* stated that her condition had reimiined unchanged; the paroxysms still ivcurrcd at intervals, but she once ])asscd six weeks without one. In May of this year she had them worse than ever, and to use her own expression, "she was dead of them." After August, 188l2, the jaundi.^e dis- a])])eared and sIk; now looks in i)erfbct health. _ Dr. F. G. Finley, of Montreal, iwcntly (Oct. 1888) made in.pii- ries for me about this patient and writes that she continues well and has had no return of the i)ain or of the jaundice. Cask 1 \.— Repeated (itlaeks of hilian/ colic. For three months jaun- dice toith repeated paroxymiiH, ch Hh, fever and sweats!. Operation. Death. Galidoiie in common duct. Mrs. S., act. 51, patient of Dr. tolling, of Chestnut Hill. Seen March 2d, 1887. She had been a healthy woman, but since 1862 had several attacks of biliaiy colic, on one occasion with jaundice. Since Christmas she she had pain in the upper part of the abdomen, and very severe jaun- dice, which has gradually deepened. The urine has been intensely bile-tinged and the faves day-colored, h^or two weeks she had been woi-se and confined to bed. A special f 'atm-e had been chills, recur- ring ckily, followed by fever rising to 103° and 104°, and then copious sweating. The chills were most severe and the fever most pungent. The stools had been carefully examined Ibr gallstones, but without result. The patient was a well-built, well-nourished woman, with 1 t il i .] r " ' i ■■ 1 i.il 12 . I 'a ' » I t. t, / .M intcn.so ictcnis ; toiif^uo coated und dry ; pulse 120, smsdl and focble; no iWvr; abdomen lar^e ; iiit al.undant ; liver didlness not increased. On palpation, nothinjr to bo delected along tlie costal border in the right liypochondrinm ; towards the epifrastrium great tenderness and (listinct sense; of increa.^ed resistance. A most caieful examination failed to reveal the presence of enlargement of the gall bladder. The history of ilie |)rcvious attacks, the persistency of the |.ivseii, (me, and the recnrrencc of intermittent lever pointed .lairly to obstruction of the ducts, probably by gallstones. Tlie qnestion of snrgical interference was raised, and possible obstruction by malignant disease at the head of the pan(;reas was also debated. March ;Jd. I^hc patient was seen at 2 p. m. by Doctors Agnew, J. W. White, and tolling. The condition was worse. The patient was weaker ; tongue very dry; abdomen distended; diffuse tender- ness, and in the epigastrinm extreme sensitiveness to pressnre. Dr. Agnew made an incision between six and seven inches (IG cm.) in length, the outer edge meeting the rectus muscle. When th<- peritoneal cavity was opened a bile-tiiiged, slightly turbid fluid escaped. The liver looked very dark, and a conical, pointed gall-bladder projected beyond the edge not more than (.ne inch (2.5 cm.) from the surface, the liver being slightly atrophied above it. On lifting the liver the bladder was seen to be enormously dilat(>d, and by aspiration 18 oz. (431 gms.) of dark bile were removed. There were no gallstones in it, but a stone was felt low down in the eonunon duct and pushed back into the gall bladder and removed. The head of the pancreas seemed hard and indin-ated but not enlarged. The patient sank and died twelve hours after the operation. Xo autopsy was allowed. Case Y.—Jaumlice of two and a half years duration. Iteearr'mg attacks of intermittent fever, with pains. Operation. Death. ihdl>ito)ie in the common dud. A. B., a woman aged 40, was in the Philadelphia Hospital, Sep- tember, 1887, when I took charge of the wards. She had been under my care previously, in the spring of 1887, wluui I was on duty for Dr. Tyson. This had been her third or fourth admission within two years with attacks of pain in the region of the liver, and chills, fever and heavy sweats. My colleagues had on t\\o occasions broudit her blood to me for examination, the existence of malaria having been 1.3 susiHX-ted. Once certainly, possibly twi.v, her liver was aspirated, the m'lirrinjr chills haviiihe at present sutfcred, .anie on ahouf two years ago and she had not been entirely free finm them for a period of three months, n..r does she think that >li. had i„ this time ever passed two months without a slij-ht tin-e of jaumlic... When first seen, she was up and about the ward and showed only the slij-htest leinon-tint of the ekin and of the conjunctivae. The urine was a little hinh-eolored. The .stools contained l)ile. On e.vninination the liver appeared to be enlarjred. In the mammary line, the nVht h)be extended lour fingers breadth below the costal margin ; in the median line a distinct irregu- larity in oudine could be made out. The gall-bladder could not be felt. ^ Palpation was not painfid. Karly in ( )ctol). r, .she had an attack of violent pain with vomiting and a moderately .severe rigor, after wliieh the temperature rose to ueai-ly 104°. and she sweated pr..fusely, the entire paro.xysms lasting over twelve hours. The next day she was di.-^tinctly jaundiced, free from fever, the tongue heavily coated and the stomach extremely irritable. The urine was very dark, con- taining bile-pigment and the stools were light-colored. The liver did not seem to be larger but it was sensitive to pressure. The gall- bladder could not be felt. In three or four days, the gastric .symptoms passed awa\- and she was ai)le to sit up. The jaundice deepened distinedy for three or four days and then gradually liglitened. The case was made a subject of almost daily demonstration in the ward-class and I etmfidently predicted a return of the j)aroxysms. Throughait the winter she had fbur or live, each similar to the one just described, varying somewhat, however, in Intensity, I had r .ade up my mind from the length of time which the woman had suffered and from the character of the attacks that the case was one of obstruction of the common duet by gallstone ; and early in February, I asketl Dr. AVhite to see her in consultation. The patient consented to an operation, and Dr. White made a free abdomi- nal incision along the line of the costal cartilages. There was exten- sive perihepatitis with [)ucivering of the edges of the liver, due to the cicatrization of old gummata. The gall-bladder was not enlarged ; ■ I- I 11 ill 14 tliorc was ji jrivat dciil of fibroid matting- of the tissues in the },mstr()- ln'patic (.mciitiim. No uallstonc coiild l.<. tilt in llio ^rull-l,l;,d,|,.,., nor in the diirt. The patient came oiil well Iroin under the intliienee of (ithvv; had no shock, and six hours afterwards lier temperature and pulse were norinal. Tiie folh)\vin^r day tlierc was a rise of tenipom- ture and slie died on tlie third day a Her the operation. 1 had l)eensoeonlideut, from the hi>tory of tiie ease, that it was one • )f ol)struetion hy jiallstones, that I was naturally chagrined at the negative result of the operation. The friends removed the body at onee to Jenkintown, l.nt I was Ibrtnnately able to seeinv an autopsy? when the f dlowing condition was found. Perihepatitis with deep | tucker ing, (.wing to the eicatri/ation of old gunnnata. 'I'he liver was not enlarged ; the appau-ut increase in size, during lil!-, was due to tlu; tilting forward of the convex surflice of the organ. Tln^re was recent acute peritonitis, confined to the region above the transverse colon. The liver, stomach and duodenum were removed together for dissection. On slitting open the duodenum, a bde-tinged nuicus was seen oozing from the papilla. Projecting into the duodenum and covered by the mucosa only was a gallstoiu', the size of a inarblf. Ft lay entirely within tiie bowel, (piite close to the narrow orifice of the duct, through which it could be >een after the removal (tf the nnunis. 'I'he stone could not l)e moved up or down, though it had slight phiy in the dilated pouch, at the term"', it.m of tlic duet. The common duet and its main branches were di! ito ; tlie former al)out the size of the index finger. The contents of iJie duct Avas a bile-stained nuieoid fiuid. The cystic duct was wide. The gall- bladder was a little enlarged, but did not contain any stones. Tlie terminal bihvducts were not dilated. The other organs presented no s])ecial change. Casp: Yl.—JanndiW of vanjimj intamty from Juli/, 1887, until Axi- (jud, J 888. Rcpcdtcd pumxijsms (f hifermittcnf fcrei: Death. A. B., act. 70, physician. Family history good ; has enjoved excel- lent health with the exception of an attack of nervous prostration in 1863. Some years after he got stout and was unable to take i)roper exercise. lie never had a strong digestion and always had to be carefid in his diet. He was in his usual lieallh until July, 1887, when he had an attack of jaundice, coming on with severe pain, evi- ! • IT) it il \V!iH one iiM'd at tlio lie Ixtily at ill! autopsy^ (k'litlv MUaiTcoIir. Tl, in fiv( <»r MIX weeks witli paiii^ nl" t| jaiiiMliee jriiuliially disappeared, Ian ictu riled !<■ siliie t;lianietei Tl. uttaelv did la.t last s,. lui,u-, |„„ i„ I ),,.o,„lH.r lie had a third attack oeialed with pain in the upper pcrtii.n (.fthealxl •eeoiKl ami in he has not heeii free t'roin tl greatly in intensity. Ahont Christn • •men. Since then le jaiindiee mm. ! has, however, varied by fc I WIS '.(• had a ,-< vere chill, followed ver and sweats lave recurred, and after each < the jaii loth, when I >aw the patient with Dr. M intci'va!> of ai.oiM ten A: :* the paro.w; 'HIS a.'^ follows : Stout, well- • d(c ned. On March nrra iic-ton, his condition was iinnrished < 5)2, feehh. ; no f I old man ; deeply janndin <\ ; pulse ever ; skin nioist ; roniplaiiied of niiich it clmijj' ; tonuiie coated; ahdoinen laruc; pannicnhis thick; omental liit palpation, the cdo,. of the liver n..t to he IMt ; dullness diniinishe.l excessive, more than three linuvrs hivadth in the middle I On not ine, and two and oue- iiie; no teiideriios on (h'cpest II" inches ((;.;}."i cm.) in the iiijiplc 1 |.rcs>ure over the pancreas. Tl,,. putieiit was hright inentalh vomitiii- had occurred thron.-lioiit the illness, Imt there had I ta( ks of nausea; bowels constipated; stools of (I • •olor of })iitty. They have not been dark and ance for months. Trii K'cii at- T"'lie ninht bclltre I s; le scanty, deeply iiile-tiiiucd. le consistency and normal in appi'ar- iw liim he had a vcr\ and one-lial fi lioiir.- II wnic \\a> 1! oiiowed hv a i)nrm -cvere cliil iiig iev asinii er and one pro- use sweatin- lie was imich prostrated by the attack, and in tl mornin- as was iiHial after an attack, the jaundi.r had deep- ened and intensitied. lie was not emaciated, thoiiol, I,,, .said that he had lost llcsh, partictdai in th 1 saw him at interval- of a April he iiad no chills and le limbs, dnrino' the pa.-t three months. I'W weeks lor several months. 'I'liroiedioiit jaundice bciran to liiihten. Fn Mav he had wa.- com])aratively comfortable, and th several viay severe par- oxy.-m.s, in which the temperature reached J(»;',°-104°. After eacl the color became more intensified, and tl some of the chills he had one complained only of a sen le urine became darker. With sovnv abdominal pains, but with others he sation of epijiiistric di.stre.ss. ThrouylK.ut the summer the chills an.Ltl'ver persisted at irregular intervals. In Augu.st the jaundice deepened and he died coinato.se. No autopsy. : I if i riglit side. She was in l)ed for two weeks. From that date nntil tiie present the skin has never been of the normal color, thongh for weeks the Janndiee wonld l)e extremely light. Dnring this period she has had repeated attacks of pain in the region of tiie liver, nsnally aeeompam-ed with vomiting and diarrhoea In abdomen ; tlu- face is fairly plumj) ; she is deeply jaundiced, color of dark, olive-yellow, not th.e light soft tint of recent icterus The conjnnctivie are deeply stained. The skin is dry and harsh. There is no eruption, only a W^w scratches on the back. She com- plains of intolerable itching. Temperature was 103° on admission but fell to the normal ; ,)ulse 100. The abdomen is symmetrical, the upper zone not especially enlarged. On palpation it Avas soft, mm- resistent and painless until the epigastric ana right hvp.)chondriac regions were reached, which on pressure -vere extremeh- tender. The edge of the liver can be felt just below the costal margin. The gall- bladder is not paljiable. Percussi(m in mid-sternal line shows not more than two inches (5 era.) of liver dullness ; in mpple line ,'>boiit three inches (7.6 cm.). The spl(H-n is not i>alpable. riiere are three inches of vertical dullness in the axillary line. » She has liad several movements of the bowels since admission ; th(> faeces are soft and of a grayisii-brown color. Tiie urine is high-colored and contains bile-j^igment, no albumen. 17 th^viuf '°|."T ;'■'"'"■,'"■ ""■'■ "" ""■"■ *l'"'-'"^ ""'>»-"» during hioe jeau,. b,,!, enne »Ik. „as admittol ,vitl, (bvor and .™t .,ain n ti.o -...gas,,.,,. ,,.gi.,„, .i„, ,,„„i,i , „„, j,,„,,,^^^ Tl,.:„ IZ It \;'''T ''■"'';';■''''■ '''■"'•'''■"'■''''• TlH, stool, w J novo,, b , Ik „,,, I, ,„.,■,.,■ ,,„,so,„. T„i,,. .1,0 „.as mad,, iho sul, ,■, oC a . d ,.t,,,„„g a „,.„, of lK,,a,i,. i,„e,.,„i.tc.n, ll.o,-, da,. i„ II ,,1! alHlih to din.nic ohstniction l.v oallstones. (inttjiici, Jifcoirri/. P\^!ur ;f'^-?."": ^^•'"''''"' ^" ^''" '"^^t-i^v wards of the ■ Uulel, ua H„„p,tal ,u January, 188r,. ..,:,1 ,1 severely, eausniix a profiise Iiemor- rluge, .said to liave been uterine. Three d-ivs ntVor fl„. ...; i .111 „ 1 . . lum Uiusairei tlie aceulent slie lind naasea and vonut.ng, an.l in the eourse of a week jaundice develo, d When admitted to the nies (7.(5 e,n.) of ve.tical liver d.illness ,n the nipple line and the same in the mid-sternal line The spleen xvas not palpable. Throughout August, she had four'severe olidls ; afler each one the jaundice deepened and each was accompanied by nausea, vomiting and a good deal of pain. In September the paroxysms were less fre,,uent, but she had two distinct ,-igors, on the 3d and on the L3th. On the 25th, the temperature rose to nearly 18 ^*;^wSi » h 102°, and she had, for ton days, an irrognhir intermittent ievor. On the 2(1, -id and 4th, there were ehills, and she had become at tliis time more intensely jaundiced than at any period since her admission. She improved between the oth and the 15th, and the jaundice got lighter. On tlie latter date she had a heavy chill. Chills recurred on the 22d, 2()th and the ■J8th. In the lirst twelve days of November she had six rigors; the jaundice again became dee])er. After this date she improved very much and through the latter part of November and the early part of December, she was remarkably well and j)re- sented only a light-lemon tint. She had two or three slight chills, each followed by an increase in the jaundice. On the 27th and 28th, the paroxysms recurred and she again bei'amc jaundiced. Atter Jan- uary 1st, the color became lighter, and by the 18th, when she went out, the jaundice had almost disai)peared. I saw her again more than three mouths aftcwards and the jaundice had comi)letely disapj)eared and she had had no recurrence of the attacks. The accompanying temi)erature record of Case VIII (.sec p. 21)- illustrates very well the type (jf fever met with in these eases. Of these eight cases, six were women. Two died after operation ; two died I'rom the effects of the long coulinued jaundice; three re- covered after the persistence of the condition for I'roni eight months to three years, and (jne passed from observation. In analysing the syin]>tonis asscjciatcd with these paroxysms, we have — First: JdHndh-v. This was present in everv instance and may be said to have been constant, though varying very greatly in its inten- sitv. It will have been noticed that in every one of the cases the statement occurs that after the paroxysm the jaundice invariably deepened. I do not remember ever to have seen a well-marked paroxysm, with intense rigor and high fever, in which this peculiar- ity 'lid not occur. The patients soon learned to recognize it and to exi)ect, as a matter of coinse, an intensification of the jaundice. With this, the amount of bile-pigment increased in the urine and the stools became more clay-colored. After persisting for a week or ten davs, the tint would become lighter, until as in Cases II and VIII, the skin would l)ccome, in the intervals, almost normal. The urine, too, wonld be lighter in color and the stools contain bile. In certain ^'"f' 19 lever. ( )n mo at tliiti admission. utHlice got Is rt'curred November or this (late November 1 and ju'c- igiit chills, 1 and 28tli, After Jan- i she went more than lisappeari'd [.see p. 21). ses. operation ; ; three re- lit months xysms, we id may bo 1 its inten- ! eases the invarialdy ell-marked s peenliar- e it and to ! jaundiee. nrine and a week or and VIII, The nrine, In certain I Tkmpkkatcre Kkcori). (Seeih^) / %■ '■ 1 i / ,^ • f ] ' n ■' , 1 1 1 1 [i 1 ' ') ll 20 ' of tho casps, I, III and VII, the jaundice for months togetlior was of the most intense , owing to ehroni(> obstruction of a main duet in the liver. I liav(! not met with such a itase, hut Magnin' refers to one under Charcot's care. Second : Fever. Tliis, in well-develo])ed jwroxysms, begins with a sharp rigor. I have rarely seen in intermittent fever chills of greater severity. In Case III, in particular, the large, stout woman would, during the rigor, shake the entire room and cause the small, wooden h(,..se in which she li\i;d to vibrate. It may be represented, however, only by a sensation of cold, a creeping chill, in contra-dis- tinction to a shaking one. The fever rises suddenly, and, as shown in the chart, may reach from 103° to 105°. At first dry and pungent, the skin gradually becomes moist, and usually within from two to five hours of the commencement of the rigor the patient is bathed in per- spiration. The entire dui-ation of the fever is from six to twelve hours ; rai'cly does it [R'rsist for an ' -'tiatod the is Jlloiir?'"" -f 'n ^ .'"^"'^ ■" ^'" '"^"-^"^^ '-»--" ^'-' ^^ttaeks s a on ,.f eonsKlera .le nnportance. They are often ^vell en^uu-h to cs. Theie ,s not pn,„-o,ss.ve deterioration of health and stren.^th, s^idi a. we nuMl .-.th .„ ,,ah-,n,ant .lisease. With the excvntion of 2d i;"t. 'V 7" '^"^^'"' ^^•''" ^^^^^ '—Jaundiced, she yeai.s, had a very fan- hiyer of pannieulus. Regnard ' found in <,ne ..,se that the excretion of urea was diminished dux-.ng the attack. Only in Case IIJ was a careful studv of the Za made d.u-xng the attacks, hut no special dinn-nut: was found I)uirj>>os>s.-Th. s.o.ni(icance of hepatic intermittent fever cannot be apprecated w.thout takin. into account the associatcxlgroup of symp- ton., and whcu these are present it points clearly to obstruction tf ho common duet by calculus. The c-ondition of the bile-passa-es in tlH^e cases is one of catarrhal, not suppun.tive, cholangitis. '" ' ' Chrom,. obstruction of the bile-duct, eidier bv stenosis or bv .rall- ^oues, nmy persist for months . -hout inducing this intermittent pyrexia, as illustrated by tiie follnN\Ing cases : Gallstone., in the common di,cf. Chronic jaundice. No fever. A man aged 77, was admitted to Dr. Curtin's ward h. the Phila- delplna Hospital suffering with Jaundice. He was a Meaver by trade an ? ; • 1 22 and tho urine high-colorod and contained bile-pigment, He diol on the fifth day after his admission. I made a disseetion with Dr. Atk>e, and tlie followinij conditions w ore found: Deeply jaundiced ; moderate ascites ; liver small,. surtiice granu- lar; gall-1 )laddersli'/! 1 1 iy distended, ])rojectin;.'()nein(!h (2.5 cm.) beyond the liver margin ; tlie common, iiepatic and cystic duets were greatly dilated. When the duodenum wi:- opened, a ncxliilar body projected beneath the mucous nictnl)rane a!>o\i' the bile pii|nll;i. This could be felt as a hard body witliin the iiead (,i !l,e j)an- reas, and Wiis at first thought to be a cnm^erons mass-. A probe was passed through into the ififiee of the duet, and on squee/ing above the pancreas a bile- gained mucus flowed from the orifice. The iKxlular mass proved to be a gaiistone the size of n cherry firndy imjiacted into the ampulla of Vater. It could neitiier he puslied into the common duct nor into the dnodenuiFi. .V second stone the size of an oli^'e was free in the duct, in whicli it could be moved u]) and down. The common duct admitted the index finger, and its main branches in the liver admitted the little finger. Tlie gall-l)ladder was moderately dilated ; contained no stones ; the cystic duct was free. Tlu; i)lad(lei' and ducts contained a bile-stained mucus. The liver presented the appearance of ordi- nary cirrlfosis. The kidneys were swollen and bile-stained. That stenosis of the common duet may ])ersist fi)r months, or years, without inducing chills and fever, is illustrated by the following ease: Stenosis of the fommnn dnct. Jtuinilice of fourteen moiit/is duration. No fever. Hannah C, aged 85, admitted to the Montreal General Hospital, September 25th, 1880, with obstructive jaundice of two months dura- tion. The attack had followed diarrhiea, and had come on without any pain. She remained under observati >" for nearly a }ear. The skin was of olive-green color; the stool' eii'v colored ; the m-ine dark greenish-brown; the liver appeared greatly enlarged, the dullness in the middle line (extending fi)iu" inches (10.2 em.) from the xiphoid cartilage, four and one-half (11.5 cm.) inches from (he sixth inter- space, and foiu- inches (10.2 cm.) from the seventh inters])ace in axillary line. She had frequent severe headaches and occasional attacks of pain, associated usually with vomiting, [e died on itions were facegmuu- m.) beyond ?rG greatly V projected is could be ■as at first rough into •eas a bile- proved to e ampulla let nor into ree in the inion du(!t V admitted contained < contained ■e of ordi- i, or yoai's, iving case : duration. Hospital, nths dura- >n without ear. '^Phe urine dark lulhicss in le xiphoid xth inter- ers})ae(> in occasional 23 The ten.perature record, which extended ovct the entire period of . .ay, occasionally showed an elevation <,f two or tluv, decrees .u she never had chills. The liver increased in size, anly narrow, th.Mvall da^^ and he Innng membrane rough. Above this part the < uct was g.-e.Hy d, Ucd ..1 the walls thickened. The gall-bladder Z^21 elatel^ d,st<.,ded ; the walls wore hypcrtrophi.,1, and the lini„t be somethino. supen„lded, probab y t^lie fe,-me„t-pro; points:—^]) increased tender- ness in the hej)atic rej^ion with possibly enhu'^cment of the j^all- bladder, as this is a more common event in snppurative eliolanjritis than in simple obstruction of the duct; (2) the more frequent return of the ])aroxysms, and in some instiuiees the irreuuhu'ly remit- tent eharaeter of the fever; (:]) the jaundice is not so intense in suppiu-ative cholangitis, and we do not see the remarkable deepeniu<>' in color after the paroxysms ; and (4) the general condition of the patient in the intervals is very different in the two conditions. When suppu- ration exists there are rarely the ])rol(mged periods of apyrexia, the freedom from distress and the general betterment which we see in eases of simple gallstone obstruction. There may be, however, the g;reatest difficulty in deciding, and, after all, in the question of treatment it does not make much difference. I recently dissected a specimen of cholangitis brought to me by my friend Dr. Lainc, of Media, l*a., \\hich \\as removed from a woman, aged 70, Avho had had from June until September, chills, fever and sweating, recurring at irregular intervals, either daily, or every third, fourth or seventh day. The liver was tender ; no tumor could be felt; the symptoms were evidently pyiemic;, and there was inflam- mation of the i-ight i)arotid gland. The temperature record, a copy of which Dr. Laine gave me and has kindly allowed me to reju'o- duce (.seep. 37), may be compared with the one previously given. The chills recurred more frequently, and the temperature is altogether more irregular than in any case of ordinary hepatic intermittent fever which I have seen. The auto]>sy showed an abscess of the gall bladder with sinuses. The cystic duct was bloi'kcd firmly with a calculus, and another the size of a cherry lay loose in the common duct, not inter- rupting the passage of the bile. There wore two septic abscesses in the lower lobe of the left lung, and there was fresh endocarditis of the aoi-tic valves. In the chronic obstruction which results from the compression of a cancerous mass either in the head of the pancreas or secondary in the lymph glands, there are occasionally rigors, due to catarrhal or su])- purative cholangitis, but the sequence of the symptoms would, I think, enable one to decide between this condition and gallstones. 25 iiixn'tant to 'cidin^' this, scd toiulor- )f tlu> tiilll- cliolanji'itis •(' Irequent litrly Riniit- intcnsc in i'('j)('ninj«' in the patient hen suppu- nrexia, tlie sec in eases itling, and, 1 (hfrerenee. me by my L a woman, fever and very third, r eoiild be ^as inflam- )rd, a copy e to repro- iveu. The ether more ever which iulder with cidiis, and not intcr- bscesses in •carditis of e.^sion of a lary in the al or su])- woidd, I gallstones. ■< I ■hi Temperature Record of Dk. Laine's Case. (;.:';<: -... ■^) iff '■' : « < ' , i ^ * 26 The varying Infonsity of the jaundice und the compnrativelj- cosy ■state of the patient in the intervals between the paroxvsms are features wJiicli I have n..t met with, iior seen referred t.., in the obstruetion by malignant growths. When the fact is recog^i'zt-d that the lodgnu.nt of a gallstone in tiie eominnn ms occur since in case I, in whicL the bile-ducts, as stated, contained a vellowish viscid, n.m-puruleat material. Dr. Abbott [iirehison inclines to the belief that the fchrile paroxysms are due to tlie simple irritation of the stone, not to a septi- caemia. To this view, Ord .>ul)S( libo,' stating that tli. paroxysm of fever is "due to local irritation of the muc ,- meml.rane piupaL^ated to the central nervous system and resnlting in pyrexia, mostly in persons api to take on {ihrilitv , and partieidarly in persons who have previonsly had intermittent liver." It was iJudd, I think, who drew the analojry lietween hepatic and lu-ethral fever, hut the analo^xy to which he referred is rather lietween the rigoi in recent cases of renal and hepatic colic and in the so-called catheter f , r. Tlicre !<, however, a renal intermittent lever, closely analogons u> the hej»atic form. It may occur, first, in tnhercular pyelitis; secnn,!, in calcnloii> pyelitis; and third, in rare instances of stone in the pelvis, without chronic suppurative pyelitis. The cases in the last category 'iit a cnrious analogy to hepatic intermittent fever, dne to gallstom. mikI without suppurative cholangitis. There are intcns<- rigors, the temperature rising to 104° and ]0o°, with great [lain in the renal region and distinct changes in th(> cliaracter of the nrine. In a ciise of the kind which I had an opportunity of studying for several months, the paroxysm- reenrred at intervals ' a few weeks ; in each one the urine hecame somew hat turbid but not purulent. Xo enlargement (tf the kidney could be di'tected, but there was decided .sensitiveness in the left renal region. In the intervals of the attacks, the patient was perfectly well and the urine became clear. Fn all of these cases the obstruction is not complete, as shown by the present of bile in the stools for long periods at a time. The associa- tion of till' chills and fever with iutensirK'aticm of the jaundice must be more than accidental. The two musi be correlated in some way, in all }i..>l)ability through a transient impaction of the stone in the duct. Such :i condition might induce the chill, either through reflex irritation as held l)y >[urchison, oi- by preventing the escape from the bile [)assages of toxic ingredients — ferments [rod need by the action of micro-organisms — v, liicli are absorbed into the l)lood instead of ' Loe. cit. i I 1 i 1' 28 cscaiiin^r fivolv i„t,, t|„. |„)„.<'I. TI bv ii gnu I Mil I increase in tl le nil ipaetion is prolniMy (.verconio TIk IxMiit uhiel. permits the ei.l.iilns u, lid! I,al'<'"<"il m ease [I, and v<>ry likelv in (he „tl n. iiiit, as reecverv ton()\v(.d. ler eases in which I iMve e.npl,as.z,..l snlli<.ie,,tiy the important diaKuosti,- indieation.s affo.dedl.ythehepat.c intermittent fevc, and a careful att<.nfion to tlie j,ronp of syn.pton.s presente.l siu.nhl onabh- n,s (,. .h-termine whether, ,„ a j,nven ease, jrallston.s ah.np are present, or whether Hnp- I""'"""' I'as snpcrvened, and the important ,p,e.stion remains a.s to the progiioMs and (he treatment in these eases Froc,nmi..-I have heen (brtnnate in the .-ascvs which F have ,seon as fhree of the.n reeov.-red ; on., after a persistence of the symp-' toms for three years. .[,u]o.i„„. f,.,„, t,,„ .....jtv with which recovery IS menfone,] ,n the literatnre, snch eases mnst be dee.ned exceptionaj. rhe o,,,u ma.,or,ty of then follow the conrse which is sketched in tH. history of ca.ses I and VI, death resulting fn.n, oxhanstion or cfi()fa!mia. Treat>nrnL-The renuirkable snccess which has recentlv been ob- ^.m.d by sn.^erevent the paroxysms I have dealt thus at length with this spec-ial .symptom, or rather -symp om-gro.H., so characteri.sti,. of obstruction of the coanmon duet by gallstones, a. I believe a ^vider recognition of its importance may be the means of saving valuable lives by timely surgical interference. tonc(umn>s,-l, I„ cancer and in eirhosis a certain number of ca.ses ^sent fever of mn.1o....te grade, but scarcely distinctive enouirh to bo pi of value ill diagnosi,> \y ((voifome .stlMcJicd to ilcr |)(»rtinii. ri'(' 1 » ' 1 i ' i ,1 i M 'i > I 1 _jj.*i^ ^ 1 jjiBu^te; 1 ■Py :^ i tI i # k J ! I i& C III [From Thk Johns Hopiaus Hospital Reports Vol II Nn , x ^ iimums, vol. II, ^o. 1, January, iggo.] CASES OF POST-FEBRILE INSANITY. By WILLIAM OSLER, M. D. Ono of the m.»t .list, -Ksing , incidents wl.ich .„„ t;,li,„v •,„ ,..„t<. fi.n,„fox,,o„„.„,,|,.,„.,.,,i„„,|„,,,„f,„^„,„l ,,^,. ■ 12 -.:.:...;. ,.,.i.::,.^::-r::;t:,:r.;::;::i««^^ doipi^H'T ;'''",:'';"'''■ ": i'""""-"' ■"■ '■''■> -■'■™'-' •■'■ '•'"'"- . """.'"■/ "" '""■ ' ' fi"»l.-"M,.nl;,l l„.ai„ ,,,„„|i,i„„ vi.- Case I.-P„„,„„,„,- ,. ,,,,„, ,,,„,„,,,,„„„ ,„•„, ,,„.,, , emabinm md MiuimiK. ■^ . ne 20 h 188 I. Faniilv l„s„„,. ,■» „,„„, „„ i,,^,,;,^. «as ., .-„, H ,rfh„,. ,„ ,1,0 „a,.. I„ .M„,.ol, ,,, |„„| „ ,„„.,., „„„,.|^ „^ p„e„m,„„a, .1,.. ,,„.valo.,«„.,. ,•,.„„, „.l,id, wa. slow, but at the c„ of T niveraify ^rp(!;cal if- zine, Deufiiiber, 1889. •Ameri,..an Journal of t..e Medici.I Sciences, Dece Medical News, 1889 ruber, 1S88. hm^ i'it , If I i l I! 'r i m I I I isi •» i ii ':} \ c •< 1 5 ;i . n 1 !'f ^ ^ ii six weeks he was able to be uj) and about. The mind at tliis time was perfectly clear, and had been so throughout the illness. About two weeks after convalescence he was noticed to be a little odd and pecu- liar; wa.s low-spirited and dei)ressed, and began to imagine all sorts of troubles; thought that he was in serious financial ditheulties. He was never violent, simply melancholic. When seen the patient was pale, with a sad, depressed (>x])ression of face. He would respond to ([ucstions, but not promjjtly, and speech seemed slow and hesitating. It was only with dinienlty that any account could be obtained fnmi him, of his feelings. His chief worry seems to l)e that he has lost the respect of his friends, and that people are plotting against him. His friends were advised to kee[) him at home carefully guarded. September 21st. Patient seen to-day by Dr. Toulmin. He is looking, and has been, much better, has gained in weight, complexion is good and expression is cheerful. He still has hallucinations, and thinks that he has done something which he shouM not. Twice he has been violent, but was restrained without much diffit-ulty. He seems to be progressively improving. Case II. — Typhoid fever ; severe attack with inueh deliv'mm. Mania during convalescence. Gradual recovery after four ino)dlin. Mary J., aged 28, seen with Dr. Fussell on February 19th, 1888. Familv history bad ; a sister died of phthisis. No mental troubles. The patient in January had an attack of mild typhoid fever, in which the mind w^as clear, the pulse not ab(jve 100, temperature not above 10;>° ; the rose spots \vere well marked. On January 29th, with the temperature 101°, the pulse 120, she was delirious for the fii'st time. On the 30th and 31st she was con- stantly talking, chietly on religious subjects. She tried to get out of bed. :uul was full of delusions. Th'-oughout the first week of Feb- ruaiy, her temperature was not above 101°, but the condition of delirium was most intense, at times becoming quite maniacal. I saw her on February 16th, in the following condition : The temperature had l)een normal for at least a week. She was emaciated, and had a wild, anxious expression. She sat up in bed, and could not be induced to lie down. She talked incessantly, ciiiefly upon religious subjects. It was with difficulty that she could be kept this time was About two tl and pecu- g'inc all sorts iculties. He expression of , and speech Ity that any i ehief worry [] that people keep him at mill. He is , (tomplexion illations, and . Twice he ffieiiltv. He tan. 3[ania >llOllfll>i. ' l!)tli, 18S8. ital troubles, loid lever, in iperature not ulse 120, she she was con- to get out of veek of Feb- condition of iacal. in . 3k. She was iat up in bed, ^^:-" ^'^- and fbnr ..oli wopk .-f . delinnm, wlin-h set in earlv in the first much eniacintP,! Tl V ' ^^"^ '''^^ P^'^' ^»t not deiusi„„s. He tl n, 1.; '^"^""7 "" ™ ^"''J"'' '» vi,K a,:;r' :it;;: , tr- :,;n;r :;-'";^--'^- ln,»noTif>,l XT ■ "joiiL cvtnrs wiucui had never te o,.,S' j:^:.;:.:;;'";,"'- "- '^'^^ ''-'^ "- ^'^ distinct l„-e,l- T . ■" '"■'*"• '•"'"I'ti'i" presented no hi. .trength, the deUH.nn and ment^a, Ir^.f^ ^'ptr™"^- "' As a ehild he ,va, aKvay, healthy. Ife is of fair intelligence and -n«;^rdttS ''t • '^ "■" •*™ '" """ '>■"-'' '--. Wa- uiiy^amiia attack, lemperature never ro«e above 10'^° fi\ the ontset the h«.d sympton. were well marL h! critxi Id lii i ': . whined a gmat doal. He did not know his mother ; ho had a dohision that she was dead. The fever only histed for two weeks; the rasli was well nmrkivl and there was diarrh(ea. The mental symptoms persisted for nciuly four weeks after the temperature had fallen to normal. In the early part of February he seemed to have recovered — at any rate to iiuve gotten rid of his delusions ; but his parents sought advice as he was, they said, a little queer. Patient is n bright, well-nourished lad, answers (piestions rationally remembers all about his illness, and in conversation nothing peculiar would be noticed except that he hesitates and is slow in his speech. His mother says he is very restless, never remaining quiet for more than a few minutes. He is most anxious minded, and constantly thinks something is going to happen to his parents. He frequently wakens at night and behaves strangely. He does not seem to know his father. His slow, halting speech is quite marked, and is a feature which has developed since his illness. Physical examination, negative. Heart normal. He cats well, and has gained rapidly in weight and in .strength. A favorable prognosis was given, and I heard in May that he had recovered. Case V. — Ti/phoid fever, severe attack. Durhuj cnnrafemnice derel- opment of de/nsiom. PcmHtence of mental i^t/mpfoim fur ten weeks, liecoreri/. Thomas D., aged 39, mechanic, admitted to the Philadelphia Hos- pital December 2yth, 1888. He had been off work for nearly six weeks, and for nearly a month of this time had been drinking heavily. l'\)r two weeks prior to his admission he had had fever and liad been in bed a great part of the time, during which he continued to take nuich alcohol. On admission he was rational. Temperature 101 .(i°, i)ulse 80. The only noticeable feature was the excessive tremor, which was attributed to alcohol, as his general condition was good. During the first week in hospital his temperature remained about 102°. There were dis- tinct rose sjiots. He had rambling delusions at night, and would constantly ^sttempt to get out of l.'cd. Dn the ()tli and 7th the tem- perature registered very low, 96.8°, but did not remain depressed for many hours. There was marked tympanitis on the 9th and 10th. ad a delusion k.s ; the rash 111 symptoms lad fallen to erod — at any jought advice ns rationally ling peculiar in his speech, liet for more id constantly [e frecpiently ;eem to know id is a feature ["ats well, and hie prognosis 'esecnce diTcl- Jor ten urcks. (lelphia Hos- ^arly a month s prior to his t part of the ulseSO. The ras attrilmted he lirst week 3 re were dis- t, and would 7tli the tem- depressed for th and 10th. 'H-me suspu.o„s a.ul pn.sented HKun- dd^ "'•''• "^ ihrough lohruary this co.Hlition persi.tod. ][,. ^vas v.tv di • ^-'-^ ^^t ■'■^l'^- ile was very iivhlo and K.oked d<,. s ... " J ^ tin/ '" ""'" ""'"'"^ .^Htistiu-torv ,v>,.l,s. Vt <,„,. p-;'V;":.i;i:;t«:::;:;:::t;Lr;i;;:::^:"';i::^ more readi v iiterestcd -.rwl ..f f;, i • ''"^- '"'"!'••- . HLUM,(i, .md at times seemed (,mte rational The T«-<. |...i,.t.s „f ,,n„.,i,,,l i„„,,« „„,,. I,c ,„.„ti„„<,l. Tl„. ,„-„.„„.sis il ..t .,11 ,,„,.,, l,|o, ,„ ,,,,,, ,■„, ,|,„ . _^j 1^^ . «..* a,,,„„g ,1,0 bete,- ,.|a«.s, wi,,, „ ,,„,,„,■„, J,,,,,,,,,^ ,;„, ' n t,tat,»,,t. It ,s ,„„.,.ost„,5; ,„ „<,.,„„ i„ ,,,<,. Ill, l,mv uill, .• r™,v.,v „f strcgel, I i,,,,,,,.,,,,,.,,, i„ ,„„„a| ,„„,,■,,, „„. mind heeomes stronmbi, usually laminated, whieh occur in the dd.j^ed auncles, particularly their apendices, in 'the vontrXi « ' of hbrous myocarditis, and in aneurism of the heart. m H rt Ma"' -11 Icnown. The i^lyp-like thrombi are very The second variety, mural, laminated thrombi, are not very un ommon, and the case here reported is of interest chiefly on account of the enormous size of the thrombus. Ball-thro,nbi, free in the chambers, are excessively rare only five cases having been recorded. ' ^ Cask l.-Large haimr ambus, free In left auricle; mitral stevo^,. 2^. S., aged 35, admitted to Montreal General Hospital, February br^i whn ' T- '''? ^"^ '"'" "'^^^' *« '^^^^^^^^ «f shortness of bi^ath, uhich withm the past three years had become .-..h ^yorse Two years ago she had an attack of acute rheumatism .ud during irfxT?! *'"'"'' '''" ^^^ ««^^«i«nally spat blood. ^ ^nJi~'7 '"*i •'''''^/" '"'"'^''^ ''^ ''^^'^'' Iiemiplegia, vith aphasia Speech returned ,n a few days, but the hemiplegia peiisted for some 'Deutsches Archiv. fur klin. Medicin, Bd. xxxvii. I ■ r'*" ■i t ^ii^i 2 montlis. AVitliin u year slie had a swond attack, sinco which time the paralysis has persisted. When admitted tiiere was orthopnoea ; face suffused; no dropsy; complete! riglit hemiph';iia ; the heart's action was very irrejjjular ; \m\sv 112, rapid and feeble; the cardiac dullness was increased ; the apex heat was normal in situation. There was a hlowiuf-; systolic nuu'mur in mitral re a\ as greatly enlarged, and contained fluid blo.nt ;ind clots. Amoii^ these was a ball-thrombus, ovoid in shape, thr -'t/o of a small pullet-egg, measur- ing 8.5x2.0 cms. It was (juitc a;'uachcd, and lay free above the mitral orifice. It Avas firm and oifistio to the touch, and on the sur- face greyish brown in color, and jn-esented little linear fibrinous ele- vations, but no roughened sp^r as if it had been adherent to the wall. It gave an indistinct sense of fluctuation as if central softening had oc- curred.' There were no mural thrombi in the chamber. The endo- cardium was opa(pie, and the walls thickened. The right chambers were greatly dilated ; the tricuspid orifice measured 12 cms. in cir- cumference. The auricular face of .the valve presented fresh vegeta- tions, many of them pedunculated. The walls of the ventricle were greatly thickened. The mitral orifice was very narrow, Just admitting the tip of the little finger ; from the auricle it looked like a small bntton-hole. At the bottom there was a funnel-shaped depression. The edges of the orifice wei'e thick, of cartilaginous consistence, and were fringed with small vegetations. The chordae tendineae were short, particularly those from the anterior muscle which was attached almost directly u])on the flaj). The left ventricle was small, the walls over 12 ram. in thickness. The aortic valves were opaque, and presented a row of vegetations. The lungs were crepitant throughout. They Avere tough and brownish-red in color ; they did not contain an excessive amount of fluid. ' Tlio specimen is preserved in the Museum of the Medical Faculty, McGill Uni- versity. y, McGill Uni- 3 I "0 ojiht kNii.ey |.,vs,.nt<.(I scvrnl old ,.i(.afn..s. I,, tl,,. h-0 capsiilo wore spots cf „1,| s„fh.niii^'. I'lial case>, and roio rs to a t i ivl li> I. +• i ■ ■ IT 11(11(1. in hi.tli ot Jus cases tici'c \va< niiti-il » ■ "«-"'■,, 2 ,.,„s, i„ ,ii,,„„.,..,, „,„ „„„.,. _, ,.„ :• m„l,,l ,„„n™| „ „,, ,|,„„,. ,^„„^,^,,,^,_^^ ,^ , t :::r:;;" ::• ";■ ' -■ ■""";","■ *-"■""■""'■• '-■"■'" '»"■"■•■ ■■-••■■' '>' „,■'''"■,.";''■'' ,"'T; ?'""'' '' ""•""""• '■■' '■'■|"-rt"l l.v .Ma,.|,,„l i„ -- Uv.el, ,,,„vul«i„„., ,,va,„™, a,„l ,•„,<.„ ,|„„„,. j^ / ^ r '" ;"" u '"""" ''''"■•■° ""^ '"""•' '" 'l- 'isl" a I. a "TH ■;'"■• "■"■'■'■. "-"™'''^ "I"'. '-"■ tl- -- of a waluuC ^^'H< li lav al>ovo tho tnciispid orilife 1. f. xon Iu.(.kl,„..|,,„,s,„ states that l.o hud first doscrilKHP' these nnl V t "rr ;''^ *''?•'"''' — -'"'^, about the sixe of snull waJnuts, and Jay tivr in the hit auricle. TJ.ese re.na.'kahl, structures are, as EeeJdiuj,duu,scn suL-ests ...lob- ular throud,. detached tr..n tl,e auricular appendix, and; bL too argetopasstlu-ougj. the narrowed nn'tral ollfice, a.^e ke .t tat^. m the aune e, growing constantly l,y the accretion of fresJ la^er of fibnn. It .s not lilcely tJ.at they produce any special syn.ptoml (eft nunde by large hminatcd thrombm. J!r^' ^:, ^'■' '''"*'' ""^'^ ^^' "'^'"'"^^^^ ^'^ ^'^« J^>'"^« Hopkins Hos- d s toea '\r"f "\ '!"'"'. ''^^^' ''''' "'^'^ ^^^-W^ -^^ -^treme uyspnoea. JMarrie'' '""^^ '■"" ' --' ^ i -i i .. , when and young. lias Jiad five cliildren, all of whom died ' Loc. cit. 'Alge: ^.neine Pathologie des Krei.slanfs, Deutsche Cliirurgie, Lief, 2 and IMAGE EVALUATION TEST TARGET (MT-3) // /^^* .."' A 4 r/ wy ^ /a #^^' / fe 1.0 I.I |50 '""^= L25 i 1.4 M IIIM |M 1.8 1.6 Photographic Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 \ '^ V :n>^ V % V Af T 1 i , t k »' !' i Family liistory nc^ative. She does not think that she has had searlet fever. lias never had acute riieumatisni. She has iiever been a very stronjr woman ; has had shortness of breath at times for ten or twelve years. For six weeligastrinm. There is i\n indistinct thrill. Dullness extends from the npj)er border of third rib, and to the right is two finger's breadth beyond the margin of sternum. On auscultation, below the nipple there is a continuous rapidly succeeding series of sounds, the first and second not distinguish- able from each other, and the long pause is absent. There is no murmur. At lower sternum the first soimd is distinguishable. It has a ringing, echoing character. At the base the second sound can be distinguished from the first, and is loudest at left margin '>f ster- num. Most careful auscultation fails to detect a murmur at any of the cardiac areas. She was ordered hypodermics of ether and tincture of digitalis every three hours. In the evening she seemed somewhat better, the distress of breathing \vas not so extreme. There was dullness at the left base, as high as the angle of scapula, \vith feeble breathing;. S2nd. The pulse can scarcely be felt. In the mitral area the first sound can be distinguished from the second, and the diastolic pause is more marked, 2'here is no murmur. The 8ec(»nd left at base is ringing. On palpation the shock in lower sternum is very marked. The discre{)ancy between the loud, cdear ringing sounds, with the moderately forcible impulse of the heart, and the extremelv shabbv. scarcely detectable prjf.c is very marked. The urine is scanty and uifficult to obtain ; it contains a trace of albumen. Has never had r woman ; has cars. For six week ago she •een in bed for las had a good lor ashy-grey ; oea. The feet scareely to be s of ether and but cannot be lurkcd shock, ill. Dullness le right is two )U()Us rapidly t distinguish- There in no ruisliable. It )nd sound can argin of ster- mur at any of c of digitalis lat better, the IS dullness at ble breathing;. 1 area the first liastolic pause loft at base is very marked, ids, with the ■moly shabby, is scanty and till nigiit and (bed on the morning of the '>,3rd i^ftaS" " " •ition of <,nnnuo.,s dilatadou of the AutojJ ly D,. We,..,, ,j„,^i,.,,.^^^ .,,,.vn.oses us ; fi.ce cvauosed. " ' I" peritoneum, ,ho,.t {oO e,-., of ,.l,,,r yellouish serum, "'ora.v. Iho nght ,>lc.ura was evervwliere adlx-reut • tlie left pleura contaiued 1 ,.>()() ce. of serum " ' oec'ud:!dbJ'^^'''''"'^^"''r;'"-"'"^-™^ occudHl I, a firm, grey,sh-red tlu-ombus Mhi.h extended onlv a .hort .stan..e:ntothel>nuu.h..softheartery. There was well mark Jill-own ■ '-'tiou of t e organ, with desquamative heart-,,ueun>ouia. T ■sn .stance was dry. r,. t,., ,,,•, ,,.„,. „,, ,„ft / J p.. «y artery w.. eom,>letely oclndcl by a gr^'isf. -red, laluiil!^ th.ombas. I ho ,,■,,],„,„„,, ,,, ^„„, ;^^ w..e e.tens.vely atherouKUous. The substance of the left luu':: Jlea,-t^ w^Mghed 1 ii ,.. (45:IG gms.) (due la,-gely to enorn.ous throm- s n the eft auru-le) The left ventricle was not hypertrophied or at. 1. 1 a,,pearet a ttl aort.c extreuuty of the orifice, where there was an open ug m asur m about o mm. in diameter, which scarc<.ly admitteh whieii the hhnxj could How. The thrombus had undergone softening- in various jiarts. The peri- cardial sin-tlice of the left auricle was thickened aiid o|)a(.ue. The right ventricle Avas markedly hyperti'opliied and dilated. It was i) cms. in length; the walls averaged 7 nun. in thiekue.-s. The nuis- cular trabeculae were thickened, and the tricuspid orifice admitted readily four fingers. The segmcMits of the valve were normal, saving a little dilfnse libroid thickening. The right auricle was also nuich hypertrophiedand dilated; its walls measured in places 4-5 m.m. In thickness. The hypertrophy was especially well marked in thetrab- eeulae. The cavity of this chamber was much dilated, measuring at the longest about 8 ems. The coronary sinus was greatly dilated. The pulmonar)^ valves were normal. The i)ulmonary artery presented several opacpie yellow atheromatous itatches. At its bifurcation there was a parietal thrombus, which became an occluding thrombus in the vessels going to the left lower and to the right upjter lobes, as already described. The s])leen weighed 3] oz., (02.14 gms.) dark-red in - ' The kidneys presented patches of atr()i)hy on tin; surfiice. The striae of the cortex were distinct. The consistence of the organs was increased. The renal arteries were atheromatous. The liver wei'died 33 oz., (935.5 gms.) and was in a condition of red atrophy. INIural thromyi are quite common, jiartu .ih.rly in the anricnlar ap- pendices, but they arc; usually small. Massive coagula, with exten- sion into the vessels, such as existed in this case, are extrcmelv i-are, and occur chieHy with mitral stenosis. Cases arc on record in which the thrond)ns has passed through the narrowed mitral orifice. Clinically the case is interesting as illustrating the disappearance of the murmurs in the last stage of mitral steno-is, not an uncommon event when the left auricle becomes over distended. There were no symptoms which could be directly referred to the blocking of the auricle with thrombi, none which we do not meet with in exti'cmo grades of dilatation of this chand)cr. CLW [From TH. Johns Hopk.ns Hospital Reports, Vol. II, No. 1. January, 1890.] I 111 cxtrc'iiic NOTE ON EXDOCARDITIS IN PHTHISIS. By WILLIAM OSLER, M. D. Within the past few yeans several writers liave ealled attention to tlic fre.|nent occurrence of vcf^etations on the heart valves in phthisis The appearan,-e of Dr. Percy Kidd's paper in the St. liartholomew's Hospital Reports,' and the dissection of a recent cas.> sngsosted a review of my post-mortems, as I had the impression that the condi- tion was by no means so common as he had found it. The follow- ing case presents ,)oints of special clinical interest. Stella D aged 19, admitted to the Johns Hopkins Hospital, November 1st, w.th c„ugh, loss of flesh and high fever. Tempera- ture on admission 10,5°. ^ Her mother died ol consumption. She had alwavs been well until her present illness which began about six months ago with cough and fovcr. Thn.ugh the summer she lo^ flesh and had night sweats. She gave up Mork in May. On admission the temperature was lugh and she was emuc-iated and an.emi,.. There were c-avernous signs at both apices, most extensive at the left; fine crepitant rales and moist sounds at bases. _ Heart. Cardiac pulsation visible in third, fourth, fiftli and sixth interspaces In the third, fourth and fifth, the impidse was wavy At apex the heart sounds were clear. At the pulmonarv cartilai here wa. a short systolic murmur, quite localized, not traiismitted to the left and not heard below fourth rib. At the aortic .'artilaoe the sounds were clear. The patient had persistent high temperature reaching twice to 105°. She rapidly failed and died ,m the 22d llie autopsy showed cavities at both apices. The left upper lol)e was small and did not cover the heart to the usual extent There were numerous groups of tubercles throughout all the lobes and many areas of gelatinous infiltration. ' Vol. XXIII. ■I II 19^ Mi !->' I G.ykibi ■^ ii ; 2 The heart was large. The cavities contained fresh coagula and a little fluid blood. The valves on the right side were normal. The mitral orifice was of medium size. The edges of the auricular surface were uniformly studded with large, recent vegetations, grayish-white in color, soft and readily removable. The majority of them were pedunculated. The aortic valves were free. There were no infarctions. Fresh frozen sections showed : — (1) marked proliferation at the attached edge of the vegetation ; (2) A finely granular substance, composing the great part of the granulations, — the granules were uniform in size ; (3) Scattered about among them were numerous large compound granular corpuscles, some of whic-h were rounded, others irregular spindles. Bacilli were not found in the stained sections. Clinically this case 'ilnstrates the well-known fact that a murmur of maximum intensity in the 2d and 3d left interspaces may indi- cate mitral insufficiency, but I do not remember ever to have heard one so localized in these regions, and inaudible at the apex. I regarded it as an instance of the murmur so common at the left sternal margin in cases of phthisis and thought to originate in the pulmonary artery, but the condition of the valves would indicate that it was produced at the mitral orifice. In 216 autopsies on phthisis there were 12 instances with fresh endocardial vegetations — mitral valves, 8 ; aortic valves, 3 ; aortic and mitral, 1. With one exception the disease was of the verrucose or. warty variety, and did not produce any destruction of the segments. The case of the ulcerative form was in a woman aged 28, who was admitted January 8, 1883, to the Montreal General Hospital, under Dr. Molson, with well-marked chronic phthisis and delusional in- sanity. There was involvement of the greater part of the right lung, with cough, night-sweats, and rapid emaciation. There was nothing in her history to call attention to cardiac trouble, and the condition found at the autopsy was unexpected. There were extensive ulcera- tive changes o" he mitral valves. In Kidd's c ;ies there were twenty-seven cases of endocarditis in five hundred ])hthisical subjects ; in thirteen of the simple warty variety, in nine associated with sclerotic changes, and in four there were chronic endocardial changes alone. In one instance the recent aagula and a ormal. The icular surface ;rayish-white f them were •ation at the ar substance, ranules were re numerous ere rounded, at a murmur 3es may indi- o have heard he apex. I n at the left ^inate in the ould indicate !S with fresh es, 3 ; aortic he vcrrucose the segments. 28, who was (spital, under ehisional iu- le right lung, was nothing ihe condition usive ulcera- The tubercle bacillus has been fo.md in these vegetations by several observers (Cornil. Heller, Centralbl. f Bacterioloje, 1887 1)^1 may be doubted, in the absence of the characteristic c anges aicM fortunate D^^rrTr *'"' "^ '^'' *" ^""^ °«' «-- -«- lortunate. Dr. Kidd, also, has not found them in his cases. idocarditis in simple warty in four there ice the recent f I J M.| ! I « ' -H CVI TUBERCULAR PJ:RIT0N1TIS. GENERAL rONSIDERATIONS-TUBERCULAR ABDOMINAL TUMORS-CURABILITY. By WILLIAM OSLER. M. D. The progress of aMcminal surgery during tlie past few rears has contributed to our knowledge of tubercular peritonitis in two direc- tions— first, in tcacliing u.s with what frequency the condition may simulate or be associated with abdominal tumor ; and, second in demonstrating the curability of a certain proportion of the ciuse ' To a consideration of these two asi)ects of the subject I j.ropose to ..^. ote the following paper, introducing their discussion by a brief summary of certain of the anatomical and clinical features of the disease. I. — General Considerations. Anatomically the classifications which have been made of tubercu- lar peritonitis are not altogether satisfactory. It is customary, and correct, to exclude the cases of scattered miliary tubercles in the diffuse infective disease and also those (!ases in which the peritoneal surface of tubercular ulcers is alone involved. Practi- cally, the great differences which we see, post-mortem, in this condi- tion result from the situation, the rate of growth of, and the degree of inflammation accompanying the tubercles, and whether there is much or little exudation— serous, purulent or hemorrhagic. The anatomi- I p* 59 . I ■ml if I '!;'...• -ti !i''i irt ' ii t..i 2 cal basis in all ca-ses is essentially the same, and the variations which we meet, though distinct and marked, are scarcely sufficient to war- rant the elaborate subdivisions of this disease made by certain writers. Thus, Spillmau,' in his excellent recent article on the subject, makes the fi')U()\ving Hve divisions: tuhercuhsr miUdire aiyuii ; tvbercidotte ukcreme; tuhfronloHeJihmisr ; prlvi-prrKonUe tubcrmUm ; fubrrculoae p^ntoneo-pleunih: T see no reason for the fourth and Hllh groups, if we bear in mind the frequency with which the peritoneal mischief is excited by tubal disease and the liability <.f the pleural membranes to be involved in the process. A large proportion of the cases m the first three divisions would at some period of their evolution come m the fourth or fifth group. In reviewing a number of post-mortems in this disease we find that they fall naturally into, the first-named categories : (1) AcMte miUnrji fuh varlationH which 8ufiial involvement. ( ;yn(>coIogists now (liagn..s,. and remove dilated tubes with su.h facility that we have numerous oppor- tunities of studying primary tiib<.rciil..sis of these organs. I have frequently been impressed with the wisdimi of this procednivas a pn.- tcH-tive measure, on seeing large caseous tubes with miliarv nodules on the peritoneal surflice, since the danger of general extension in such cases is very great. ITegar's monograph * is a storehouse of interesting information on this subject. A third point, worthy of attention on account ..fits importance as an aid in diagnosis, is the frequent involvement of the pleura. Sev- eral of the French writers on the subject have dealt very fully with this, notably Fernet^ and BouUand,* and Spillman, as remarked above, inakes a special sub-division to include these eases. In Boulland's list of eighty-two cases there were thirty-eight with tuber- culosis of the pleura, with or without efi'usiim. [n only three of the seventei u post-mortems, of which I have notes, w as thei-c tuberculous pleurisy,— a comparatively small projiortion. In the twenty autopsi(.'s in Mane's list there were nine with pleural involvement. In twenty-five of Bristowe's* forty-eight cases, the pleura was affected. It is oflen only a dry ])leurisy, occurring most frequently without pulmonary affection, and due to a direct extensicm through the diaphragm. The jiericardium is also liable in these cases to be the seat of an adhesive tubercular inflammation. A^f-— Tubercular ])eritonitis occurs at all jieriods of life. It is (jommon in children, in whom it is often associated with intestinal ' Uel)er Peritonealtuberculose, Hiiue. Korschach, 1889. Hienitaltuberculose des Weil.es. Stuttgart, 1886.' ^Quoted by Boullaad. * Pans Thesis, lS8o. 6 Keynold's System of Medicine. !' . "' I "I . m \i--r, If) ami incseiitcric flisoaso. Full statistics doalinf; witli its prevalon-i' in iiilimcy and cliildiiood, arc! not availalilc ; I am Hiirc the li^nros which foUou, do Milt represent the trne j)ro|M>rti<)n of eases at tliis period of life. It is most common between the ages of twenty and forty. In old ajic it is rai'e, hnt it may oocMir even in advanced life, as in ( "as(( XXI of my series, in whidi extensive disease exist<'d in a man of oiffhty-two. In my own eases the distiil)iition has been as folh»ws ; I'ndcr ten, 'J eases; from ten to t\\<'nty, I ; from twenty to tiiirty, 4 ; from thirty to forty, 5 ; from forly to i\i\y, 7 ; from fifty to sixty, 1 ; and above eighty, 1. Adding to these, (l{) cases of Roul- land,' 48 cases of 1 1 fine,* ."il) cases of Maiirange,^ (in which the age was given), and 45 eases of Fenwick,^ makes 22'2 in all ; and joining these figures to those of Brist(»we, Hilton Faggeand Leiu'rt,* l.'i") cjuses, we have a total of .'}r)7. Thes(! analyzed according to ages give, under ten, 27; between ten and twenty, 75; from twenty to thirty, 87; between thirty and forty, 71 ; from forty to fifty, 61 ; from fifty to sixty, li) ; from sixty to seventy, 4 ; above seventy, 2. Hex. — The disease is certainly more prevalent among females. The statistics of general hospitals and of average mediciil practice may perhaps show a })repondcranee of cases among males. This was the ctuse in liristowe's figures at .St. Thomas' Iios|>ital, in Fagge's at (hiy's Hospital, and Fenwick's from the Lond(»n Hospital, while in my series of twenty-one cases, f-lfteen were males. But when we go over the recent literature of the laparotomies which have been performed in this disease, we find the number of females to be largely in excess. Thus, if we take the figures of J^oullaud, Iliine, Maurange and my own, there are GO eases in males and 131 in females. Jiacc. — It is stated that the disease is more common in the negro than in the white race. Several of the leading j»hysieians of this city have expressed themselves strongly on this subject, particularly Dr. I. E. Atkinson tmd Dr. W. T. Howard. Three of the four cases which have occurred at the Hospital have been in coloi'cd people, but ' Loc. clt. 2 Loc. cit. '■' Piirin Tliesis, 1889. De I' Intervention Chinirgicale dans la P^ritonite Tubercu- leuse. * Lectures on some Obscure Diseases of the Abdomen. London, 1889. ' Quoted by Spillnian, loc. cit. Ii its prevnicii'-*' in ' the (itriircs which ■s at this period of twenty and forty. ndvaiH'<'d \ii\', ivt* sense existed in a ition hiis h(>en as [ ; from twenty to fty, 7 ; from fitly , (>!• eases of JJoui- iii which the aj;e II all ; and joining LelxTt,* i.'io ciuses, :oages give, under ity to thirty, 87 ; 61 ; from fifty to ( ^* »ng females. The Ileal j)ra(!tiee may es. This was the I Fajrii-o's at (Juy's tal, while in my when we go over '^e been performed largely in excess, laurange and my s. nion in the netrro >hysieians of this bject, particularly e of the four eases jlored people, but 1 P^ritonite Tubercu- lon, 1889. there are, so fhr as I know, no figures which could enable us u, arrive at a d(.t,n.te op,„,on as to the relatively greater tmp.encv of the dis- ease among tiieni. Cliuii'itlly it is extremely ditlieult tion of the eases nf tube rcul to make a satisfactory classifiea- !U- peritonitis, and I shall 1 !ier«'onIv refer to r?'" -^I !"' '""^"••"^ '" ^'- "-le..f onset and «. peculiar symptoms not, JUS a rule, very fully discussed. ' ' The process may be completely /aA./ and the ...uption take place so s ,wly and so painlessly that the patient may not have preseuCd a smgle sy.nptom of abdominal disease. Th .dition hal thus been nut w.th .n he operation fi.r hernia, and more frequently still in assocumon w.th ovarian tun.ur. In thr f ...y ..ase; it ..,s found acdentally, and, so far as could be ascertained, there had not been special symptoms pointing to abdominal disease. Thu< in ('a.,. V ' . man agc^ 40, well nourished and believed to be in good healtl/ was a mined to t lie M....treal Geoend Hospital with stnnl^nlated 1^ le.nia. He died e.ghte, n hours after the operation, and extensive tubercular peritonitis of the fibrous variety ^^as fouml. The left pleura was also involved. I„ Case XI/ a giVl, ag.l I s, .as admitt.xi to hospital with severe typh,.id fever, of whic-h shedied. Th<. abdom- inal symptoms were those or.linarily met with and there was no his- tory o previous trouble. The post-mortem showed, in addition to <"lmrac eristic typhoi.l l.^ions, an extensive tui.ereiilar peritonitis, whu-h had taken its start from the Fallopian tubes. The l,in..s were not affiH-ted Case XII,'a healthy looking, well-nourished childT.f five died of malignant diphtheria after an illness of a {^^s■ days. An -.cute nnliary tuberculosis existed over the entire peritoneum, which con- tained a slight amount of serous and much fibrinous exudation. Ihere were tubercles in the spleen but none in the lun.^s V case at present in the Hospital, in Dr. Kelly's ward, illustrutel "this latency m the disejise. Th.^ patient had a large ovarian tumor which ^v•as removed October 18th. The peritoneum was found universally cov- ered with recent tubercles of various sizes which also existed over the surface of the tumor. The literature contains very many ca.ses of this kind, so that it is a tair conclusion to regard the disease in many instances as latent in its ' Of the series of 21 casea. 8 i ' 1 1 1 ; I a r course, and it is possible for the process to go on to healing without having induced serious symptoms. The onset of symptoms may be mddeii so that the diagnosis of enteritis or hernia may be made, A remarkable instance in which it was mistaken for the last-named disease is reported by Thoman,* A well-nourished woman, aged 30, was suddenly seized with pain in the abdomen, vomiting and fever. The physician avIio saw her believed the sym})toms due to a hernia, which he thought he found and reduced. The condition continued and in the evening Thoman was called in. No hernia was found externally but an the al^domon was distended and ])ainful it was decided to operate. The inguinal ring was found closed. In the furtlier c(jurse of the disease, the peritonitis became more marked, the ascites increased and death oct'urred on the fourteenth day. The post-mortem showed extensive tuberculosis, both layers of the i^eritoneum being covered with a recent eruption. There were no tubercles in the lungs or pleune. This case is not unique, as y'^illmau' (piotes another instance in which the symptoms were so urgent and deceptive that internal strangulation was suspected. This suddenness of ouset is very deceptive and usually leads to the diagnosis of a simple acute peritonitis. The following case which I saw on several occasions with Ross of INIontreal illustrates this point as well as the importam c o^' the pleural symptoms so liable to supervene in the course of the disease : Case I, — Acute peritonitis; tympanites; abdominal tenderness, ivith loss of flesh and irregular fever. Pleurisy loith effusion. Tubercles on peritoneum, pleura, and parietal pericardium. G, C, aged 17, colored, was admitted to the Montreal General Hos- pital, Januaiy 2.3rd, 1884, with an attack of acute peritonitis which had begun suddenly three da}s before. For a year he had had ii'regularity of the bowels, with occasional pains, and had lost flesh. On admission, temperature was 104°, pulse 92, The abdomen was tympanitic and there was pain on pressure. Under appropriate treatment the pain became less and he improved. The temperature fell and be(.'ame sub- febrile, until February 1st, after which it was very irregular, rising to 102°, 103° or 104° at night, becoming normal or even subnormal ' All. Wiener Med. Zeitung, 1887, page 306. Loc. cit. ;o healing without t the diagnosis of istance in which it . by Thoman.^ A id with pain in the ) saw hei' believed ;ht he found and ;ning Thoman was 1 the abdomen was The inguinal ring sase, the pevitonitis th occurred on the > tuberculosis, both t eruption. There 3ase is not unique, symptoms were so IS susi)ccted. sually leads to the ving case which I il illustrates this Lj)toms so liable to (d tenderness, with sy loith effusion, ericardium. treal General Hos- I'itonitis which had id had irregularity h. On admission, as tympanitic and reatment the i)ain 1 and became sub- y irregular, rising )r even subnormal cit. , - 7 . in the morning. Towards the end of February there was a retiu-a of the pam and tenderness in the abdomen. Early in March, s.ous of pleurisy on the left side and a friction nun.nur developed near the loft nipple, thought to be pericardial. By the 17th of April there was well-marked ctiusion into the left pleura. The heart in'^puls vas felt to the r.ght of steruu.n. The abdon^cn became mor edis! tended, a httle hard ; no ascites. On the ;JOth, l.V litres of ser m were removed rrain ^vas normal. Dr. Koss, in comment- nig on this case,' notes particniarly the abrupt onset of the a.-nte penton.tis, winch un.ler appropriate treatment rapidly disappeared. The disease may set in with prono.mced !;a.frie syn,pfo>ns and sini- ulate ulcer or cancer, as in the following case already published in my Pathological Reports, ^[ontreal General Hospital, 1878. Case IL— Acute tahercdar infummafion of f/>c peritoneum. Persistent f/a.^tne symptom.. Small caseous num in left Um,. Rinht-sided pleurisy. ' J. McT., aged ;3o.-Had been a soldier for twelve years, latterly a sador; admitted to Montreal General Hospital in September 1876 complaining of weaicness, loss of appetite, and frequent attacks of vomiting. No albumen in urine. Blood normal. Systolic murmur at apex. Xo enlargenuMit of abdominal organs. Tenderness on deep pressure along right costal border and ensiform cartilage. The vom iting became more marked, and he had o.msional attacks of diarrhoea. ' Canada Medical and Surgical Journal, Vol. xiii. ,:) I ! r 'I 'iJi The symptoms pointed, though vaguely, to disease of the stomach, either round uh'er or cancer. The vomiting was with difficuhy con- trolled, and patient became very weak and anaemic, the skin slightly icteric. Pie gradually got so feeble that he was unable to move from bed, and the vomiting was so persistent as to necessitate feeding per rectum. Through »Ianuary and February the vomiting iliminished, but the patient wasted slowly, and the case was regarded as malig- nant (hsease, involving perha])s the i)eritoneum. In the beginning of May the peritonitis became acute and general, and he died on the 25th, profoundly exhausted. For some weeks before death hemor- rhages occurred in various parts of the skin. AutopHtj. — The peritoneum, contained 3 litres ot a turbid, slightly bloody Huid, in which were flocculi of lymph. Here and there the coils of intestines were matted together by easily separable adhesions. The transverse colon and stomach wei-e in this way glued together ; the former covered also the anterior border of the liver. The entire peritoneum, except the portion over the stomach, was of a dark red color, infiltrated, sodden, and readily stripped off from the subjacent tissues. Localized patches of lymph occurred here and there upon it. The whole membrane presented a great number of small white areas, flat, not projecting above the surface, and ranging in size from a hemp seed to a split pea. As a rule they were isolated, but occa- sionally groups were; seen. They existed in about ecpial numbers over the intestines, mesentery, and parietal peritoneum. Beneath the latter were from eight to ten larger white jiatches, which, on section, had a caseous appearance, were firm to the touch, not encapsuliited, and extended to the depth of about four millimetres. On examina- tion of these small and large white masses, they were found to be almosi entirely subperitoneal and composed of aggregations of lymphoid corpuscles, a little smaller than the colorless blood corpuscles, and with one, rarely two, nuclei. In seciions through those on the intes- tinal wall, the corpuscles were seen to infiltrate to some extent the muscular coats. The mesenteric; glands were but little enlarged. The heart showed numerous ecchynioses on ])ericardium ; the walls were flabby, the muscle pale ; very little blood in the chambers. There were 2 litres of turbid fluid in right pleural sac. Visceral and parietal layers congested, and covered with flakes of lymph. A few cc. of fluid in left sac. n%i ■i ic of tlie stomach, vith difficulfy con- c, the skin slifjhtly able to move from ;'ssitate feeding per niting diminished, •egarded as nialig- lii the beginning and lie died on the ;fore deatli hemor- t a turbid, slightly lere and there the jparable adhesions. ay ghied together ; Uver. The entire was of a dark red from the subjacent 3re and there upon ber of small white nging in size from isolated, but ocea- ut equal numbers 3um. Beneath the which, on section, , not encapsulated, res. On examina- were found to be >;ations of lymphoid od eor})uscles, and those on the intes- 3 some extent the ittle enlarged. ?ardium ; the walls the chambers, sac. Visceral and 3f lymph. A few 9 T^left L : ,J " "'^"" '""^""^^^ ^ Sood deal of serous fluid. made up ofa small CO viH- 1 Y '^^'H^^^ ^^^nvh on section was tubercles i„ dthc- j,- '" "'^ '"'«■ I l«e were no miliary Tlie spleen wei-lH.riSll „,„„. „nait,.r«l. enlarged. ' ' ^ ^^'^^' " Stands were not IV, .In. mistake „as, I Wiev:, Z^: "' '"'"""'' ^'^" '" ''^ Case III._,1h,„/,. ,/ ,„,,/, nbdomiml dkmsc. ■ m;,,h,„l ..„„ M.SS G., aged about 30, lairly well nourished, seen in Oee„l«r .;^tJre Ltlarrl,t^:rs::t^^^^^^^^^ 'Canadian Practitioner, 1888. I' 10 I i') ! ) t I: I ! i . t lui.' )! . ■ii J i saw, showed an irrejrular fevor range, not at all characteristic, the tem- perature sometimes dropping to normal. After persisting for about six weeks, these symptoms subsided, the fever left, and she got up and began to gain strength ; but shortness of breath became a marked feature and she remained pale and developed a slight cough, and it was for these symptoms that I \vas consulted. The abdonien was a little full, tympanitic, nowhere tender, no signs of any effusion. On inspection of the chest, it was seen that the right side scarcely moved; the apex beat was far ->ver in the left axillary line. There were dullness and other signs of extensive exudation in the r.giit pleura Temperature was normal. She was aspirated with great relief and two weeks later fluid was again withdrawn. She improved rapidly and by tlio middle of December, the breath sounds were well heard over tiie greater part of the right lung, but percussion resonance was defective over the lower half, and at the base quite flat. Considering the nature of the abdominal attack, the patient's family history and the gradual onset of th.^ pleural effusion, there can be but little doubt that this was a case of tubercular perit.jnitis, mistaken for typhoid fever. A.^clte.^ is a frequent symptom but it does not as a rule become very marked ; thus Biat,^ in an analysis of eighty-one observations, found .mlv thirteen instances with extensive ascites. In the acute miliary tuberculosis with rapid exudation the effusion may be bloody, but judo-ing from the published reco"ds and from my personal expe- rience this is not so common as in cancer, though the opposite state- ment is usually made. It has frequently bc>en mistaken for the effu- sion in connection with cirrhosis, of whicli, indeed, it may sometimes be a complication. It is somewhat remarkable with what frequency acute tuberculosis of the serous membranes occurs in this disease. Moroux ' 'uid Wagner ' have called attention to the involvement of the peritoneum, which in mv experience is not so often affected as the pleura. I have notes of six cases in which acute tubercular pleurisy occurred as a find complication in cirrhosis. Cases with extreme fi/mpanifes are also common. This condition, the result of impairment of the tone of the muscular coats, is a very constant feature in all forms of the disease. There are instances m 1 Paris Thesis, 1884. « Paris Thesis. 1883. » Deutsches Archiv f. Klin. Medicin, Bd. xxxiv. icteristic, the tem- rsisting for about , and she got up became a marked ght cough, aiul it le abdomen was a my effusion. On le scarcely moved ; line. There were I the riglit pleura. 1 great relief and improved rapidly s were well heard sion resonance was flat. ho patient's family n, there can be but nitis, mistaken for as a rule become ,'-one ()l)servations, itcs. In the acute ion may be bloody, my personal expe- the opposite state- staken for the effu- , it may sometimes ith what frequency irs in this disease. I involvement of the ften affected as the tubercular pleurisy n. This cimdition, Lilar coats, is a very ere are instances in 883. 11 ^ed to Lir' *" "" '"*'"'"'^' "^^'^'' '' '■" ^^^«^ VI' *^> be refer- Of special symptoms, I wish to speak of two only ; one of which has not received the attention it deserves Sub-nonnal temperatures.-Mmy writers refer to the fact that the temperature in tubercular peritonitis may be normal, bu it lot. n erally know^ that the temperature may' be subnormal we kf o." month, at a tune. My attention was called to this fact about four v J ago by my colleague Dr. Musscr, at the Philadelphia Ilospita'Io has made a number of observations on this point. In the c^e of fibrous tubercle, without much iuflammaton- process o ZLn omi:: "t1 ™" 7' tf ^ ^^^^'- ^"^ -b-'--^ temperatu; s :e com non. Thus, m Case VIl, to be fully given under an othersect^on the temperature during the patient's entire stav in the Hospi Hi was subnormafor a greater part of the day. In d,e earlv rnZ nlZ thermome er rarely indicated more than 96° or 96.5° /a g dual .t tJae afternoon, fiie same was noticed in a second case, upon which laparotomy was performed, Case VIII. During her conva lescen e for days at a time the temperature did not once re^ach 98°rttXin: November 28th, 29th, 30th and December 1st, the temperl .J taken every two hours, day and night. On the 29th 'and 30th^ ranged between 97° and 98°, but twice registered at 96°. Thro '^^ out December 1st, 2d and ;3d it only once reached 98° • the we was between 96° and 97.5°. In the diagnosis of doubtful setii symptom may prove of great value. In a case of Sir Edward Sieveking's,at St. Mary's Hosnital Lon S t7lS itt,'- ^- ^TT' ''' '''-'''' -Pe-nrf fir ^MtTh 21st to Ap d 6th ranged from 95.6° to 96.^°. Such references as tmsoccurin the litera:ure,but they are by no means comn on L d the fact IS not widely recognized. Fig>aentat!on.-An in.-rease in the skin pigment, partictdarly on the face, .s an occasional symptom in tuberculosis of tie periton um I was specially described by Gucneau de Mussy in 1879,^ but I remem: W m tlie session of 1872-73, that Sir Wm. Jenner at UniverUy College Hosp,tal, pointed out this condition as simulating Addison^ ^Transactions of the Pathological Society of London, Vol. xx, LtudeBurlaPignaentationdelaFacedanBlaTuherculoseabdo,nl„aire.PariM879. \m 11 ll ' I ! ^1 I u 12 disease in a tuse of extensive abdominal tuberculosis. It wa.s present in a marked dej^ree inCase VII,andI have seen oueother instance. In Case XII of Boulland s pajKir, the symptoms of Addison's disease were pronounced and, post-mortem, tubercles were found in the supm- renal capsules as well as on the i)eritoneum. 1 think the condi- tion may be present when tiie tubertdes are confined to the perito- neum, and an increase in the pigmentation does not necessarily mean that the adrenals are affected. II._TiiM()R Formations in TuBKRcrLAU Peritonitis. To the occurrence of tumor-like formations in tuljercular peritoni- tis we are indebted for much of the increase in our knowledge on this subject, as the errors in diagnosis have shown the frequency with which these tumors occur and also how amenable the condition is to surgical treatment. The question has not been fully considered by any recent writer, yet its importance may be gathered from the fact that in 96 eases in which laparotomy was performed, in 37 the diag- nosis was tumor, ovarian or otherwise. One of the best and most suggestive, and perliaps the first, of the papers to deal with this question was by Dr. W. T. Howard, of Bal- timore.' He reviewed the literature of ovarian disease with special reference to this point, and showed how little attention had really been paid to it ; yet, even in 1885, before laparotomy had become so common for iMjritonltis, he was able to refer to several instances In which the mistake had been made of confounding encysted effusion with ovarian tumor. As he remarked, the standard works on gyne- cology did not allude to the subjecit, and with the exception of a brief note in Kaulich's^ monograpli, there was no reference in general medical literature. Busey ' had previously reported a case in which an encvsted peritonitis simulated ovarian cyst, and Gardner* an in- stance "in which the diagnosis of a suppurating cyst was made. More recently Van der Warker* reported an interesting case and discussed the propriety of laparotomy in tubercular peritonitis. I Transactions of the American Gynecological Society, 1885. •Prager Vierteljahrsschrift, 1871. 'Gaillard'sMed. Journal, May, 1880. Quoted by Howard. ♦ Canada Medical and Surgical Journal, 1885. * American Journal of Gynecology, 1887. i. It was present )ther instance. In Addison's disease bund in the supm- tliink the condi- iied to the perito- t necessarily mean Peritonitis. iilxjrcular peritoni- knowledge on this lie frequenLy with the condition is to ully considered by lered from the fact cd, in 37 the diag- ips the first, of the r. Howard, of Bal- [isease with special itcntion had really jmy had become so I'veral instances in g encysted effusion H-d works on gyue- exception of a brief eference in general •ted a case in which id Gardner * an in- 3t was made, interesting case and tir [jeritonitis. ■d. I 13 tre^tmenf of^T'v"' "^"'^^''''^Ph^ ^"^ I-P^''^ on th. operative treatment of penton.t.s m recent French and German hteratnre I tliege tunior-like formations. We may ro<»g„i»,a„at„„,i™liy, and ,«ssil,lv ,.|i„™lly, f„„r ,,n„„« {(t.) Omental TnmorH. On the thin and delicate layers of ti.e epiploon hiher.les will be found If present at all on the peritoneum, but Jhev do not often -.n large masses wh.ch can 1. felt through the abdominal wall Tl" omental umor m connection with this form of peritonitis results from a s ow tulx-n-ular process whi.-h gradually puckers and r he membrane, nnt.l it forms an elongated firm m,iss attached t. d. transverse colon lying athwart the up,K. part of the abdonl Tins eond,t.on, perfectly well recognizcowels were ..hstinatelv constt pate.. On admission there was severe al)dominal pain'; dorsal decubitus, w.th knees drawn up ; pulse small and frequent ; tempera- ture normal ; t.mgue heavily coated ; abdomen distende,!, no flu<-tua- t.ou, no tenderness, except in the left lu.nl.ar region over the descending colon. Hoart and lungs negative. May ard. The .'ondition remaiiK-d praetieallv the same. Much pain and tenderness over the ab,lo„ien. A har,l tumor could be pkmly felt ,n the right iliac and huubar n.gions, lying .,uite to the right of the middle line. She was removed to a ,,rivate hospital and Dr. Gardner performed laparotomy. A large tubercular mass was found •n the omentum, occupying the position above noted, in some places It vvas adherent to the intestines. A fanval fistula resulted and she died of exiiaustion. Klebs • describes an extensive fibro-caseous thickening of the peri- toneum whieh in one ease formed a dense, opaque vellow mass a hands breath in width attached to the parietal layer' and stretched across the abdomen just below the navel. Such a mass miglit be readily confounded with an omental tumor. Fenwick savs ' that the thickened eapsule of the spleen may produce a tumor-like body in the eft hypochondriac region. More eommon I should think would be the tumors associated with thickening of the capsule of the liver to which he also refers. Here an exudation sa<-culat(.d between the capsule of an enlarged liver-and, as Striimpell notes, this condition IS not uneommon in tubercular peritonitis-and the anterior abdom- ina wall may produce a localized tumor of great distinctness. there might possibly be in tubercular disease a cystic accumulation within the layers of \\x^ great y the layers of the omentum. Obliteration of the fommen of Winslow by tumor or by chronic i^ritonitis has been followed by encysted hydrops between the epiplooic layers. ' Handbuch der Pathologischen Anatomie, Berii '369 "-^"^ ^^^- ..cit,p.338. !i*:l^ 16 (h.) S(tc<'i(lat<(l Kriuliidonft. Tlieso ivro the most cominuii, us tluy iirc undotihtcdlv tlu" moat puz/liii^ of the alxlominiil tumors prtKliu'cd hy tiilM-rciilous disciisc; so piizzliiijr, iiulccd, that, as a loii«i' list of cases shows in wiiicli the operation for ovariatomy has been porfonncd, the very elect among gyna'cologists may he deceived. In these cases a sero-tihrinons or pnrnlcnt exudation is conHned and limited hy adhesions formed between the inl<'stinal coils, the parietal peritonenm, the mesentery and the abdominal or the pelvic organs. What is felt as tumor may be entirely Huid or it may have an irregular nodular character from the presence between the (ioils of large caseous masses. These saccnlated tumors, due to tnberelosis, may, as in other forms of peritonitis, be met with in the npper, middle or lower abdominal regions. In the upper zone, which includes the stomach, liver and spleen, encysted collections of fluid arc extremely common. Thus, we have the localized peritonitis associated with gall bladder disease, and with varions affections of the stomach and of the liver and spleen. The effusion in these cases may be limited entirely to the upper region of the i)eritoneum. In the tubercular disease by far the most common sacculated exudation occurs here with peri-hepatitis, and as in the case of Emma G. (p. 99) over the surface of an enlarged liver, may lead to the suspicion of a gall-bladder timior projecting below the edge of the ribs. I think, however, from an analysis of the cases, that these encysted peritoneal tumors are less common in the upper abdominal region. In the middle zone, which includes the peritoneal cavity from the level of the transverse meso-colon to the false pelvis, and which embraces the omentum and intestine, these encysted tnmors are much more common and as the record of operations shows aie very fre- quently mistaken for ovarian tumor. In reviewing a list of such cases, it seems that they fall into two divisions, those in which the entire anterior portion of the peritoneal cavity was occupied by a large collection of fluid and those in which a more limited sacculated exudation was found on one or the other side of the abdomen or in the middle line. The following remarkable case reported by Gardner,^ of Montreal, illustrates the former :— ' Canada Medical and Surgical Journal, Vol. xiii. 17 A. IJ., HKi^l 23, nmnarricHl, was st-nt to hi,,, l,y Dr. |{,«s for .xain- •a -n, us .hen. l.a.l l,,... n s..s,.inon of p,..^..an<^. «,.,. ,.„,dX >u.., o, ,1... e, th. ten.pe,.atnre runnin. ve.y hiol. , he eent,v ot the anterio,- part of the abdonnnal wall aho. t tl.: navel ^0 was .ede.na and a ..l hh.sh. The diagnosis of snpp.^^i^^ ovanau eyst was ,„ade. At the ope.-ation, on ...achinK the perito- neum ,,o separation of parietal fVo.n visceral layer eo.dd he'n.ade The kn, e ente,-ed a eol eetion of flnid, passi,.g thn.n.h what seen.ed and „r.jrated ri,e gene.-al eo.idition improved for ten days The temperat...-e then .-ose and she d..veIopeen, and another small collection lay under the left lobe of the liver. On cnreful oxam.nation it was found that the anterior peritoneal cavity wa.s con- verted into a suppurating cyst, extending from the liver to the pube« Ihe pelvis wa« nearly filled by the globular mass referrc(J(i'''^s except the tnmsverHc colon, closely mat! "(1 top;cr of these cases the tumor is more localized and either lateral or central in position, and it may be quite impossible to make a diagnosis from developing ovarian tumor. The following is a case of the kind to v.liich additional interest is added by the gradual and complete disa])pearauce of the tumor. Case IV. — Ilfness Hitaulaiing typhoid fever ; development of an ab- dominal tumor which (p-adaalli/ disappeared. Rapid puhnonari/ iubercidosis. Early in November, 1884, T n-as consulted by a yoiing lady from Montreal, from whose statements and from the a i< n ' part of the |)eri- Ivis. It is intcr- ('l,at which point MU'lbrat'ons some- ian tumor arc not •asp descrihed by lorc localized and quite impossible '. Th(^ following is added by the npment of an ab- Rapid puhwnary yonn;^ huly from our' < t r phy- T was obtained : )mcwhat delicate, » fined to bed with ;ure ranged from stended. By the I the peritoneum, sisted in the left IS turned on her 76. 10 rijrlit side. The urine bc-ciirae very copious in amount, of low .iKnifie gravity— I OOr,. Tl,,. ,,,„.stion was discus,set, working its way up in front of the ululnn.ci,. ||.. pn.,li,.t,.l gradual absorption and m'ommendcd m.-isinn aiul drainage when tlw fluid iK-caiiic thi, kcncd Ihn.ughout Scptcmhcr she in,pr.>ved very miu-h and tl... .mor mined in SI... On S..pt,,nlK.r liOth, Dr. MacDonnell .x.te. tl.at beyond a doubt an cncystct disappear.^ :,nd there was lefl nothing moiv than an ..l.scnrc scum, of tidiness and thiek<.ning in tl... left side. I .ould scan-elv believe fn.m the exai, - illation that there had [...en the large tumor des..ri[)cd and sketched by Dr. MacDonnell. The lung symptoms were mark..! and the patient was raj.idly failing. She returned to her horn... and died in December. The majority of the eases in which encysted effiisiiais have been mistaken for ovarian tumor, have been of this kind. The exudation is sae(-ulat«l either between the intestinal coils, in ^vhich case it may be deep-seated and give only a sense of obscure fluctuation or, a> is mc.re usual, the parietal peritoneum forms the anterior wall of the sac and the collection simulates an ovarian cyst. Lastly, there are the sacculated exudations within the pelvis proper in which case the di.^ase almost always starts from the Fallopian tubes. The t.ibennilar process may l)e exi-liisively upon the parietal peritoneum and th<> .oils of intestines glued to the lateral walls may shut off completely the pelvic from the geni'ral cavity. (c.) Retracted and thickened intestinal coils. The matting together and thl-kening of several coils of the intes- tines may form a mass of great distinctness and even lead to the diagnosis of a solid iuiuor. This is most frequently met with in the 20 ^1 csecal region. They are not necessarily fixed tumors but may be freely movable as in Case IV of Spaeth's paper.' The following case is a good illusti-ation : Cask V. — Tumor in ric/lif iliac rer/ion, believed to he malifjnant. Gradual loss of jlexh and drem/th. Pain and diarrhosa. Tumor formed of inteMinal coih in ccceal ree/ion. Man aged 48. For twelve months he had had pain in the right lural)ar region and in the right groin. Micturition was frequent and he had occasional diarrho-a. He had not passed blood in the stools, and there liad been neither obstruction nor vomiting. There was a well-marked tumor in the right iliac region. Towards th entire coil inav form a iinn knot, lying do.se against the spine. WJion matted together l)v adhesions this coil of intestines may give on examination the i.lea of a solid mass. The foll.nving is a remarkable instance of the kind • ^ Sarah A., aged 82, admitted to the Philadelphia Ilosj.ital, December 22, 188 ^ with ascites, stated to be of several months duration. At first tiie effusion was nio.kn-ate but it increased so that tapping was necessary. Abu.it five litres of a sero-fib.inous fiuid ^^,.■c removed. The hver oonld not be f(>lt, bnt presented about three inches of vertical dullness in the nippk^ line. The spleen was not paljiable. After withdrawal of the fluid, a rounded, firm mass about the siz(, of a cocoanut, could be felt, and seen, in the central part of the abdomen. It was somewliat movable and a little irregular on tlu" surface. The fluid reacciimulated and she was again tapped and an eqnal amount withdrawn. The tumor was centrally placed, and so readily separated from any of the abdom- inal viscera that I tiiought it very probably of retro-peritoneal origin. The autopsy, January 20th, 1888, showed tlie ].eritoneum cov.^red with flakes of moderately firm ]ym])]i. The tumor was seen to be made up of the small intestine greatly shortened and thickened, the coils closely united with each other forming a mass the size of a lar-e cocoanut, closely adlicrcnt to the spine. It seemed scarcelv credible that the small intestine, even puckered and thit^kened as it was, should form so firm and so small a mass. The mesentery Mas very greatly thickened. TJiere was much pigmentation of the peritoneal coat, the muscular >vall was greatly tiii(;kened and the mucous mem- l)rane of the ileum was thrown into thick fokls, resembling the val- vuhe eonniventes. Tlie transverse colon and sigmoid flexure were much contracted. There was thickening about the ai)i)endix and in the mucous membrane of the ciecum there were two small ulcers. The liver presented senile atrophy but no (urrhosis. There was extensive perihepatitis. ^ ^', A 22 The other organs presented no special changes. Tubercles were not found, and the case appears to have been one of chronic peritonitis, starting possibly from the csecal region. A very similar condition to this has been found in the chronic tubercular disease. Some years ago I performed a post-mortem for Howard, of Montreal, on a woman aged about 3U, who had signs of chronic disease of the peritoneum with ascites. On t)pening the abdomen, the entire cavity ^vas converted into a large fiecal abscess. The anterior wall of the ciecum was completely destroyed by the tubercular ulceration and the fluid ftoces had passed directly into the peritoneal cavity. The small intestine formed a i)uckered and retracted coil which lay close against the spine, forming a firm bunch which, as in the other case, presented a strange appearance in contrast to the greatly distended peritoneal cavity. Prochownick ' reports a remarkable case in a girl of 16, who pre- sented in the right side of the abdomen a hard somewhat nodular tumor, which extended from Poupart's ligament to a point above the navel. ^Vt the operation the mass \\as found to be composed of the entire intestinal tract, from duodenum to the beginning of the rec- tum, united in a single coil, closely matted together and covered with lymphoid granulations. The coils may not form, as in these cases, a uniform tumor, but there may be a separation into three or four irregular masses, divided by fissures and covered with thick lymph. It is possible for the coil to form a resonant tumor ; thus Goodell writes that " in one of his cases of tubercular peritonitis the intestines were gathered up towards the sternum in a bag of false membrane, making a well-defined resonant tumor, which was very puzzling until the abdominal cavity was opened."^ (^een, even an acknowl- edged expert like Gairdner may l)e led astray. The lumpy, nodular character of the mesenteric tumors j^ives to them also a certain degree of distinctness. The mistake is sometimes made, nor do I think it can always be avoided, of confounding the large caseous nodules situated l)etween the intestinal c('ils with the mesenteric glands. The possibility of their re(!Ognition depends very much on the degree of distention of the bowels, as extreme tympa- nites may completely cloak a very large tumor of this character. The tumoi-s formed by contracted and thickened intestinal coils usually lead to error in diagnosis, nor do I see, save in most excep- tional circumstances, that this could be avoided. The recognition of the saciculai- exudation, more particularly its dif- ferentiation from cystic ovarian disease, offei-s really serious difficul- ties, the extent of which may best be appreciated by the fact that of 96 cases of laparotomy in tubercular peritonitis, in not less than 30 ovarian disease was supi)osed to be present. Such being the case, it may be worth while to discuss briefly certain diagnositic details. * New York Medical Journal, ii, 1889. 25 of the intestines, or when it is in (xiies or cord-like ilways feasible to e caseous masses ition of mesenteric L>r, in the lectures rtion of the cases enlargement and 3 French speak of eum. Jacobi has loi-s oil - difficul- rhe omental tumor ly other, but as an , it is not always ! elsewhere, to de- even an acknowl- c tumors gives to stake is sometimes f confounding the inal e((ils with the ition depends very is extreme tympa- his character, ed intestinal coils ive in most excep- )articular]y its dif- lly serious difficul- by the fact tliat of n not less than 30 being the case, it liagnositic details. There is no single criterion which enal)les us to say in a given case that the condition is one of encysted peritonitis, mlr indeed is there any special group of symptoms which can l)e r(>gard(. and strength mnv perhaps be taken into consideration, but it must not be forgotten tliat in many of the cases the patients have been r..bust and well-nourished. The mode of onset is in the majority of instances gradual, but tliis is such a variable factor that it is not of very much value ; perhaps the most which can be said on this point is that ther(> can usuallv be elicited a history of obscure abdonu'nal pains, irregular febi-ile attacks and alto- gether a greater degree of gastro-intestinal disturbance than generally accompanies the slow evolution of ovarian cysts. If the case has been under (.bservation for some time, the fever record should be of great assistance, as high or very low temperatures more commonly occur in this condition, though it is true that ia inflamed and snppu- rating ovarian cyst there may b(! fever of a hectic type. Second. The local physical signs. If possible, these are more deceptive than the history and symptoms. The question is not so much between the characters of a sacjculated exudation and ascites, but it is the extremely nice one of discriminating between two varieties oi sacculated effusion, ovarian and peritoneal. In typi- cal cases, the physical signs have conformrd in everv particular to those of cystica ovarian disease. There are a few" indications which may at times be useful ; thus when the sacculated tumor is limited and small the outlines may not be so dcHnite and clear as in ovarian disease. This is a point referred to by several writers. The position and fol-in may be variable owing to alterations in the calibre of the surrounding intestinal coils of which in part the walls are composed. At the periphery of the tumor irregular, nodular bodies —cheesy masses— may sometimes be felt, which in several instances have led to the diagnosis of malignant disease. Depression of the ¥ i--' i 1 V 1 : :i ' 1 • ! ■ ;'ii It , '.:l' i k '■ ■■' !' i < ■ ' 1 ' f i ' ' 26 vaginal wall is not a safe indication one way or the other, as I find the condition mentioned as present in ovarian tnmor as well as in encysted peritonitis. Third. In every case the condition of the tubes and of the lungs and uleura should be most thoroughly examined. The association of a tubal tumor with an ill-defined, anomalous mass in the abdomi- nal cavity should arouse suspicion at once. So also the evidence of involvement of the pleura or of the apex of one lung. It is rather surprising, in looking over the reports of cases, how little attention seems to have been paid to these most important and common con- comitants of tubercular peritonitis. III. — The Curability or Tubercular Pkritonitis. Until within the past few years, the general opinion in the profes- sion has l)een that this disease is incurable ; and in looking over the text-books of medicine, Avith but few exceptions — lagge a notable one — tlie prognosis is given, as in the words of Flint, "always fatal." Henoch,' in his admirable account of this affection in children, says that when recovery has followed in certain cases in his practice, he has thought the diagnosis incorrect, and that the peritonitis had really been of the simple chronic form. Yet there exist not a few reports among the older writers, indicating that a form of chronic peritonitis, not to be distinguished from the tubercular, did occasionally get well. More recently McCall Anderson,- of Glasgow, in a clinical lecture published in 1877, reported three cases illustrating recovery in tuber- cular jieritonitis. The history and the symptoms left no doubt as to the correctness of the diagnosis^ but the cases were regarded as alto- gether unitpie. Gee,^ in 1881, stated "that recovery from tubercular peritonitis is common." Gairdner* also has insisted upon the occa- sional cure in this affection, while admitting that there was a hiatus in our knowledge of the changes undergone in the progress towards healing. Ashby,® in his article on peritonitis in children, says "a large inunl)(>r of cases completely recover." Fenwick, in his recent lectures,*' s))eaks less hopefully of permanent cure. The evidence ' Vorlesungen ueber Kinderkrankheiten, 4te Auflage, 1889. 'Lancet, 1877. 'Lancet, Jan. 1st, 1881. *Loc. cit. ' Cyclopedia of Diseases of Children. Edited by Keating. Vol. iii, 1890. ' Loc. cit. ;he other, as I find umor as well as in es and of the lungs I. The association lass in the abdomi- i?o the evidence of lung. It is rather low little attention and common con- Peritonitis. in ion in the profes- n looking over the — Fagge a notable int, "always fatal." )n in children, says his practice, he has •itonitis had really t not a few reports chronic peritonitis, casionally get well. 1 a clinical lecture ;■ recovery in tuber- left no doubt as to ■i regarded as alto- ry from tubercular :ed upon the occa- there was a hiatus B progress towards children, says "a iwick, in his recent ire. The evidence « Lancet, 1877. Vol. Ill, 1890. I 27 has been rapidly accumulating to show that in a considerable number of cases, recovery in this disease is possible, either spontaneouslv or after operative interference. (a.) SponlaneoHx Cure. There is no inherent imj)robabih-ty why tubercles on the per- itoneum should not undergo involution as they do elsewhere 4na- tomieally the peritoneal growth bears in its evoluti.m a close analogy to the pulmonary, and tliife is still further borne out by the retrograde ehat.ges through whieli it passes. Just as the aggregations of miliary nodules in the lung may uiKlercussion wave. Neither liver nor spleen palp:il)l('. Area of liver dullness diminished; two inches of vertical splenit; dullness." The case was regarded for a tiine as on(! of ordinary tympanitic distention, associ- ated with sluggish and constipated howels. The jx-rsistent elevation of temperature ranging from 99° to 102° and slight tenderness in the flanks, with recurring night sweats, aroused a suspicion of tuhercular trouble, but the examination of tiu! lungs was negative. Throughout the month of February, there was a daily elevation of from 1 to 3 degrees ; he lost Hesh and began to cough ; there was, however, no expectoration, but examination determined a few scattered rales, most marked at the left apex, behind. During ]\[ar{;h he continued to lose in weight, the sweats were less troublesome, the temperature rarely rose above 101° ; the condition of the abdomen remained the same ; there was slight tenderness in the flanks ; no dullness ; measure- ment about 75 cm. ; no signs of effusion could at any time be discov- ered ; the local disease had at the left apex behind become more marked, the breathing was slightly tubular and there were numerous mucous rfdes. The constipation remained a marked feature, the bowels were never moved without a purge or an enema. He gradu- ally failed without any further development of the pulmonary symp- toms, and death occurred on the 19th of March. The post-mortem showed disease of the left lung, partly old, with slight fibroid change and many recent tubercles and eheesey masses. In the abdomen, the peritoneum was obliterated by imivcrsal adhesions between the layers. The coils of small intestines were united together by old fibrinous bands ; here and there in the adhesion were pigmentations and small, hard, dark tubercles, Nimierous adhesions existed over the liver, uniting it strongly to the diaphragm, and in these, too, there were many old fibroid tubercles. Here the peritoneal disease was practically cured, but the ill effects remained in the weakening of the intestines. The pulmonary not the abdominal affection caused death. Similar ca.ses might be drawn from the records of any path- ologist of large experience. In Cases XIII and XIV of my series, 2{» .special rcsiataiK-e ; ■ Hanks ; in i Iliac ess, no |)ertMis.sion of liver dullness IS. I lie case was distention, assoei- )ersistent elevation t tenderness in the icioii of tuhercular :ive, Throiil(niro-peritoneal membranes, there are at least t\ventv cases of peritoneal tuberculosis in which recovery took place. He places the number of recoveries much higher than this, but I have excludcKl many doubtful cases on his list. In many instances, of course, this may have been only a temporary improvement, iiut in three> instances quoted from Buequoy, the good health persisted ten, twelve and sev- enteen years after recovery. The subsequent history of operative cases removes all grounds for skepticism— reasonable perhaps a few years ago— as to the genuineness of these cases. One of the most interesting of the cases quoted by Boulland is from Louis. A man aged 24, with great enlargement of the abdomen, signs of pleural affection and extreme marasmus, was attacked with Asiatic cholera. He nearly died from the excessive purging, but the abdominal effu- sion disappeared and he ultimately made a good recovery. In read- ing the details of the long list of cases given uy Boulland, one receives the impression that the cure of tubercular peritonitis cannot be a very ' Loc. cit. 4' ( \ 1 1 ;f ■ i f H ^ ,1^ ' 1 ^ 1 if Jm i 1 ■ ii IB '^ ^/M i , III j^ 30 iiiHMmtuoii event, ('use ITI, to whioh [ have already referred, as siiniilatinjf ty|)h()id, is an illustration, I have no doubt, of a elinieal group by no means rare. The following is an interesting example of marked improvement in, if not aetiial healing of peritoneal tuberculosis : Case VI I. — IILstori/ <>/ >in olm-urc ahdominal ajfirtioii irlthfci'cr and /».s,v qffloili. irnidnal liiiprooriiient. lU-dcJined ahdomhud tainor. Local disaiHC of fhe luu;/f*. Pifpncntation of flic skin. Marked, iiiiproremrnf. A. B,, aged 31, merchant, admitted to the Johns IFopkins ITospital May 18th, liS(S}>, complaining of swelling and distress in the abdo- men, with weakness and loss of Hesh. Family history is good. Father and mother living and healthy ; two brothers living; two sisters died when children. He had dysentery 15 years ago and with that exception has always enjoyed good healtii until October, 1888, when, after exposure to cold, he hiul an attack of obscure trou!)le in i'.c abdomen. There were swelling, tenderness and a sense of distension and weight, par- ticularly in the region of the liver. There was no diarrhcca, rather constipation. Me lost Hesh and became extremely weak. At Christ- mas he \vas up and about, and in January attended to his business. The strained, distressed feeling in abdomen ))ersisted. Throughout Februaxy and March he remained pretty well, though far from his usual condition of health. The swelling of the abdomen subsided greatly. Early in ^\.pril the distention increased again so that he could not button his trousers, but he had neither pain, diarrha>a, nor fever. He again lost Hesh rapidly. Condition on admission: Large boned man, 5 ft. Ill in height; marked emaciati(m ; orbital fat much wasted ; eyes sunken, with deep, dark rings about them ; cheeks very hollow. The forehead, cheeks and (shin were distinctly pigmented ; this darkening in color he had noticed gradually coming on since October. The skin of abdomen and backs of hands were also pigmented. The chest was large ; ribs prominent. P]xpansion was deHcient at left base. Percussion was clear with the exception of the left base, where the resonance was slightly defective and here fremitus wa.s diminished. There v.'as also slightly defective resonance at right apex and the right clavicle was more prominent than the left. On auscultation there was feeble breathinir rciuly reterntl, as oiibt, of a clinical •cstinj^ example of oneal tuberculosis: tion wUh/enr (tnd abdonibuil tiunor. 'he xk'm. Marked IFopkiiis I lospital tress in tite ubdo- /in^ and healthy ; ■(>j)tion has always after exposure to abdomen. There and weight, par- > diarrhrea, rather k-eak. At (.'hrist- ed to his business, ted. Throughout )ugh far from his abdomen subsided again so that he lin, diarrho'a, nor ft. Wl in height; sunken, with deep, 3 forehead, cheeks ■x, in color he had skin of abdomen ■^t was large ; ribs Percussion was nance was slightly 3 v/as also slightly lavicle was more s feeble breathing 31 with fine nlles in tiie lower axillary and infra-scapuhir regions. The contra.st between the two sides was most marked. At the right apex there were moist soimds heard just beneath the clavicle, and behind in th(! upper part of inter-sca])ular area. Abdunien was moderately distended, uniform. Xo fluid dise<.ver- able. Flanks were tympanitic. The resonance was defective just below and to the hjft of the navel, in an areaeipial in si/eto the palm of the hand. On palpation, no tenderness, but in the region Im'Iow and to the left of the navel there was an ill-defined, tumor-like nniss, r&sistant, not painful but slightly tender on deep pressure. It was readily separable from liver and spleen. Helow, the margin was well defined, Fiiver dullness not increased. Kdge of spleen not pal pal )le. In- guinal glands not enlarged. \o tgions. The temperature was subnormal. Trine negative, not increased in amount. He luul slight morning exixrtoration, nuico-purulent in character, which did not contain tub.iHMl health prrsistcd. The attack in 18MS, with swllino. and tenderness „f the alulon,..,, and lossot MeHh, was, without .,ne.stion, I shu.dd huv, tiii.erenlosis of the pentonemn. The exist.-ne.- ut' tl... tiimor-Iik,: mass, fh,. snb- mmnal t,.m|.eratnre,.nrv<., the si.rns of inv..lv,.ment of the plenraand of th.. Inn^', the dillus.. |.i-m<'ntati<.n— all point to t!,e exist..|i(.,. of tins atleet.on. The st.ikiiijr in.p,ov..m..nt u hi..h ....ewiTed throuc-hont May an.l .lime has persisted, and I see no reason why a permanent ••ure shonid not be established. The ni the fondi- ion was with- it last report, good health, is and manv 33 8nhMM,u,.nt cases, was advoeattd strongly l.v nej.ar ' and hy Koenin" in (i.rinany, l.y I.awson Tait in Kiij-lund, and lias >inee been pnu- ti.rt..n, .M,in(le..f New Y..rk, (;,m„|,.|| of I'liiladelpliia', Krils of Baltinn.re, (Janliier of Montreal, and others. In two eases reeently under tivatnient in the Hospital, laparotomv has been performed, in one i;,r tnberenlar peritonitis, thon^di a .lo.ibt existed whether (.r not a tumor was pres.-nt ; in the other an ovarian tnmor was found aeeidentally to be eumplieated with a latent perito- nitis, '{'he first euse pivs..nts ieafiires of very special ii.teiv.t, as rapid amelioration Ibllowed the removal of the fluid, uhile the death fr.mi acute disease, after .onvaleseen.v was established, enabled ns to stialy the ehanoes in the peritonenm which are associated with the healin.r of tiibcnuilar processes. " Cask V [ I l.—llidnry of olm-nre alulumliHil lrna/>/r for .srrcmf. nwul/ti^; acute rwarerbaflon wit/, hhjl, /,,vv. IhuUful' ahdonunal tnmor. Laparotnoii/, dnrnuujc ; mphl Improvement, nisrhnyed, fer/hu/ well. RetarH with acute pne.vmo,il,i, death. Chronic tuh'erculnr peritonitis in proeexn ofhealin;/. S,,philix of rectum. A m,/loid lira; Emma G., i- 28, admitted August 28th, complaining of pains in abdomen. ^ Father and i.K.ther probably liv-'ng, one bn.ther and one sister living; tw.. sisters and two bn.thers d with weakness and shortness (.f breath. Her present trouble began aln.ut six tncmths ago with swelling of abdomen, which has been variable in extent and has on several occasions almost dis-' aj)|)eared. She has generally been constipated, lia.s been short of breath and has had palpitation of the heart. She had been working up to a few days before applying to Hospital. On admission the fol- lowing note was made: "Temperature 101°. Patient is a well- ^! ' Loc. cit. •Centrulblatt fur Chururgie, 1884. # i 1 1' i h 34 grown, not emaciated woman. The tongue i.s coated white. The abdomen ,s ,nuch distended, measures 86 centimetres; it is symmet- ncal, extremely tender to toneh in the npper zone, particularly below he r,o-ht ,<,stal n.argm. Ti.e lower zom- is more flaccid and less <;nder. ()„ percussion, ^^•hen lying on back the flanks are dull, um- l.ihcd region resonant; on changing posture, flanks become resonant an. the fl,neritoneai growths. ' The temperature on the evening of the 4th w i- ' 04° She rallied well from the operation. The temperature fluctuated from 99° to 102 until the 14th, when it fell to 98°, from which date until the 30th the range was from 98° to 100°. Her general condition im- proved very rapidly and she was up at the end of a mouth She had no cough and expressed herself much better. She was about the ward, and ed. The intestines eum presented lid then washed iuation by Dr, the ])eritoneal ^ 8he rallied i from 99° to date until the condition im- month. She was about the oi)ei-ation, the s good ; she is 35 up every day ; the abdomen is still a little distended, and on palpation is tender on right side, and there is here l)etween costal margin and illiac region a well-deflned firm swelling, slightly resistant and very tender. On percussion there is tympany in umbilical and left lateral regions almost to the back ; to the right there is dullness from 5 cm. beyond the navel. On firmer percussion flat tympanv can be elicited except in the extreme right flank where it is dull." She continued to improve through November, and on December 12th she was dis- charged. The following note was made : "Patient wont out to-day feeling quite well. All signs of tumor have disappeared ; the abdomen is soft, but in the right hvpochon- driac region a little more resistant than elsewhere ; here, "too, it is now tympanitic." The temperature had been normal and sub-normal for weeks. The patrent was re-admitted January 8th, with lever and urgent dyspcona. She stated that she had been at work since her dis(;liarge. On December :]Oth, she had a slight chill, followed by fever and cough. On January 4th, she had another chill, with quite' high fever, and°on that day went to bed. (Jn admission her temperature was 102°, res- piration GO, pulse 120; physical signs showed an extensive area of consolidation in the right lower lobe, which extended anteriorly to the nipple line and as high as the fourth rib. The sputum was muco- purulent, a little blood-tinged and contained numerous pneumococci but no tubercle baccilli. The abdoiuiui was not specially distended, but was quite tender in the upper zone. On the 11th and 12th she seemed bettei- but the physical signs persisted. Tem].erature was not high, never reaching above 102.5°. ( )n the 14tli, she passed blood in • the stool, and in the evening she had a i)rofuse hemorrhage from the bowels and died at 10.20 p. m. The following is a condensed report from the autopsy record by Dr. Councilman : A well-built, wi-U-nourished woman. " A smooth cicati-ix extended diagonally across the abdomen, 14 cm. in length. Pigmented macular scars over flu entire body, more marked on the anterior stu'face. Peritonemn adherent to anterior abdominal wall over the liver. A few slight adhesions with the omentum. ^Fhe adhesions over the liver if f I' 36 wcro firm, and contained :i i> good deal of fat. Here and th (ire in the udl.esmns wore firm, wln-tisl, nodnles, Mhiel, varied in size from a pin's iK'ad np to 3 mm. in diameter. The omentum was thickened, its nm)er snrtaee smooth, its lower surface covered witi, numerous small, up to 2 mm. m size, firm, nodules, especially numerous along the thick<.ned ... er.or horder. A[ost of these were pigmented. No adhesions between ,nt,.st.nal coils. Over peritone.1 s.u-face, n..merous small, hvm nod.des slightly pigmented. Many of these were seated flat on tlie peritoneum, others in small connective tissue bands, attached l)v one cud to the serous surface. The tubercles were generally seated at the cue of these. They extcndc, but were most numerous or .0 cm. above the valve. The large intc.stine on its surface con- tained very tew of these nodules. The mesentery contained numerous tubercles, partly seated on the membrane, partly along the intestinal border, ,,, a f(.^v places matted together. The surface surroundii... them WMS thickened and puckered as though from slight cicatricial tormation. Nearly all of these contained in the tubercle dark pio-. ment. The posterior surfao cont^iined a few, and gen.Tally smaller tul)ercles than on the omentum. In the right pleural sue, 400 cc. of purulent fluid with flakes of tiDrin Ihe pericardial membranes were adherent, slightly thick- ened but presented no evid.mce of either tubercle or caseation. The heart showed no S})ecial changes. Lungs. The left was bound down by old, tol,>rably firm adhesions. Ihe tissue was crepitant. Muco-pus could be squeezed from the small bro.u.hi. Right lung slightly adherent at base, somewhat c-om- pressed by the pleuritic exudation. The entire pleural surface cov- ered with fresh exudati.m \\hich (,ould be stripped off. The lower lobe, the middle lobe and part of the upper lobe were solidified. Cut surface smooth and reddish in color, and from it a reddish fluid coi.ld be squeezed. The posterior parts of the upper and middle lobes were grayer in color than elsewhere. Portions excised sank in water. 1 he bronchial glands large, pigmented, not caseous _ Liver was large, weighed 2910 grammes; the entire surface, espe- cially the upper, was covered with adhesions, in which and in tlie capsule there were numerous tubercles, either single firm nodules or flattened masses. Even when these were apparentiv situated in 37 and there in the 1 size from a pin's ifikeiied, its npper rons small, up to •ng the thickened i No adhesions numerous small, ^re seated flat on nds, attached In- Mierally s(>atcd at same frequency, most numerous its surface con- tained numerous ig the intestinal ace surrounding slight cicatricial )ercle dark pig- encrally smaller ! with flakes of slightly thick- :'aseation. The firm adhesions, eezed from the somewhat com- al surface cov- ff. The lower kvere solidified, a reddish fluid er and middle ixclsed sank in Lseous. 3 surface, espe- ich and in the ! firm nodules tly situated in the liver surface they could be stripped off with the capsule, which was very much thickened. In reality this was not the capsule, but a thickened and newly formed connective tissue membrane over the entire organ. _ Spleen. Capsule slightly thickened and presented numerous adhe- sions, in most of which were small nodules. Kidneys showed no special changes. The mesenteric glands were enlarged,firm, whitish- gray in color, a few of them slightly pigmented. Xo caseation. No tu!)ercles. Small intestines showed no special change. In the rectum there was a loss of substance encircling the entire bowel with nuich cicatricial tissue about it and two recent- looking, deeper ulcers from which apparently the hicniorrhage had come. No tuberculosis of the tubes. The microsco])ical examination showed the liver to be intensely amyloid. The tubercles in the peritonetnii were composed of num- bers of sub-miliary nodules, very iibrous, containing few cells in a firm tissue. In the middle of the masses, giant cells with mural nuclei and fatty granules: no caseation in the nodules. Tubende baciilli were very al)undant. Tliis case presented in turn many points of interest to the physi- cian, the surgeon and the pathologist. In the first place it is a good example of primary tuberculosis of the peritoneinn ; not even in the pleura or pericardiinn, both of which showed old adhesive inflam- mation, were there granidations, and a most rigid search failed to find tubercles elsewhere. Surgically, the operation was a success as the symptoms were relieved, the general health improved and she left the Hospital looking and feeling well. Then the accident of an acute pneumonia gave an opportunity of studying the condition of the peri- toneum four months after an acute; exacerbation and showed the tubercles undergoing fibroid change but still retaining their charac- teristic structure and still very rich in bacilli. The t)ther case illustrates the latency of peritoneal tuberculosis and the I'xtent which it may reach before inducing serious symptoms. Case IX. — Gradual swcUim/ of abdomen ; tumor on left side. Ova- riotomy. Krtemive tuhercnlar peritonitis ; recoDen/. Bridget N., age 42, admitted to the gynax^ological ward October 17th. Married 19 years, has had 8 children. Has been ill, IIP l! year!! on and iphflMPTO 38 oft, ever amve the birth of her last child 5 years ago. Has had met- rorrhagia. She has had successive attm^ks of abdominal swelling, and within the past year has noticed a lumi) on the left side, which has gradually grown larger, and it is for this she sought relief. On inquiry she states that every winter she is apt to have a cough, and has had pleurisy on the right side. Her mother died of pulmonary hemorrhages. Other members of her family healthy. Dr. Kelly operated October 18th ; i-enioved a tumor of the left ovarv, the size of a cwoanut. On the right side the ovary was as large as a lemon, cystic and the tube greatly dilated. The ovarian tumor and the entire peritoneum, visceral and parietal, were (u)ver(!d with miliary tubercles. The intestines were in places matted together. There were 500 cc. of fluid in the peritoneum. The tubercular nature of the growths was demonstrated microscopically. The nodules were firm and hard, some of them pigmented. She did well after the operation and was sitting up out of bed by the 6th of November, with the wound perfectly healed. The t(>m])erature ranged for the first ten days from 98° to 100°. After the 28th the range was be- tween 98° and 99.5°. On Dec. 18th the following note was made : " She has gained in flesh and looks well. Tiic abdomen is a little distended but is not tender and there are no signs of ett'usion. There are dullness, nlles and feeble breathing at the base of the right lung where she has had pleurisy. The apices of the lungs are clear." The statistics showing the results of this operation have lately been collected by several writers, particularly Kuemmel ' and Maurange.' This last writer has made an elaborate analysis of the cases re- corded to date, seventy-one in all, with the following result : There died ailer the operation, six ; by generalizaticm of the tubercle, seven ; there recovered sixteen teases, of which no further mention than this i^ct was made ; fifteen (-ases were alive at the end of six months, and twenty-eisdit cases had survived a year. Of the American cases, Maurangc includes those of Homans (3), of Van der Warker (1), Morrill and Bradford (1), Cabot (2), (ioodell (1), and Bruen (1). To these I can add the foD-wing cases. Goodell writes 3 that he has operated upon four cases, in i\V. of which the 1 Arohiv. f. klinische Chirurgie, 1888. Bd. xxxvii. ' These de Paris, 1889. " P"vate letter, Nov. 28th, 1889. 39 0. Has had met- lominal swelling, e loft side, which ;oug;ht relief. On lave a cough, and ied of pulmonary ly. tumor of the left ! the ovary Avas as ;ed. The ovarian etui, wei-e (;overed 2S matted together. > tubercular nature The nodules were iid well after the 3th of November, irc ranged for the the range was be- g note was made : abdomen is a little of ett'usion. There ! of the right lung lungs are clear." on have lately been 1 ' and Maurange.^ s of the cases re- ana; result : There -he tubercle, seven ; • mention than this nd of six months, )se of Homans (3), ,Cabot(2),(;oodell ing cases. Goodell n all. of which the Nov, 28th, 1889. ascitic fluid was recognized, but in addition ovarian disease was sus- pected. In none of the ''ascs were the tubes or ovaries diseased. So far as he could ascertain, all of the cases got well. One of them, however, after six months excellent health, returned w itli a i)elvic tumor and ascites. She refused an operation and is now probably dead, Mundc writes' tliat \w has operated on three cases, in all of which there was as(!ites, and the diagnosis of obscure tumor was made. In one case the patient recovered Irom the operation and died two months later of pulmonary disease, wliicli was not evident at the time of the o])eration. In the other two cases, the recovery was tem- jwrary and they died afterwards of exhaustion. In ail three, a distinct abdominal tumor appeared to exist; in two general, in tiie third in the left ovarian region. Thei-e was no doubt in any of the cases as to their tuberculous nature. Kelly has operated upon four rases.- The first case was in 1880, There was temptjrary im])rovement. Some njonths after a second operation was i)erformed. The patient is at present alive and w(!ll. The operation in this case was performed for tubal disease and peritonitis was found. In the second case there was no definite diagnosis but a tumor mass was evident. An encysted pui-uJent peritonitis was found which was drained. Patient recovered tem- porarily and died one year afti'r of phthisis. In the third case, the diagnosis was a parovarian cyst. The first operation was in May, 1889. The al)donien was drained, improvement followed for a time, but the fluid re-aceumuiated and on three subsequent occasions, at intervals of about six weeks, the peritoneum was incis(!d and drained. At the last operation the tube and ovary of the right side were removed, Tlie patient is still under ol)servatiou and has evidence of some fluid remaining in the peritoneum. The fourth cacic hits already been referred to, in which the tubercular disease was found as an acciderital complication with an ovarian tumor. Homans' ^ fourth case, operated upon March 19th, 1889, left the Massachusetts General Hospital in June (piite well. His second case, included in Maurange's statistics, operated upon April 20th, 1887 — referred to at page 44 of his statistical account of three hundred and :ii:;l ■n ' Private letter, Nov. IStli, 1889. * From notes given by Dr. Robb. 'Private letter, November, l88!). 1. , t - I -« p I - II f h .J- 40 forty-four laparotomies'— is of great interest, as Dr. Cutler examined the peritoneal growth and found it to be tubercular. In :May, 1889, more than two years after the operation, she remained perfectly well. Two eases operated upon by Gardner, of Montreal, have already been referred to in previous sections of this paper (pp. 80, 83.) H. P. C. Wilson, of Baltimore,'^ has operated upon one ease in which the disease was thought to be a cystic ovarian tumor. The entire peritoneum was studded with miliary tubercles. The patient recovered from the operation but died six months attcrwai'ds. Dudley, of Chicago,^ operated upon one case in 1884. There was d(juble ovarian disease as well. She recovered but a fistula remained. Death occurred in 1 888. G. E. Shoemaker ' reports a case of recovery. To these t-ases, tor statistical i)urposes, may be added the four reported by S])aeth,' as they are not referred to in :\Iaurange's paper. Of these, one died after the operation ; the second, three months after of acute phthisis; the third, four months after of tuberculosis of the intestines, and the fourth, at the time of report, had intestinal disease. M. Schmidt*' has reported two cases, one of which recovered com- pletely and was well more than a year after the operaticm, the second was benelited temporarily but death occurred five mcjiiths after. Imlach^ states that he has had five cases, all of which had resulted in api)arent cure. ( )f these additional twenty-six cases, the results cannot be said to be on the whole so satisfiictory, as fourteen cases were dead at the time of the report, one of an intercurrent pneumonia. The majority of writers on the subject speak hopefully of the oper- ation in suitable cases, and from what we know of the natural history of the disease and from a study of the cases in which laparotomy has been performed, whether specifically for tubercular disease, or by acci- dent, w^e may regard it as not only justifiable but urgently indicated in many cases. Secheyron^ concludes from an analyses of forty-two <'ases of lapa- ' Boston. Sawyer & Sons, 1887. '' Private letter, Nov. llth, 1889. 3 American .Journal of Obstetrics, Nov., 1889. ♦Medical and Surgical Reporter, April 13th, 1889. s Loc. cit. " Centralblatt f. Gyniicologie, 1889, No. 32. ' British Med. .lournal, Dec. 14, 1889. sNouvelies Archives d'Ohst/.trique et de Gynecologie, No. 11, 1887, quoted in American Journal of Obstetrics, Vol. 21, p. 447. 41 Dr. Cutler examined lar. InMay, 1S81), lained perfectly well, lutreal, have already ;r (pp. 80, 83.) id upon one ease in varian tumor. The •ercles. The patient IS att(>rwards. in 1884. There was Lit a fistula remained, rts a ease of rec;overy. • be added the four in INlaurango's paper, d, three months after )f tuberculosis of the lad intestinal disease, hich recovered com- op(>ration, the second 1 live months after. [' which had resulted ts cannot be said to be ^ere dead at the time lopefully of the oper- of the natural history ivhieh laparotomy has lar disease, or by acci- )ut urgently indicated rty-two cases of lapa- ir, Nov. 11th, 1889. macologie, 1889, No. 32. ', No. 11, 1887, quoted in rotomy, that interference is not called for in the acute or chronic dis- ea.se when generalized, whether with or without sero-pnritlent effu- sion, and thinks that the operation is only called for when symptoms of strangulation or of jjcrforation of the intestines appear. lie acknowledges that encysted tubercular peritonitis calls for surgical intervention as the (-ondition is really one of cold abscess. Spaeth, too, does not write very encouragingly, but in a disease heretofore believed to be incurable the statistics of Maurantre show such a percentage of recoveries, that wc may place the operation among the triumphs of recent surgery. Two questions remain for consideration, what cases are most suit- able for (operation, and how can we explain the beneficial influence? Undonbtcdly the cases of the first group, those with fresh eruption and considerable effnsion, whether free or sacculated, offer the best chance of recovery, as the disease is more likely to be primary in the peritoneum, the general condition is usually better, and the subse- quent chances of general infection are much slighter. When the Fallopian tubes are extensively diseased, and when the j)rocess has extended through the diaphragm to the pleura, the (condition is of course less favoi-able. The e::istence of marked omental tumor, in the form of a ti-ansverse ridge, need not necessarily be an objection to operation, as we have seen that in two of (xairdner's cases, si)onta- neous resolution of snch ma.ssestook place. In cases then with some- what sudden onset, rapid development of ascites with fever of mod- erate grade, we may be most sanguine of sncccss. In the class of i-ases with extensive ctiseous masses in the perito- neum and a purulent exudation, the outlook is necessarily less hope- ful, but even in such instances, particularly when the exudation is sacculated, la})arotomy may be advised as a palliative measure. In the chronic adhesive form, no benefit could be expected to fol- low the operation, which could (^idy be intended to remove an omen- tal mass or to oj)en a sacculated effusion. In the majority of the cases of this group nature is effecting a cure in which she scarcely needs outside assistance ; and the danger lies not so much in the peritoneal disease as in the risk of pulmonary affection. If i|: 18 It is difficult to exjJain the beneficial results of the operation. It interesting to note that not alone in tubercular {xjritonitis, but i in 42 other forma with effusion, the simple opening and drainage of the cavity has seemed to exereise a very benefieial effect on the subsequent course of the disease. Tims, Homans reports a case' in which an exploratory laparotomy was performed in a woman, aged sixty, with enormous ascites: Forty pounds of fluid were n-moved and a soft tumor was found attached to the sacrum and right ilium The abdo- men was sponged out and sewed uj), as it was found impossible to remove the tumor. The i)atient i-ecovered rapidly, was greatly relieved and the fluid never re-accumulated. Death occurred a ye^r subse(piently, and at the auto])sy a sarcoma was found fdling the pelvis. This would indicate that the thorough drainage of an ascites, even of enormous extent, may so alter the condition of the pcritonenm that the fluid is not re-formed. More remarkable still are the eases which indicate that the mere opening of tlie al)dominal cavity modifies in some way the develojiment of new growths. Gairdner states" that Sir Spencer Wells informed him of a case of apparently cancerous peritonitis, in which, after an exploratory incision, the symptoms subsided and the woman got well. Mr. Lawson Tait^ comments at some length on this remarkable tendency of abdominal neoplasms to undergo retrograde changes after an exploratory incision. His statements on this point are most interesting and deserve the careful consideration of physicians as well as surgeons. He says that he has seen tumors disa])pear atler laparotomy in cases of dis- ease of the liver, spleen and head of the pancreas. He does not specifically mention cancer of the peritoneum. His remarks deserve quoting, as they bear directly upon this subject. "The cases are far too numerous, and the results indicate se- quence far too clearly, for us to dismiss the phenomena as a mere coincidence ; nor can we accept the explanation of subsequent medical treatment as having brought about this much-desired ending. I am satisfied that the mere opening of the peritoneal cavity has a direct influence in setting up the process of absorption of the tumor, and my ectnviction in this direction lias increased my confidence in the principle of exploration. That some emphatic physiological change is at once set up by opening the peritoneal cavity is clearly » Loc. cit., page 40. * Loc. cit., page 46. •Edinburgh Medical Journal, Nov. and Dec, 1889. 43 11(1 drainage of the •t o» the siibseqiiont 1 case ' in which an an, aged sixty, witli •cniovcd and a soft ilium The alido- ound impossible to pidly, was greatly ath occurred a ye^r IS found filling the ainage of an ascites, in of the peritoneum >lc still are the cases linal cavity modifies Jairdncr states'" that pparciitly cancerous sion, the symptoms Tait^ comments at )minal neoplasms to incision. ng and deserve the surgeons. He says my in cases of dis- reas. He does not lis remarks deserve results indicate se- enomena as a mere tiou of subsequent luch -desired ending, itoneal cavity has a ptiou of the tumor, d my confidence in )hatic physiological ml cavity is clearly ge 46. i indicated by the uniform onset of a most distressing thirst, which lasts (or days, and is not seen so markedly after any other operation known to me. lict the incision in tiie abdominal wall l)e made down to the peritoneum, but let the serous envity remain unopened and this thirst is not marked. 15ut let the peritoneum be opened but a finger's breath and the result is marked. Tliat a tlieraiieufie change is effected in tiie peritoneum itself by the mere opening of the cavitv is now universally recognized in the treatment of what we call tuber- cular peritcmitis by abdominal sei^tioii. I have now had a large experience on this ])oint, and can say ])ositively that we can cure permanently and spoeeritoneiim died six mouths after the operation, The autopsy showed that the effusion had not l»een reju'odueed and that lieaiing had occurred. A third ease of Ahlteld's' is still more interesting, in wliidi ho found, diirini;' the perfornianee of Freund's operation, the [)eritoneum eovered with }rranuhition.s. At the aut(tpsy, a year and a halt' after- wards, there was no trace of the tubercles. iSovcral views have been advanced in r'xphunition of the beneficial effects of the operation. Thus, Cameron, of Iluddersfield, thinks that the curative action is due to the removal of the ptomaines which aceiimidato in tiie ascitic; fluid and the absorption of which is res])un- sible for the constitutional disturl;ance. I'ossibly it may be by a reduction in the activity of the inflamraator. ])rocesses about the tubercles, wliich some have sup[)osed are kept up and eneourajied by the ascitic fluid, but it is more reasonable to su])pose the existence of the latter to depend upcm the activitv of the former. I scarcely think we are at pres(Mit in a position to give a thoroughly acceptable explanation why incision and drainage should in thes(^ cases of tubercular and other neoplasms so remarkably inhibit the growth and often induce retrograde curative changes. Are all oi ihese cases of cure truly tubercular ? Spaeth" raises this question and throws doubt upon the diagnosis in the absence of the proofs afforded by the discovery of the bacillus, or the infective nature of the growths as demonstrated by inociulation. I cannot see that in practice this is an entirely forcible objection ; for, as a rule, the peri- toneum is the seat of miliary and nodular growths in only two affec- tions, cancer and tubercle — the former a very rare, the lattei- a very common occurrence, and without histological examination, it may be impossible in certain (aises to say which of the two conditions is be- fore us. Spaeth makes the interesting statement that there are numerous ca.ses of other chronic diseases of the peritoneum which, at first glance, look like tuberculosis, but which on examination prove to be simply chronic peritonitis with nodular thickenings or lymphoraatous growths. ' Quoted by KuemnieJ, from Deut. med. Woch., 1880. * Loc. cit. notlicr case, also iiiid (iiluM-flcs in »ii. 'Pile autopsy and tliat licaling iii}f, in wliitli ho >ii, tlic pc'iiloiu'iim and a hall' uf'ter- II of tlie bi'iioticial (Idorsficld, thinks ' ptomaines which t" wliich is rospou- V it may bo by a •ocosses about the ind onoourajjjed by so the existence of rmer. I scarcely oughly acceptable in these cases of nhibit the growth Spaeth^ raises this he absence of the le infective nature (jannot see that in IS a rule, the peri- in only two affec- (, the latter a very i nation, it may be conditions is be- lere are numerous ich, at first glance, jrove to be simply horaatous growths. * Loc. cit. i My colleague, Dr. Welcli, iiif<.rms me that his experience coincides witli this, and thai there is a form ..f chronic peritonitis, usiii.liv a.>^sooiated with nnieh olliision, in which the p<>ritoneiim is studdeil with fibroid or lymphomalons nodides. lb' has, in Flint's Practice (Otli Edition, iSM(i), de,-cribcd these; nodules as occurring in chronic serous ])eritoiiitis luid speaks of the didicidty in the diagnitsis l)e- tweeii this condition and liil)ercular peritonitis. The point is one not often referred to l)y patholdgists. Birsch-JIirschfeid ' speaks of fine libroiis nodules occurring in large lunnbers on the peritoneum in chronic iuHammation, similar to those wliieh are seen U})on the jjlcura. Kokitansky,- t(M), speaksof papillary fibrous growths of sub-serous connective tissue as a result of hyperiL-mia of the peritoneum. IVochownick,'' in a paper upon la|)arotomy in chronic peritonitis, has some very interesting observations upon this subject. Two of his five cases wort; regarded as tuberculous until an examination was made. In the first case there were two elastic tumors by the side of the uterus. At the operation extensive union of the omentum with the pelvic peritoneum was found. There was a hemorihagic etliision. The tumors were made up of encysted exudation. Over the intes- tines there was a grayish gramdar deposit. Although he states that this was regarded as tuberculosis, I do not see that he mentions the existence of any tuberde-like granulations or nodules. The exami- nation of portions removed from the omentum showed that tubercles were not present, and it was evidently a case of simple peritonitis. A second case, much mor(> remarkable, occurred in a girl of sixteen years, with a well-marked tumor in the left side of the abdonuMi, which upon operation was found to 1k> cuimposed of the coil of intes- tines. The entire peritoneum was covered with hundreds of small nodular tumors. On examination these were fi)und to be made up of a lymphoid tissue, chiefly seen at the outer margin of the nodules, the centres of which had in many places undergone softening. Munde was present at the operation in this case and refers to it (American Journal of Obstetrics, Vol. 19, page 8!»9) as one of multiple carcinositi of the parietal and visceral peritoneum. The ' Lehrbiu'h dei Pathologische Anatomie, 2te Aufiiige. '^ 3te Auflage, Bd. 3, p. 13S. ^Deutsche med. Wochensclirift, 1889, Number 24. M 1J ( T » il: ^i III Ft I : 15 I i -11: 1 i ': r i 1 1 i '. , i i il m V i ii ' 46 patit'iit, it may Ih' mciitioiitHl, made a nipi*! rciovi'i-v, hut I s(m> iio nnU' as tn tlic siil)s('(|U;eneraHzed jrrowth which cominonlv (Mcnrs in the form of a miliary eruption. They were essential Hhrous ont^jrowths of the peritimeum and not of its serous epithelium. Me says they resemble somewhat the fibrous outgrowths met with in the capsule of the liver or spleen. I have never seen ca.ses of this kind, unless, indeed, as is possible, T have mistaken some of these eases for fibroid tubercles. On the other hand, it is e(iually possible that those who have described these cases of chronic nodular peritonitis, nuvy have confounded this condition with the healed tubercular disease. Indeed, in reference to Emma G., Case VTTI, Dr. Wck-h tdls me that had not Dr. Councilman, at the date of the opei'ation, examined the nodules removed and demon- strated their tuberculous nature, he v ould, at the auiopsy, which occurred four and a half months subsequently, scarcely have regarded the nodules as tubercular, so hard and fibroid had they become. In this respect the case is one of the greatest importance, as it shows how essential the examination of the nodules is, taken fresh at the time of the operation. [t must not be forgotten that in certain cases the bacilli are very difficult to find in peritoneal tuberculosis, though they may, as in the ease just referred to, he most abundant even when the tul)ercles are very hard and fibroid. In all cases, when possible, the inocula- tion of a rabbit or guinea pig should supplement the hist( .logical examination. The important practical point, however, is the relief and cure of ' Transactions of tfie Pathological Society of London, Vol. xxi. )vt.'rv, l)ut I stH* IK) li'raniilatioiiM nf tlio liroiifi'lioiit the liver, walls nt' the portiil 2, was adinittcil to anl Sicvckiii;;' and II was covered (tver iiditleH and witlioiit L'W litres of Hiiid in •rraiudatiniis were lized ifi'owtli whieii i|»tion. They were nd not ol" its serous • Hlirons oiitfirowths Iced, as is possible, T reles. On the other :les(!ribed these eases ndess of the head and pain ,n the back. Temperature was 104°. Pulse 84, strong and full, kespirations 38, shallow. The tongue was dry and brown • the skm very hot and dry. He coughed very frecpiently and expec- torated slightly blood-stained naicus. The abdomen was not dis- ^nded; .t was a little tender to the touch in the right iliac region. Ihe lungs and heart were normal. He was ordered antipyrin-5 grs.-and to be sponged every three aoursand given a fever mixture; and, if the temperature reached lOo , to 1)6 given a graduated bath. 12th.— Passed a restless night. Temperature at 9 a. m 102° Cough troublesome and expectoration slightlv tinged with blood' E.^im.nat.on of the lungs negative. The condition of the urine was as follows : Amount passed about 500 cc. ; dark reddish brown in color; acid 111 reaction ; moderate amount of grevish sediment • spe- cific gravity 1024 ; albumen present. Microscopical examination showed numerous epithelial and granular casts, and much granular ael)ris ; no blood corpuscles. Towards evening the temperature rose again to 105° and was re- duced by a graduated bath. 13th. — Patient passed a restless night. Tr mperature between 104"^ ecially likdy to ►ligation, features of tliis laimoglohinuria oms of perfora- esions in ileum ; he Joiins Hop- in the lumbar Dfhroath. He d and ]iad pain 1 he must have t at work until t he has eaten the head and S4, strong and y and bi-own ; tly and oxpec- was not dis- it iliac region. 'd every three •atnrc reached a. m. 102°. I with blood, the urine was ish brown in ^diment ; .spe- examination luch granular and was re- between 104° and 105°. He had a liquid and slightly blood-stained stool. He was conscious; pulse 110, dicrotic. Tongue dry. Examination of the abdomen negative. The blood was examined on several occasions with negative result. The urine presented the same char- acteristics, but was perhai)s a little higher in color. 14th. — Temperature at 9 o'clock 104.4°. Patient did not seem so well ; was dclirous ; passed urine involuntarily. 15th. — Temperatiu-e again 105°, reduced by a graduated bath to 102.4°. Urine presented the same dark color ; specific gravity 1022, acid in reaction ; numei'ous tube casts, no red blood corpuscles ; abundant hicmoglobin. 16tli. — Temperature lower, not reaching 104°. Pat'ent conscious ; pulse 1(14, no longer dicrotic. Tongue swollen and moist, uniformly furred. Abdo leu not distended, soft, no tenderness, a little gurgling in the r' > iac fossa. Splenic dullness began at the lower border of the 7ti! -' .'Xtended four finger's breadth vertically. Edge not pal- pable. Heart sounds clear. Exuniimition of the lungs negative. 700 ounces of urine passed in the 24 hours ; pecific gi'avity 1018 ; color deep blood red. It contained albumen, granular and epithelial casts, hiomoglobin, but no blood corpuscles. 17th. — Temperature uot above 103°. Passed a very comfortable night; was dclirous at times. Pulse 120. Tongue moist and furred. Conjunctiva} a iittle jaundiced. Abdomen not distended. Heart sounds clear. Urine cherry red, not quite so dark but con- tained a larger amount of sediment ; specific gravity 1016. 18th. — Patient seems better. He complained of pain in the abdomen for which he was ordered a turpentine stupe. In the even- ing, at 9.30, he had a rigor. Tlie temperature fell to 97°, but after the chill it rose again to 102°. Between 8 and 11 o'clock he had four loose stools. The abdomen became very painful and a little swollen. At 3 a. ra. the temperature was 104°. There was great pain in the abdomen. There was no special distension. At 7 o'clock the tem- perature was 104°. 19th. — At 10 a. m. the pulse was 120, and extremely feeble, scarcely to be felt. The patient seemed rational. There was no special hardness of the abdomen, no great distension. Dr. I^afleur diagnosed perforation and the propriety of a lapanjtomy was discussed and neiratived. y, & « > , V i If 1 iU The liver dullness was almost obliterated in parasternal line ' there w.. a fla tympan.fc note. In mid-axillary line there was a 5th x.b m the left antenor axillary line. The splenic dullness Ttlfatty "''' '" '"'• ''''' '^'*""' '"'""^ ^"^'""t^^^' -^ ^"^" Po^^-moV^em, by Br. WeM.-In peritoneum 25 cc-. of offensive browmsh-yellow fluid. The lower coils of the intestines were eX mosed ,n places and there was exudation of fibrin on the surfaee. rhe hver had fallen baek from the abdominal wall. The diaphragm on Z Tf \ 't ^""'^^1^""^^^^ *" tl- lower n^argin of the 3rd rib on tlie left to the upper margin of the 5th. In thorax there Avere no adhesions. Jh r^ •?'' Tr''/'"' " "^'^^'' ""^"""* "f blood-stained serum in each cavity. The heart weighed 325 gms. ; the valves were normal, the mu. alar substance flabby and pale. There was general pulmon- ale a'dema m the lungs ; no foci of pneumonia. The spleen was large and soft; and weighed 550 gms Ihecapsuleof the kidney was not adherent. The left weighed 926 gms. rhe cortex was pale-yellow. The stria, were obscured. There -Both of them siiowed signs of decomposition nor^ml/''^'' ''''' '""^^ ^""'^ ^'^'' ^^'' '^''"'^'^ P''^'"*^ '^^^^"'g ^^'>- In the intestines the first ulcer in the ileum was 130 cm. from he valve. From this point the ulcers were numerous. Many of them were transverse, some presented the remains of shreddy, yellow 6 cm t , u'^' fTi' ' '"'• ^'""^ '^'' ^"^"•^' ^^^ -regular in;hape, 6 cm. ,„ lengu, and 4J cm. in breadth, with undermined edges and a sloughy, m<,derately congested floor. Near the centre of this were two perforations about 2 mm. apart and about 2 mm. each in diameter In the upper haif of the large intestine there were a few scattered elevated patches with yellowish surfac-es and infiltrated margin. M,crosc,>pical examination showed in the substance of the kid ' ney epitheluim of the tubules, granular and much broken containing fatty globules of small sixe. There were numerous straight thick non-motor 'jaccilli. ^ ' ^^' 5 parasternal line.' i 7th interspaces line there was a led high to the splenic dullness uatose and died cc. of offensive ines were ecchy- oii the surface. The diaphragm of the 3rd rib lined serum in is were normal, eneral i^ulmon- ns. '{t weighed 226 seured. There ame condition. ■d nothing ab- 130 cm. from •us. Many of u-eddy, yellow ^ular in shape, ned edges and e of this were h in diameter, few scattered ited margins. s of tlie kid- :en containing raight, thick, The heart muscle showed fine granules and a few oil globules. This case offered much difficulty in the diagnosis. We thought at first it might be malarial remittent fever but as the examination of the blood proved negative, this was excluded. The persistence of the fever at a high level and the dicrotic character of the pulse fa- vored typhoid fever. The latter symptom was regarded as very sug- gestive, but it is curious that several writers have noted, particularly in these forms of renal typhoid, the absence of dicrotisni. The oc- currence of profuse hemoglobinuria, with his severe initial chill again suggested malaria, l)ut we relied upon the negative character of blood examination to exclude this. There were practically no abdominal symptoms other tlian slight pain. It was not until tiie seventh day in the hospital that he had diarrhoea and this followed the chill, asso- ciated with the perfi)ration. The I'igor, the colkipse tempeniture, the pain in abdomen with slight swelling and more particularly the almost complete obliteration of the liver dullness in the mammary line, led Dr. Lafleur to the diagnosis of perforative peritonitis. Case II. — Gradual onset, with femr and eouyh ; no rigor. Besfless delirium, diarrhau ; well marked rash. Much albumen and many tube casts in urine. Remarkably low temperatures. Acute otitis media. Death about 22nd day. E.densive ulceration in ileum. Acute nephritis. Josie H., aged 25, was admitted to the Philadelphia Hospital on October 9th in a condition of delirium. From her friends the fol- lowing history was obtained. She had enjoyed good health witli the exception of an illness of three months duration, eight years ago. which had followed the birth of a child. She had been complaining for a few days of headache and of a feeling of fatigue and loss of appetite. She had a slight cough, but no expectoration ; was feverish at times in the evening and her sleep was disturbed. She kept at work until Saturday the oth and on Sunday the 6th took to her bed, the fever becoming more marked. On admission, the temperature was 104.2°, pulse 123, not dicrotic, respirations 22. The patient answered questions, but rambled at times. The tongue was dry and tremulous ; examination of the li •H i . \ 1 i 1 m i'i i i 1 < > I m- ■I If : ! ! 1 ■; i 1. , ! 4 if J 1; ot bod. I he pulse raneed fV„m 100 tn ^'i(^ ' i' ., ^ of the 12th rose to 160 Til ' ^' """ ^'''^ ^''"'^'"g 10th and 1 If h n I ""' '"^'""t"""' ^«« of „ri„e on the ha , K. doses, and a digitalis ponltieo on the abdomen. ' On the dinun, was n.a.-ked ' "' "'^" '^^^"^^ -osultus ten- On the 13tl, she refused to take nonrishment. The tenn.erature at -3 a. m. was 100.8°- at 12 m ini ro , , ronij)eiature mv^^.4 . IJie temperature remained low all niirht nt m , v registered 97.4°; at 4 a. m., 97.2°; at 7 a m iH TI ^'i ""• '' small, llo to 100 ^iw. f i , " ^^^^^ P"Jse was 9^0 / *""''' "'^"i-'slii^ent better and there werP 250 cc. of urine passed on the 13th ^_ Tl|o following notes were made of her condition at the mid-day iica\\ sediment of mucus; snec fie p-rivlfv moo ^- .it,, „i.Hc acid, a co„i„.. p.«i i.a^^f XL f I . S';", rl' WP,-P t-V, „ (• J •'' '™"' '" <«"« 'l'»t at. first el.ev ^^\!^ I«"n. Tlie amount *'. On the 12th were withdrawn tube casts. On small that Dr. 1 of digitalis in lonien. On the )igastrio regions. g suDsiiltus ten- iio temperature L01°;at6.30p. at 10 p. m. it TJio pulse was md there were it the mid-day as a distressed, S' ; pulse rapid vertical splenic with deposit of reaction acid; third by bulk )us large and t at first they lecimens were le with a tew e coarse gran- and, in a few, er there Mere numerous bacilli, some of which seemed to be in the tube casts. Here and there red blood corpuscles were seen but they were not numerous." On the 14th the teini)erature, wiiicli had been subnormal at 7 a. m. roso by noon to 100.4°, and for the remainder t)f the day it kept be- tween 104° and 105.o°. She passed 440 cc. of urine in the twenty- four hours and slept better. She also took more food. On the loth the tem{)erature at 8 a. m. was 97.3° ; at 2 p. m. it rose to 101.4°, juid the pulse ranged from 120 to 140. There was a discharge of blood-stained iluid from the right ear ; nothing to be seen in the meatus and no tenderness over the mastoid process. In the evening the temperature again sank l)el()w normal, and at 10 p. m., 1 a. m. and 4 a. m. it stood at 97.8°. On the IGth the temperature was 99.2° in the morning. She had had a restless night, but looked better in tlu; morning. She had passed urine involuntarily and the (piantity for the twenty-four hours was therefore doubtful. The discharge from the right ear continued and there was n'o special tenderness on either side of the head. The anomalous temperature curve and the discharoe from the rio-ht ear suggested a doubt as to the true nature of the case. Puncture of spleen was made with a fine hypodermic needle and cultures prepared from the fluid. Aft(>r midnight the temperature again sank. On the morning of the 17th the temperature was 97.8°, remained about 99° all day, but at 8 p. ra. sank to 97.4°. The pulse was 120, very feeble ; passed a very (piiet day and seemed to recognize her friends. On the 18th the temperature at 1 a. m. was 97° and by 8 a. m. rose to 98.8°. The urine presented the same features as before, but the granular casts were less numerous ; the amount of albumen was large, and bacilli were still seen in the urine withdrawn with careful antiseptic i>recautions. The continued hw temperature necessitattHi the constant application of hot cans. The bowels had not moved for several days. The delirium persisted. On the 19th, the temperature at o a. m., was 96.4° ; at 8 a. m. 96.8°; pulse very feeble 140. She was given an injection which brought away a partly formed yellowish stool. At 2 p. m. the ther- mometer in the axilla could not be made to register more than 95°. The patient seemed ^'ery dull, heavy and lethargic. At 3 p. m. the temperature rose to 96.4° and by 5 p. m. it was 98.4°. She had i J /.<■ i ' 8 hicoouffh through the day and more rapid respiration Tl.n . tare at 8 n m wm 07° „. in 1 resjuiation. The tempera- 'i '?n .1 ' "* ^^^ ''• '"^ '^^•4° and death took i,laee it o.dOon the morn iKrnf flir. 9nfi. • ix i piace at wdl-„,a,l,., „-..||-„ .i,|,e,l y„„n.. w„ma„- (I,. ^ ^ 8i.l<.r„l,:,. ,li»,.|,a,.,.,. ,■,,„„ ,|,e,.i«l^ elr ' " '"''"' '^°"- Al„l„„„.„. Tl„. |H.rit„no>,m m„ s,„,Krt|, , ,|„. |.,„,,,. ,„:, , , f „ Stomach and duodenum showed no speeial ehan^m^ TI,. • • The mesenteric, ghtnd.s Mere greatly enlarged and deeply congested One presented a soft eheesv r-enti-p Ti,^ i- , ^"-^ '""fe's^PO- full of uo,Ki, .he sui^tar,:.:;;,;:,,,^"" ■■"'■ "-" '"'■«^' '"^ --* . giammo., the capsules were thin an.i ,-,.a.lil,v detaehed ; the SMvfaoe 9 The tempera- i took i)lac'c at kiiiffto her bed. was that of a ^vas pale; con- cr coils of the s swollen, ht pleura ; the ic heart was of i?lit chambers; a little pale. ■! ha?morrhage, ally abundant itio congestion ned ; no trace The jejunum 'Gued, and at was swollen dozen small ir tissue, and er foot of the or four large ! seen. One •e and there leers. The ntestine was !iT?morrhagie •e of even a ►^ congested, the vessels about 400 the surfltce was pale and mottled by the presence of ninuerous stellated veins. On section, the sul)staiice was miiist and from the larger veins blood flowed freely. There' was marked contrast between the cortex and pyramids, the former being greyish-white and uniform. The tubuli Bellini appeared swollen and presented only liere and tluMe a fnll vessel or e(ingestraetieali v we have to deal with an acute m most instances, a he.norrluigic u.^phritis. Xaturally i, adds n.uch' l^r7 '' 'Tr' ^"' ^'^" '"••'^"•-^ '« always rendered u.ore dubious Uagner,' however, has had tive eases of recovery in sue- c-<..s,on, hut the h„h nu.rtality nu-ntioned by Amat-10 deaths i'. iz cases— IS the more common expr rienf.. A discussion of the r.-lation of this forni of nephritis to the tvphoid rr u7 '"'.'"T^ '""^^'>' ^'y *''^' '^"^"■"' ^'^' ^y ^'--- l>t"-. Lines or the result of a mixed infection-would be beside my present pu po^j ^v^nch ,s soldy clinical ; nor » • s Virchow's Archiv, Bd. 105. * Centralblatt fiir Bakteriologie und Parasitenkunde, 1887, p. 74,1 ^H ; f,^' ^^H ( ^H ■ ) ^H i V " ^^^^V 1 <^-< ^^^^^^^H ^^^B .> I ^^^^^^^Ki- 1' ^^^^^^^^■i { J:.,}:: ^^^H! 1 ' f , ^B' ' ' " , ^^^B' I'll-' ' ^B : ^^^H' j , !'■ . f . 1 1 H ' I ;.!/: ' k ' :■ \ r ' i i. ! .. r W B J ' ^H|| m 1 ^H ' ^^^^E B it-' 1' ■t i .!' n -: HII «i "' b|^^^^ii| III were .u^ative ; in tl.roe there were s,aphyl.>co<^ci, in one the A.«./». /W./u. and in one the pvoteu. vulgari,. He hoUln that the ama-lm.. >vh..i. ex,.t m all the !ayer«..rthe inteHtines in ay«ent,-rie nUeration, paH. with the n.ieru- cirKaniMMH and detritnH through the portal veins to the l.ver. 1 he micro- cocci excite the «uppnration, but only in consequen-e of the leH.ons ... n el hv the amoeba.. The pns seems to die rapidly in the absceMoH, bnt the aLb,e remuine.1 alive for a n.u.h longer period often over two .nonthH^ HiHtoloKically, KartuliH deHcriben three /.onen .n theab«ce.H NvaU.-hrst, e detritus zone, containing fibrous granulations and amroii second the cell .one, consisting of youn« cells which stain deeply and between wh.ch can be seen p<.rtions of liver tissue, liver cells and capillunrs, and tlur.l, the limitation .one. separating the disease fron. the >ntact hver tissues. His n.ost recent communication i« in the C'entralblatt fur f 'f «■' S' No. •-', 1890, in which he reports two Cases of dysentei y whveh had origin- ated in Athens, in both of which a.n.«ba. were present in the stools, similnr in character to those met with in the Egyptian dvsentery. Massiutin ' has stu.lied this question under Losch's supervision. He has found the parasites in live [.atients-one, a ease of chronic dysentery of seven vears standing ; the second, a man with chronic intestinal catar a third, a case of typhoid fever with late diarrhea and mudi mucus in the stools ; the fourth and fifth were cases of diarrhea with fluid '""^f *,toob. The ama-bic presented active movements and seemed o have the same characters as those described by Kartulis. He -V - > siuular anueboid forms occur in other i .- nal afiections -'>d <^; " " normal f.eces. We regard it. however, as uu.kely that Uie -"^^a . ild induce all of the conditions in the dysenteric processes. Dysentery (onsists anatomicallv in a combination of diphtheritic and purulent inflammation, whic!^. i„d„ees rapid and deep ulceration of the affected part. We have no Tnalogy to show'that ameboid parasites can i-'>- "'-''"-' ""^^^^^^ rather believe that the ,.yogenic micro-organisms, well known as exc er ulcerative processes, are concerned with the am^lue in the causation of tropical dvsentery." u- , i i,..,i This practically embraces the entire literature of the subject. I had, after the publication of Kartulis' paper, made several examinations in Philadelphia with negative results. During a visit to the Hospital Dr. Lut.e,' last October, stimulated our interest in the matter - h-'a d that he had frequently met with the parasites in tropical ,lysenlery. We 5 Abstract in Centralblatt fur Bakteriologle Bd. «, p. 4ol. cilhiK f' Wl-^tained, bu. it had not the redd.sh-brow. and anchovy-sauce-likc appearance presented by the pus in many cases of he|>atic abscesses. ^ 1 made an exan.ination of the pus at the Uiological Laboratorv within three-,uar,ers of an hour of its withdrawal and found in t i'n la e numbers, the anm-b. which Kartulis had described. The n le h u£ aken at once to the Pathologic laboratory where Prof V ^ 1 l" Counctlman con.n.n.ed the okserva.ion. On each succeeding ay the tune of dressing, pus was removed from the drainage tube l,efore iVril on was begun. n the first two days the amceb. were quite numerou a iS ;:• ,t;\_ -^'-'"-« following days they weresti?i found, but .no;;! tOTMs were n„t .o common, p.ubaldy owing to the fact that stron-^er solu- tions of bichloride were used for irrigation. Subsequentiv thev ..C ve v numerous, and we found them each day. in the pus as it eanie from he i rZ age tube, until his death on April 5th. i[ ! ill- I iffipH^ After the operation the dysenteric sympton^B did not abate ,n the shght- e.tThe continued to have from eight to -^-" -;;™^;,t L ^^^^^^ varied a good deal in f^;^r:ZZ::^lTt:::^er. .ade and there with pus and P'-^*^"^'"^/ '''^;''l; „„ several occasions, there np of a greenish pu tae.ous --^-^^^^-^^^ifj^ usually slight in were '-g-"«^"j-,^«;^^; ^ J,f fi," ^ ,,ownish liquid evacuation, in amount. Occasionally theie wa^ .i i « 4t nwmuiJuil MgAJM r ■aMHJII 'iuHR ^^'l' 4 O S L F. R , which, from its ringing n.i.ility, coiiKl be heard at a considerable di t;(nce. She was so much better liiat she was allowed lo get up and another patient was placed in the room with her. This seemed to cm :e and woi:) he , and shmdy after- ward the barking sounds became much :nure frequent, occurring every one or two minutes, aad -I'.e complained of great soreness of the muscles of the chest and abdo- JTK-n. The i v>vemcnts, however, did not increase. She WHS again pli:ed in seclusion and in bed, and again "iipnjvement followed, but she still barks and she has rot given up entirely the use of bad words. She i- a docile, intelligent child, and :;eems anxious CO get well. She has kept a diary, whii h displays no special peculiarity. She writes verses, \s iiich are not worse than those usually composed by girls of her age. The patient, as you see, is a bright, intelligent child, and there are still to be seen occasional lateral jerkings of the head, and now and then the right arm is elevated with great quickness. You have also heard the peculiar sharp sound which she makes from time to time, which sometimes resembles a hiccough. More commonly it has a barking quality, which is not nearly so marked as it was some weeks ago, when usually two of the sounds succeeded each other with rapidity. In addition, this child has presented several of the symptoms which Charcot and his pupils regard as characteristic of the affection. I have just spoken of the emission of involuntary sounds and words. The use of bad words, for which the ingenious expression coprolalia (ficcal speech) has been invented, is present in very many of the cases, forming a feature very distressing to the relatives. You can judge from the letter of this child's mother how grievously troubled she was over our patient's "slips of the tongue." She cried bittei'y when she told us of it, and said that she wished daughter i "le heard at a illowed to get room with her. sho'-dy after- nure frequent. »e complained ie,3t and al)do- increase. She ;d, and aj,'ain ; and she has ;eeins anxious h displays no Aiiich are not dh of her age. elligent child, Lteral jerkings rm is elevated •d the pecidiar to time, which commonly it so marked as of the sounds addition, this iptoms which :eristic of the if involuntary for which the ech) has been ses, forming a hild's mother our patient's Illy when she it': daughter CONVULSIVE TIC. I S dren of te o!" •'""' ""[ '''' "P"'"''^^' ---' --" ^hil- the m^vf 7 '" f •'"■' ^'^''' P-^'-^i^tently used words of ine most obscene cliaracter. A second peculiarity of a similar nnturr is the rencti t.on of any sound or word heard, for wh.h ie ,'ame . nd the word .s repeated by the patient so soon a hea d' iew ,amr ^ " " n"f "''^" °'^^"'-- ""^ °" '---"a use! T '■"" "■'' '^°'"'"" '"'° ^'^^^ hospital, she but has not been a special feature. This curious imita .on of ,n,,scular movement has been described, no "iy in the face muscles, but i,i those of the extremities and simulates closely those of the remarkable M Ua 1 Use known as /././. The term ,v/.>/v>../. has been a pHed to this mimicry of movements. 'M'i'"ea So far our patient has not p'resented any symptom of and hr :??';• "'"" '''''' ''''■ -treme^lS c/ and he addiction to poetry could be so considered Upon this aspect of the affection Charcot lav ' eai stress, and thinks that sooner or later the cases inva i mental change is the existence of hxed ideas and Guinon, whose article in the n^a^o;..r/n■ Kn^J^^ ''^"'^ ^s the most extensive on the subject, describes hese as very often a fear of impending trouble or a ear o places (a.orapMia). In other instances 'there IS fohepouy>]tmr m which the patient incessantlv de- mands the reason for the performance of even the sin- plest actions of life. " Folic du doutc- and the curious, irresistible impulse fo.m of this obsession which has been noted in some instance,, is what has been termed arithmomania in which the patient is possessed with an irresistible desire J: time past he na.s not felt as well as usual. On November 1st, while at his supper, ,„ a restaurant, he found that he could not read the S pape^^ He was sure that this came on quickly, and had been his chief' aSy: ance, as he was an ardent politician. He had no definite headache, but o s r, K R , f '. * < .1 ' t , i to do some special mathematical problem, or to count up to a certain number before doin^' a certain action. In brief, the main peculiarities of the disease are: the invokmtary movements, the iitterini; of words or cries, coprolalia, mimicry of words or movements, and, in very many instances, mental symptoms, chiefly some form of obsession. The majority of the cases present only the first two or three of these features, and it is not until the more advanced stages that the mental symptoms be- come marked. The prognosis, according to Charcot and his pupils, is extremely grave, and very few cases recover, but years may elapse before the onset of mental symptoms. The diagnosis is easily made in cases such as the one before you; but there are several conditions which in certain features simulate the disease very closely. Thus copro- lalia and the irresistible tendency, on all occasions, even the most solemn, to use obscene words have been de- scribed apart from any motor phenomena. There is the oft-quoted case of the Marquis of Dampierre, who, from early youth to his ninetieth year, involuntarily uttered, even under circumstances the most solemn, the words " uwrdr .' " and ''foii/u cochon .' " Still more common is the existence, partic'iiarly in children and youth, of a fixed idea. One of the com- monest is the " (ill trie dr foia/wr," which impels the individual to touch certain objects, and of which the great Dr. Johnson, as is well known, was a subject. One of the most graphic accounts, probably autobio- graphical, of this imperative impulse to touch objects is given by George Borrow in his La7'cno;ro, the Scholar, the Gypsy, and Priest^ in which the practice was followed in order to prevent evil happening to the lad's mother. In many points the affection has a close resemblance to the common habit-chorea or habit-spasm, with which indeed the involuntary movement of convulsive tic is identical. I do not remember, however, to have seen at i em, or to count rtain action, lisease are ; the words or cries, Its, and, in very y some form of resent only the is not until the symptoms be- id his pupils, is over, but years mptoms. The the one before hich in certain Thus copro- •ccasions, even have been de- na. There is ampierre, who, , involuntarily ist solemn, the particularly in »e of the com- ch impels the of which the was a subject. Dably autobio- :)uch objects is 1), the Scliolar, e was followed ad's motiier. ; resemblance m, with which ivulsi\-e tic is 3 have seen at CONVULSIVE TIC. 7 the Philadelphia Infirmary for Nervous Diseases amone the numerous cases of habit-spasm which clme ZZ chn.cs particularly to the clinic of Dr. S. We Mi hell a smgle instance in which other symptoms d'elo.ed his middle" r"'' ""'u"'''^' ^"^'""' '" ^^'^•'^h the lad put his middle tuiger into his mouth and bit it severelv md at the same tune with the index-finyer compressed Je time H T'. ''''^ '^'^'' '^^^^' -'"tinued'for a o >g time, and had resulted in the production of a thi k callosity on both surfaces of the second phalanx of hit hnge.. A somewhat similar trick is reported to have been p,aet,sed by Hartley Coleridge when a boy, on Iv .f I recollect anght. he was in the habit of biting h am And cp.ite recently there was at the clinic a girl mne years old. who. during convalescence from choiea leveloped the curious trick of first smelling and then blowing upon anything she took into her hand With hysteria the relations of the disease are not thought to be very close by Charcot and his pupils rhe affection usually sets in at a period of life earlie; than that at which hysterical symptoms begin, and ver^ many of the cases show no manifestations of hysteria The utterance of loud involuntary cries and anomalous" sounds IS, however, a special feature of certain cases of hysteria which may thus present a resemblance to this form of convulsive tie. They, however, are not neces- sarily associated with involuntary movements, and are usually of a more bizarre character. I remember a remarkable case of the kind which was brought into Iro.essor Wagner's clinic at Leipsic. A child, aged about fourteen years, had for several weeks uttered the most remarkable inspiratory cry. followed by a deeo- toned expiration, both of which were audible at a -reat distance. They persisted during the day with "each respiration, but ceased during sleep. The child was worn to u skeleton. Dr. Gapen, of Omaha, brought to the hospital last ■I ..J time pa-st" he hWnot felt as well as usu« ' On >, ovember 1st whiJP nt k;= supper, .„ a restaurant, he found tl,. ' ■ corJd notTea 1 .' 3 dlilv^^^^^^ He was sure that this came on quickl,, an.I l:ad bee^, his S amfov ance, as he vas an ardent politician. "^He had no v WiLMAM (>su:r, M D HAI.TIMcpid' S HOPKINS l'N|\ K8S1T1-, This rme illustmtes the following ..(unts- Cn Tl.o ,. • .• .ord.bli.dness with disease ... the uL^L i^ .^ '^'7;; narapha.s.a which so often a.eompanies this conllitioa; ,!3) Thetl >ce o hemianopsia fron. interrnption of the fibres of the op radl tiun, wifliout disease of th. occipital lobe Clinical SvmiXHY. -Inability to read a newspaper the first vnnv t^>n; t,,ncal worcl-mndne., retention of intelligent iLln,; ZpZL n^ord. and .enteure.-parapka^ia; ri.kt ho^nonyrnousheJn^^. no paralyse ; pers.tenc. of this condition for over , ,nonU., ,oitk radml loss of mnsrnlar strength and n.ntal po.er. For ^A/ .,-. • jj"^ death, paralysis of right arm and leg. ^ ■• i , i 1 ! 1 ' f ^j f I:!. I lipuii his lictui (^iiyiii;,', " It in all wroii;!;' Iiorc, l'rcHV)it ilKloii cnnititioii : Vij^Droiiw-lctokiii^' iiiin lor his ago ; I'acc intd- iif,'ciit ; siicaUs clearly ami rapidly, with (Kra.-ioiial intcrniptioiis ; no paralyse; inovciiu'iits of thf aiin.s, k'jr.s, and Caco pcrtivt ; no los.s of sciiHation on cither sidi- ; no inco.irdination ; ho j^taiids well with hiseyes shut ; nlloxfs noinial. Speech: Thonj,di he speaks clearly niul intelliirontly, and utters some sentences without internipi ion, rcpiyiiijr promptly and lluently to (hics- tions and evidently undert^tanding evcrvthin-,', 'there is very distinct speech-disliirhance; thus, for some time he could not give the address of his residence. He says he knows where it is, hut could not prommncc it He told thelirst name of the man with whom he lived, hut could not say the-econd. lie could not name his own occupation, hut said, " Keen keep, keep. Oh, you say it lor me." When told— hookkeeper-he re- peated It distinctly. He occasionally misplaces words. In referrin<' to a wetting which he had spoken of, he said, " Deliherate attacks of wet dns. " VV hen a jirmted or written |>age is i)re.-ented to him he does not appear to comprehend the words. The word Philadelphia at the head of a hos- pitiil hlank, he rea.l P, r. i, n, g, r, e, k. VVIu n told that it was Philade'l- pliia, he replied, " Oh, certainly it is, I've known it tor sixty-five years " His age, 72, written on a slip of paper, he read 21;]. He did not recog- nize tlie words "Cievelaiid and Harrison" at the top of a newspaper co- lumn, hut when read to him, .said, " I know all ahout them " and he.rau making some very shrewd observations. He can write his name, but say.'} that since his lailure to see he does .so with dithculty. Pie writes as well with his eyes shut as when they are open, but does so with hesitation He wrote the name of the hospital, and the words " Philadelphia Ke- cord. He could not read the words of his name after he had written ttiem. He names objects held before him (jiiite readily. Dr. (le Schweinitz examine', the eyes, and reported the presence of right lateral homonymous hemianopsia. Dr. de Schweinitz's renort is hero annexed : '■ Right eye: An oval optic disk, with the scleral ring plainly followed all round, and both superficial and deep layers very gray ; the veins full and dark the arteries unchanged in size; a fine retinal haze veiled the upper and_ lower margins of the disk ; there were no splotches or hiem- orrhages m the general eye-ground, and no changes in the macular region. Left eye: An oval optic disk, with well-marked scleral ring, more visible than on the opposite side, because the retinal haze seen in the opposite eye was less apparent. A similar appe, ance of the retinal circulation and an absence of gross changes in the retina and choroid • the disk was also gray, but not so devoid of color and capillarity as that upon the opposite side. ^ Xovnnlwr 21, IS-SS. Patient was admitted to hospital with no essential oliange in ius condition, thougii he did not seem to misplace words so often He could not say his age. 72, but said " (!0 an.l 10 above that and 2 above that -that's 72." He knew the day of the week and o the month, and what year it was. He was asked how many years after Burns s 'joatli he wius born, and said 5000, but a once corrected himself and said " >,o, no ; I do not mean that— twenty-five " The state Iiu-eil his hand ! ; f'aof iiitcl- ■rniptioiis ; no •I ; 111) losM of I with hiseyt'8 li utlor.s Hoiiio ic'iitly to <|iic,s- Vfi'y distinct e the address pronounce it. could not say said, " Keep, L'cpcr— he ro- rcferrini^ to a of'wet drcM.s." OS not appear lead of a Iioh- was IMiiladel- ty-tiveyeaiH." lid not recog- iiew.spaper co- ," and lieiraii inie, hut says ivrites as well h hesitation, adelphia Ke- i had written 3 presence of ;z's report is Jily followed -he veins full :e veiled the ihcH or hteni- the macular 1 ring, more seen in tiie the retinal md choroid ; iirity as that no essential place words id 10 above le week and many years -•e corrected The state O^l'HH, .SKN.Soiiv AI-ilASlA 8 of word-hlindness iitrsi^i,,,! rt was di(li,.nlt to ir.^t hin, "' wri i • "'"' * '"''^''''" (">-^.Tvcr." It *rom dictation ,;., ,,,, |.,,,,|, ,,;,;;',;; ,,.'' "''J ""P'-Hihle for him ,o ,io so The oval oiilliiii" nf (.,i,.|i li,,,,,.,, ;., >i point There i. deei.Iod .ontn '.ti„„ o/^M t.^ ' ''" '"."'f ,' ^"'""""^ *''" "-"g- the right si.lo,- that is, upon th. -i,io nnno LT , "''''' """*' "^'"'"-"l ",„m. -r;:itJ;.::;^::u;;-!;^.:^'!;3;!-'^:;- He not care to talk with (he otiu.- atie s \V l'''*l''';'T ''""^^' '""' ^Ji'l generally placed his hand upon' 4, Zl '"^^l' ''"^^' '"^ ^''^'' ^"^ plirase " All wrong here." ""'' '^'P^^ted several times the Rth Thn f 11 • ^^^''" •'".^'^ "*' has voniitci frcriueTitk- er/< Ihe followniirnote was ni'ido- " T.,IL- . i *■ . • " l>gentlyaml plainlv at first hner .. 1. '''' ^'''''''>:- .%Hks intel- understand what hJstates \ ulS>„.l i '''I''"' '^ '"'^ '>'^^'"lt to tlie ha.Hls is ef|i,al. lie walks w'"' '"■",''"" ''^'^'i^^- ^he grip in there is no actlal ,,arulvsN ' '''' " ''^"'^'"■'"^' ^""<^''"'g g"it, tIm'ugE t^BSBi^^^?^^ -■■■ for several days; no paraksis f oti n n-of ^ '?• ^''''' t''' ■" ^^^ understand and usuallv answers co Teot Iv f ''"f ''*'"• He seems to noted, he would not giVe 1 i? a 'e con-e^^^^^^^^ "•'^'''' "' ^^'^ frequentlv first spoken to, his speech is cleaf am iS'. ^'"'f'.f "''' '''^'''''- ^^'''«» becomes very incohcVent an,l m n , T 1' i" 'Y' '" ^^ ^''''' "'inutes and restless at night irettin-^ o , * 1^' i V ''^ '"" ''^^^'" vervnoisv ^>" the 12th the notfw ^" Ke ., S ir; "'"^'"^ '^'V*"^ ^'^^ w«rd.''^ "o paralysis : talks without diffK^v •!::.''"'' '""•''^•'"" = "" ^'^^'^ = otliers m a senseless manner. 8avs com) : f j*^ ;ir^^'«"« ^O'-'-eotly, distil rbaii ce of scnsati(m. ■ C(mtinually ' Lord, h dav On the loth the note , liave mere) N( Tl was ns morning could not b ■ Has I l)een very to the left, but sonieti le roused H( of the CV( Pupil mes moves it to the riirjit. X wakeful for the past two les with his head turned TIT I - n , 1 ^ t' uui an- Muscles of the right side of fac piis equal and of medium SI conjugate deviation •e seem to act as well as th. ze ; react feebly to light '' I ose on the left. m m L 1 HI I'll 1 ■MB'/jit : :m , fii mji^:k ^^^^^^&V'^ m m is . * OSLKR, SENS,ORY APHASIA. the last twenty-four lioi.rs. He moves tlie ri-l,t ley but when Vftolh falls more rapxlly and with n.ore dead weio-ht^than t'he ,e H 1 i a senu-eonnuose condition. There are loud bronchial ra V' He 4nk and died on the aftei'noon of the IfJtli Pod-morfem Jive /loui; after death : ]}odv nioderatelv well-nourished ■ no ngor mortis ; calvaria thick and svmmotrical. ' nourished , f.innT ''"'' "'T"^V"V' ''''y ^Josely adherent to the skull ; sinuses con- tained recent blood-clots; a moderate amount of Hui.i cscS on removal of the brain. At the base the membranes were i o ma T caroti.ls were stifl and atheromatous; vertebral and basilar arteries in the same state. Xerves at the base normal. aiteiies in Cortex : Pmin.jderately injected; the posterior part of the left hemi sphere ooked fuller and the c<.nv.,lutions were paler t.u on thVri side Ihis was particularly marked on the parie al and enn omM if portions of which look softened. More accuratelv deteriniZ v ht and touch, the suj.erticial soft areas were as follows • ^ ^ ^^1. The entire supra-marginal and the lower ,)art of the angular ].Mr;Jr V''°ft"'''"" ,'"V^ "^'. ^^'' ^""'t '"''' ^^^^o"'l temporal o-yri which bulge distinctly, and the veins of which are much distended"' o. Ihe two annectant convolutions joining the first temporal -n-rus and ofVvivi'us "'"^••^'"^-"^- •-'>• --'"'^ ^^fter separatioi/ of" 'tk^fisj;.;.' Though these i)arts were softened and contrasted by touch in -i marked nianner, with the rest of the brain, superficially T I id L' look very different, and were only a little paler ii color ^ the i\'ei"indlSonr "iT '''"' '"^ V'''' '^'' "P^" '"''•' f«"»^l ^^^ to .,n!l .1 '^f'"''l^'^['o"^; Jlievpresente.l occasional flakes of atheroma and recent soft blood-clots, but no thrombi. The posterior cerebri 7Z T\ T: f ''^''?' ^'«"tricle was not distended on Uie left side riie caudate nuclei and thalami looked normal. On the ou er w'd of theleft ventricle, just at the pointof (iivergence of thede cend i"' and posterior coriiua, there was a grayish- white su'^^lling, preseSg conSste bloodvcs.sels_here and there, an' horn and -ecti(,n 4, passing through the outer tliird of the left crus. tM^ Tranaverso section of left hemi«r)Iif»ro »,..;„ .i showing the area of .oftenin,r P 's ,| • '^7^'^"^' -W.ra.narginal convolution, N caudate nucleus , 0. J7., tail of ca.i.late n'uclou,'- V>U ''ct ^^■' '''"'T"'^'' ""«'«"« •• «• optic thalamus; P. 0., „arioto-occi,.,tal f|,su"e p , o " T'"" '""""'^ ' ''^ "- fissure (?) ; Sup. Ma.g,, supra-n.arginal ,yZ. ' "''"'"''' ^^"^'"-^'^'PiM inul::n!!:;"!;;!i;:3i;;Sonu.nV'^ the fibres behind the <; d^I^ S IK;'" :;''r''^'' ""1^ f '"^'"'^'•"^ caudate nucleus, where it „.,ss( d n .','•- ""'' *''^' ^'''^ »^' the orly, the white f bres of I e' c; it .1. ' '^'"'T'^^ <'-•>'"• Posteri- the softening reach.ed , ho en, K Jn V ""^ '".'■'*'^'*^^*^- ^''^t^'nally, dark in color. Ex en a ly in,'/' '^ FT''": '-'•'>- ^vhich was matter of the ccnv^.lutions ' ''"' ''"' "''^ '"^■"'^'^" ">« gray crr^emS'imT"'^' "'^ '^"^'^"'="- "-'--' ^he thalanu.s, and the . S^S';r:;tS;:^^;::r,;;,r;;ri'^;:^^!- ^^^r- involution. second tc.nporal gvri ^ '' '""'' "^ ^''^ ''"'•'' ""*' ^he base of ' the Tirif?S'ra'U!r::;!;;:vt'^? '"''' ''^'"'^'"'^'-'^ -- '-•-^'• patches of extrav sS;,; ' ' m2±^;;|:r"T"''' '"^^'•«1---1 -i^li The vessels were c-pf.. u J . !.' t"'J'^ be.ord.nary necrotic chansre. many (»f the small but part of the temporo-sphenoidai 7o"be"'t? i^vii ; no miliary aiieiiri.- ms were found, iller ones were blocked with dirombi. At the 1 unusually firm. The branches of th lie margin of softened The d posterior cerebral art( ower area was rawing was made from ■I'V wei'e free. portion of the supra-marginal which passed through the 1 ection gyrus, at half an inch from t\ 2 ower le terniina- I- 6 m 1 ! OSLER, 8EXS0UV APHASIA. on of the Sylvan fissure. The softening here ^va. more superficial than at any other po.nt an,l seen.ed to involve the grav matter In ti>e pos- terior part of the first an.l . L Td seemed to separate the parietal and occipital lobes. The ang dar gyrus hes at a higher leve than shown in the section; the white Ltter of i was softened, but the gray looked very natural. The drawino is an :| ' ^'rU erficial than In the j)08- ached to the !h tile draw- isjihere, and gular gyrus matter of it iwing is an acing-paper CL HI n, . "'^ WILLIAM OSLEIl, M D rojessoroj M„iwme ,„ the Johns HopUins University, nor country, but whose work is in the world T e t:l:ti Zrv t ^''^^-^ '« ^^^^ wirustttrr; been able to efface^'t ^a's TeLZ^el tl^X not of th.8 country, not of our blood - whose liie ha. special work has revolutionized the science o Ted? cine who3 enius has shed lustre upon our craft j;f^riooL!;sx^nru^;fs-.jr 00 after a long enslavement, ecclesias ical ami So' sophical. received its eniancipation. Forsak!n| the ^K f// BALTIMORE JOHN MURPHY & CO. I89I ^'^^ 1 tion of th at any ot' terior par "; < gray niati i 1 ■ ing was tj seemed to lies at a 1: iM was softe P exact rep L T 1 upon the traditions of the elders, and scouting the Sliibboleth of schools and sects, she has at last put off tlie garments of her pride, and with the reed of humility in her hand sits at tlie feet of her mistress, the new science. Aot toany one man can this revolution be ascribed: the Zeit-geist was potent, and like a leaven worked even m unwilling minds ; but no physician of our time has done more to promote the change, or by his individual efforts to win his generation to accept it, than Rudolf Virchow. And now, as the shadows lengthen, and ere the twi- light deepens, it has seemed right to his many pupils and friends, the world over, to show their love by a gathering in his honor, on this his seventieth birthday. To-day, in Berlin, a Fest has been held, in which sev- eral hundred members of the profession in this and ot.ier countries have been participants, as subscribers to the fund which was organized for the occasion. It seemed well, also, to his pupils who are teachers in this university, and to others, that the event should be marked by a reunion at which we could tell over the story of his life, rejoice in his career, and express the gratitude which we on this side of the Atlantic feel to the great German physician. Let me first lay before you a brief outline of his life : Kudolf Virchow was born October 13, 1821, at Schi- velbein, a small town in Pomerania. Details of his family and of his childhood, whidi would be so inter- esting to us, are not available. Educated at the Gym- nasium in Berlin, he left it at Easter, 1839, to begin his medical studies, and graduated from the University of that City in 1843. The following year he became assistant in pathological anatomy to Froriep ; and in 1846 he was made prosector, and in 1847 a lecturer at the university. In 1849, on account of bis active participation m the political events of the previous the Shibboleth of off tlie garments f liumility in her , the new science, tion ho, ascribed : aven worked even Li of our time has ■ by his individual 3t it, than Rudolf , and ere the twi- his many pupils V their love by a ^entieth birthday. 3ld, in which sev- isioa in this and ts, as subscribers the occasion. It ■e teachers in this jvent should be uld tell over the and express the ) Atlantic feel to utline of his life : 3, 1821, at Schi- Details of his 3uld be so inter- Lted at the Gym- , 1839, to begin a the University year he became Proriep ; and in ■<47a lecturer at t of his active of the previous K II 3 year he was dismissed from his university positions and, as he mentions was onlv mit grossen beschZi i":f «/-"^!'f 'v'-gHy in fact hv fhe eXrt of le" profession of Herlin, and particularlv of the medicll societies. n August, 184-.. he received a calHo tlie cha.r o patho ogical anammy at Wiii-zbur", a po.it n which he held until 1856 when Iw H 1" f"?'""" vote of fl.ft fonnif., , "' ^"*^"' "y f'le unanimous vote or tlie taculty, he was recommended for and re ceived the appointment which he still hoir'namelv professor of pathological anatomv at Be li 'Sf£ i'S whl h noV-""-'^''^' ''''''''^ His'-cefehrTtec ■Tk ' , ^^^ '" ■'« one hundred and twentv e.gh h volume is the greatest storehouse of fa £ in scientific medicine possessed bv us to-day. life wl;^ W ;;;l^^;:' ''" ""''^'^"^^"'' Igor into the minutiaj of pathological anatomy, and his atti- tude of late years has been critical rather than produc- tive ; but his interest in all that pertains to our profes- sion is unabated, and is a feature of his character to which I must allude. Too often with us, in our gath- erings and society meetings, the " men of rathe and riper years " are conspicuous by their absence. In this respect our great master has set a notable ex- ample. Amid cares and worries, social and political, with a thousand and one ties and duties, he has never held aloof from his brethren ; but as the weekly medi- cal journals testify, no man in Berlin has been more active, and for years he has held the Presidency of the Berliner Medicinische Gessellschaft, one of the most important medical societies of Europe. Surely the contemplation of a life so noble in its aims, so notable in its achievements, so varied in ^K // Jil iciously success- U8ti'iou8 worker, ef of the people, jpressive logisla- ly of ubsolutism t siicli strong in- It in any assem- attentiou of his 3s liave been re- merica. r varied work, I ive tiie morning ;hological Insti- Ijreat length on me, and made a which were re- the next day. ipations, it has 1 his old \i<;or uy, and his atti- ler than produc- 18 to our profes- lis character to us, in our gath- I of rathe and r absence. In a notable ex- 1 and political, !S, he has never e weekly medi- has been more •esidency of the ue of the most t us pursuits may well fill m with admiration for the lar reaching, and i,. one way or another has , f..)* ^ each o..e of us It is well to acknowled l«b wh ch we evervHlay practitioners owe to >, . eat lea,ler8 and workers in the scienti.i. brand es of' ,! with t^I Jrv i" '""f' ':' -^•--''^'"'. consume., witn the petty cares of a bread-and-butter stru.r.rle S wr„::v"''^ """i """"'' ''^ ki^^- fiStu: 7, t . r , ® Professn.n (and you of the public) &:::i,T^y r^^y- /^'''« ie-o,f which shou ii ' "^ Ivi? , ? ""•'" '"'"■'' '^ '''*^ «"«^^«'- ^''icl' 'i life, .such aa Vin.how's, g.ves to those who to-dav, as in nas Jen medicine and who, ut.hxing the gains of science fail by which they are attained. As Puusanias nestered "askil^.. ■",' '"^ '\'''^ "''' ^"h us still those who, . asking not wisdom, but drugs to charm with " «.« tZTT '''. «'"- f!-Sres? of sciJnie, fottt g that the chaos from which order is now anpeari",« h,f livIl-Kr^^ 'T''^' '>-V^'- work if '^oileMi; . iiving _ by the man whom to-night we delight to honor. so noble in its , so varied in BALTIMORE JOHN MURPHY & CO. 1891 IMAGE EVALUATION TEST TARGET (MT-3) 1.0 I.I 11.25 2.5 ■- IIIIIM |50 "'"= ^ m :^ 1^ 12.0 u •* I. WUu 1.4 1.6 IS a? K Va e /2 ^y <^ e%> J? Photographic Sciences Corporation 23 WEST MAIN STREET WEBSTER, N.Y. 14580 (716) 872-4503 \ iV •s^ :\ \ «^ %^ ^\<\ 6 I ^ tion of thi at any otl tcrior par gray niatl ing was ti seomf;d to lies at a h was softe: exact rep upon the 11 l!i i ■ B|B|B™M|i iiW K // Ul m BALTIMORE JOHN MURPHY & CO. i8gi ir : I u () tion of th at any ot) terior par gray mati ing wag ti seemed to lies at a 1: was softe exact rep upon the / 'Mi .Ji,.i^>..L.^..;. / <^X III DOCTOR AND NURSE Remarks to the First Class of Graduates from the Tr^-ining School for Nurses of the Johns Hopkins Hospital n By \yiLLlAM OSLElt, .M. D. Physician-in-Ckief to the Hospital n ' ) ill BALTIMORE JOHN MURTHY & CO. tSgi ! 'td % '■n 1 t. J , . 1 ■ , f *. - b i ■t DOCTOR AND NURSE. Remarks to the First Ct aqq /^t^ n^ iriiL riKhr I.LASS OF GRADUATES FROM THE Training School for Nurses of the Johns Hopkins Hospital. BY WILLIAM OSLER, M. D., Physiciun-in-Chief to the Hospital. Mr. President, Members of the Board of Trus- tees, Members of the Graduating Class-Ladies and (xentlemen : — There are individuals-doctors and nurses, for example-whose very existence is a constant re- minder of our frailties ; and considering the notori- ously irritating character of such people, I often wonder that the world deals so gently with them. The parson never arouses these feelings-no matter what may be his views on celestial geography, his cloth and tie speak of dim possibilities, not oV the grim realities conjured up by the names of the per- sons just mentioned. The lawyer never worries us- in this way. We can imagine in the future a social condition in which neither di inity nor law shall ^^1 have a place-wlien all shall be Friends and each one a I rlest, when the Meek shall possess the eai-th; but Ave cannot picture a time when Birth and Life and Death shall be separated from the grizzly troop, which we dread so much, and which IS ever associated in our minds with " Dhvsiciin and nurse." Broad! Yes, but mercifully for us in a va-^ue and misty way. In tlie sl>ado,vs cast by the turi^ts of tl.e temple of oblivion, towards which we travel we play hke schoolboys, regardless of what awaits us m the vale of years beneath. Sufferins and disease are ever before us, but life is very pleasant; and the motto of the world, when well, i; "forward with the dance." Fondly imagining that we are ma Hapi,y Valley, we deal with ourselves as the King did with Gautama, and hide away everythins that suggests our fate. Perhaps we are wise M ho knows ? Mereifnlly, the tragedy of lite thouMi seen is not realized. It is so close that we lose all sense of its proportions. And better so; for, as a great philosopher has said, " if we had a keen vision and feeling of all ordinary human life, it >,ould be like hearing the grass grow, or the squirrels heart beat, and we should die of that roar which lies on the other side of silence." ..Tff °i™^' '"''™^'''' " '' '"^ "''^"' ■'""'•ness, a sort of fool s paradise, not destroyed by a thought, but by the stern exigencies of life, when the " mi„. lids and each possess the when Birth ed from tlie 1, and which " physician in a vague Y the turrets h we travel, what awaits ffering and •y pleasant ; s " forward hat we are Ives as the everything are wise, life though we lose all ' ; for, as a :een vision ^ \v^ould be I'el's heart ch lies on indness, a t thought, he " min- isters of human fate" drag us, or-worse still- those near and dear to us, upon the stage. Then we become acutely conscious of the gre^t drama of human suffering, and of those inevitable stao-e accessories— doctor and nurse. " ° If, Members of the graduating class, the medical profession, composed chiefly of men, has absorbed a arger share of attention and regard, you have, at least, the satisfoction of feeling that yours is the older, and, as older, the more honorable, callino- In one of the lost books of Solomon, a touchiirJ pic lire IS given of Eve, then an early grand! mother, bending over the little Enoch, and show- ing Mahala how to soothe his sufferings a- to allay his pains. Woman, "the link among tne days," and so trained in a bitter school, has in successive generations, played the part of Mahala to the little Enoch, of Elaine to the wounded Lancelot. It seems a far cry from the plain of Mesopotamia and the lists of Camelot to the Johns Hopkins Hospital, but the spirit which makes this scene possible is the same, tempered through the ages, by the benign influence of Christianity. Many among the ancients had risen to the Ideas of forgiveness of enemies, of patience under wrong doing, and even of the brotherhood of man ; but the spirit of Love only received its incarnation with the ever memorable reply to the ever memorable question, Who is my neighbor 9-a !i. \i I' ?'■ ? :' i '" ! ! f t ■;' " 'it * ■ '^^■ : I '.i'- \ . 1 6 reply which has changed the attitude of the workl Nowhere in ancient history, sacred or protane, do we find pictures of devoted heroism in woman such as dot the annals of the Catholic Church, or such as can be paralleled in our own century. Tender maternal affection, touching filial piety were there • but the spirit abroad was that of Deborah not Itizpah, of Jael not Dorcas. In the gradual division of labor, by which civil- ization has emerged from barbarism, the doctor and the nurse have been evolved, as useful acces- sories in the incessant warfare in which man is engaged. The battle is ever against him, for the worst foes are in his own household Collectively, man, the race, with passions and ambitions, weaknesses and vanities, has made, by barbaric inhumanity, countless thousands mourn and even to-day, when philosophers would have us believe his thoughts have widened, he is ready as of old to shut the gates of mercy, and to let loose the dogs of war. It was in one of these attacks of race-mania that your profession, until then unset- tled and ill-defined, took, under Florence JVight- eng^le-ever blessed be her name-its modern position. Individually, man, the unit, the microcosm, fast bound m chains of atavism, inheriting not alone feature and form, but legacies of feeble will and strong desires, taints of blood and braln-what f tlio world, profane, do vonian such 'ch, or such y. Tender wore there ; eborah not vhich civil- tho doctor eful acces- ch man is im, for the ssions and made, by Is mourn; [d have us 5 ready as > let loose attacks of ien unset- 3e Night- i modern !osm, fast lot alone will and in — what i wonder that many, soro let and hind.M-ed in run- ning- the race, tall by the way, and need a shelter in whidi to recruit or to die; a hospital, in which there shall be no harsh comments on conduct, luit only, so tar as is possible, love and peace and rest Here, we learn to scan gently our brother man and-chief test of charity in your sex-stiU o.entler sister woman; judging not, asking no quastions, but metmg out to all alike a hospitalitv worthy of the Hotel Dieu, and deeming ourselves honored in being allowed to act as its disixMisors. Here too are daily before our eyes the problems which 'have' ever perplexed the human mind; problems not presented in the dead abstract of books, but in the livmg concrete of some poor fellow in his last round, fighting a br.^^e fight, but sadlv weio-hted and gomg to his accoi nt " unhousel'd, di'sappohited' unaneled, no reckoning made." As we whisper to each other over his bed that the battle is decided and Euthanasia alone remains, have I not heard in reply to that muttered proverb, so often on the lips of the physician, "the fathers have eaten sour grapes," your answer, in clear accents,— the com- forting words of the prayer of Stephen ? But our work would be much restricted were it not for man's outside adversary-Nature, the great Moloch, which exacts a frightful tax of human blood, sparing neither young nor old ; taking the child from the cradle, the mother from her babe I I 8 :/.i»< ; I ■f -1 and the father from the family. Is it strange tliat man, unable to dissociate a personal element from such work, has incarnated an evil principle— a devil ? If we have now so tar outgrown this ideli as to hesitate to suggest, in seasons of epidemic peril, that " it is for our sins we suffer, "—when we know the drainage is bad ; if we no longer mock the heart prostrate in the grief of loss with the words " whom the Lord loveth he chastoneth "— when we know the milk should have been steril- ized— if, I say, we have, in a measure become emancipated from such teachings, we have not yet risen to a true conception of Nature. Cruel, in the sense of being inexorable, she may be called, but we can no more upbraid her laws than we' can those of the state, which are a terror only to evil doers ; and so it is with the greater laws of Nature. The pity is that we do not know them all ; in our ignorance we err daily, and pay dearly a blood penalty. Fortunately it is now a great and grow- ing function of the medical profession to search out the laws about epidemics, and these outside ene- mies of man, and to teach to you, the public— dull stupid pupils you are, too, as a rule— the ways of Nature, that you may walk therein and prosper. It would be interesting, members of the gradu- ating class, to cast your horoscopes. To do so collectively you would not like; to do so indi^ vidually-I dare not; but it is safe to predict 9 certain thino-s of you, a. a wliolo. You will he better women for the life which you have led here AI women are g(,od, naturally; the bad are made so by men. IJut what I mean by - better women " IS that the eyes of your souls have been opened tiie range of your sympathies has been widened and your characters have been mouldee a privilege and a pleasure to help vou ' And finally, remember «hat we' are-useful supernumeraries in the battle, simply staee aoces- sones in the Drama, plaH„g minor,' but I^sential parts at the exits and ent..,nces, or piekin^-up, her -Hhere, a strutter, .ho m,.y have .rippec!'u,.„ You have been much by the dark river-so near to usall-and have seen so many embark, that vou now know the old boatman too well to dread him'; so " When the Aiigel of the darker Drink At last shall find you by the river brink, And offering his cup, iavite your soul Forth to your lips to quaif-you sliall n„t shrink "_ And why should you ? Your passport shall be the blesstng. of am in who.e footsteps you have trodden, un whose sick you have ministered, and for whose children you have eared. i ] mess. In